Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis

  • Saransh Jain
  • Rajesh Padhan
  • Sawan Bopanna
  • Sushil Kumar Jain
  • Rajan Dhingra
  • Nihar Ranjan Dash
  • Kumble Seetharama Madhusudan
  • Shivanand Ramachandra Gamanagatti
  • Peush Sahni
  • Pramod Kumar GargEmail author
Original Article



Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.


To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.


Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.


A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully—34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure—7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.


Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.


Acute pancreatitis Infected pancreatic necrosis Percutaneous endoscopic necrosectomy Walled-off necrosis 


Author’s contribution

SJ, RP contributed to acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision, and final approval of the manuscript; SB, SKJ, RD, NRD, KSM, SRG, PS contributed to analysis and interpretation of data, drafting of the manuscript, critical revision, and final approval of the manuscript; PKG contributed to study concept and design, analysis and interpretation of data; study supervision, drafting of the manuscript, critical revision, and final approval of the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Ethical consideration

Institutional ethical clearance was obtained for two studies on natural course and outcomes of patients with AP.

Supplementary material

10620_2019_5696_MOESM1_ESM.mpg (19.3 mb)
Short edited video of a patient undergoing percutaneous endoscopic necrosectomy (MPG 19732 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Saransh Jain
    • 1
  • Rajesh Padhan
    • 1
  • Sawan Bopanna
    • 1
  • Sushil Kumar Jain
    • 1
  • Rajan Dhingra
    • 1
  • Nihar Ranjan Dash
    • 2
  • Kumble Seetharama Madhusudan
    • 3
  • Shivanand Ramachandra Gamanagatti
    • 3
  • Peush Sahni
    • 2
  • Pramod Kumar Garg
    • 1
    Email author
  1. 1.Department of GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia
  2. 2.Department of Gastrointestinal SurgeryAll India Institute of Medical SciencesNew DelhiIndia
  3. 3.Department of RadiodiagnosisAll India Institute of Medical SciencesNew DelhiIndia

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