Acute necrotizing pancreatitis (ANP) is associated with significant morbidity and mortality. The most feared complications are multiple organ failure and superinfection of the necrosis. Endoscopic management of complications related to necrosis is now well established.

The aim of our study was to outline the epidemiological, etiological, therapeutic, and evolutionary profile of acute necrotizing pancreatitis.

This was a single-center, retrospective descriptive study conducted over a 6-year period, from January 2019 to October 2025, including all patients admitted to our department for necrotizing AP with a CTSI (CT severity index) ≥ 4. The diagnosis of acute pancreatitis (AP) was based on the revised 2012 Atlanta criteria

Of a total of 167 patients admitted for acute pancreatitis (AP), 63 had acute necrotizing pancreatitis, an incidence of 37.7%. The mean age was 56.7 years (range: 23–85 years), with a male-to-female ratio of 0.75. Clinically, all patients presented with typical pancreatic abdominal pain. The diagnosis of AP was based on clinical and biological criteria in 61.9% of cases (n = 39), with a mean lipase level of 1536.3 IU/L, and on clinical and morphological criteria in 38% of cases (n = 24). at admission, systemic inflammatory response syndrome (SIRS) was present in 77.7% of patients (n = 49) and persisted for more than 48 hours in 42.8% (n = 21).

The abdominal CT scan showed acute pancreatitis stage E according to Balthazar in 80.3% of cases (n = 53), associated with parenchymal necrosis in 53.3% of cases, with a mean CTSI score ≥ 6, while stage D pancreatitis was observed in 19.6% of cases, with CTSI ≥ 4. The etiologies were biliary in 63.4% of cases (n = 40), metabolic in 7.9% (n = 5), alcoholic in 3.1% (n = 2), iatrogenic (post-ERCP) in 6.3% (n = 4), ampullary tumor in 4.7% (n = 3), pancreas divisum in 1.5% (n = 1), and idiopathic in 12.7% (n = 8). All patients received appropriate rehydration, anticoagulation during hospitalization, and early reintroduction of food. The outcome was marked by the disappearance of symptoms in 59% of cases, the onset of local complications in 22.2% (n = 14), including two cases of early infection of necrotic collections, and recurrence of another episode of AP in 15.9% of cases. The follow-up CT scan at 6 weeks, performed in 54 patients, showed regression of collections in 51.8% (n = 28), an increase in 22.2% (n = 12), of which 16,6% (n = 9) developed organized necrosis, and stability in 25.9% (n = 14). Symptomatic collections were drained mainly due to infection or compression of adjacent organs, while asymptomatic collections did not require treatment.

endoscopic ultrasound-guided drainage was performed in 42,3% of cases (n=11) (two double pigtail plastic stents in seven patients, one Biflanged stent in three, and for one patient, a LAMS (HOT AXIOS stent). Endoscopic necrosectomy (two sessions) was performed in two patient, surgical drainage in three patients, and radiological drainage in two. After drainage, 13 patients showed symptom improvement (81,2%), and three deaths occurred: two due to septic shock post-drainage (one surgical, one endoscopic) and one from an unrelated cause.

Our work showed a favorable outcome in the majority of patients receiving appropriate therapeutic management. Endoscopic drainage of symptomatic pancreatic collections is effective and less invasive and should be preferred whenever feasible.