Infected Pancreatic Necrosis (IPN) following Acute Necrotizing Pancreatitis (ANP) remains clinically challenging with associated significant morbidity and mortality despite treatment advances. One of the critical factors that decides the outcome is incorporation/adoption of appropriate treatment strategy at right time in the course of illness. Recent literature suggests similar clinical outcomes by either endoscopic or minimally invasive surgical drainage strategies.1,2 But in a real-world scenario, the applicability of either treatment strategies, including their feasibility and challenges have not been adequately addressed. We aimed to evaluate the management strategies followed in a cohort of patients of IPN - including their timing, challenges, and outcomes, when managed using standard treatment protocol.

This was a prospective observational study including consecutive patients of ANP with clinical suspected IPN (fever, leukocytosis, persistent organ failure). The study was conducted at 2 tertiary care hospitals over one year (January to December 2023). All patients were managed using standard treatment protocols by multidisciplinary team including clinicians, endoscopists, interventional radiologists, intensivists, and surgeons. IPN was labelled after excluding other causes of infection and SIRS. Blood culture and sensitivity was performed in all subjects before initiating antibiotics. IPN was managed initially with empirical antibiotics and were changed later according to the sensitivity. Patients who didn’t improve with appropriate antibiotics within 72 hours were considered for drainage. Assessment for EUS guided drainage with dedicated metals stents, including LAMS (Lumen Apposing Metal Stents) was attempted as a first preference. If EUS drainage was not feasible (due to either immature or distant collections), one or more percutaneous catheter drainage (PCDs) was considered, as a part of minimally invasive surgical (MIS) step-up strategy. Subsequent strategies of MIS approaches including upsizing of catheters, necrosectomy, retroperitoneal surgical approaches were considered during the treatment course if required. The outcome measures included - treatment strategy adopted, timing of intervention from onset of ANP, duration of treatment, clinical outcome, and mortality.

117 patients were included during the study period (males 62%, mean age 37.46 years). Etiologies were alcohol (38%), idiopathic (32%), gall stone related (18%). 38 patients (32%) could be managed conservatively. Of the remaining 79 (68%) patients who required intervention, initial drainage performed was EUS guided in 30 (38%) while 49 (62%) underwent PCD placement as a part of MIS step up. The mean time interval between onset of ANP and intervention was 33 days in the MIS and 35 days in the EUS drainage. Early drainages (<4 weeks) were performed in 30/79 patients (38%), of which EUS drainage was possible in 8 patients while the majority (22) underwent MIS (10% vs 28%; p=0.06). The overall clinical success rates were similar in MIS and EUS drainage. The overall mortality was 20.5%. There was no significant difference in mortality between EUS drainage (22.2%) and MIS (30%).

Minimally invasive surgical (MIS) step-up remains the primary modality both in early (< 4 weeks) and overall drainages in IPN despite efforts to consider EUS guided drainage. Adopting the specific modality of drainage is decided by the feasibility and safety rather than choice in real world clinical practice. Mortality occurs in about 20% of patients despite standard treatment protocols and aggressive treatment strategies.