The step up approach in the management of infected pancreatic necrosis. A case report

Abstract

Presenter: Maria Liz Sanchez MD | Hospital de Clínicas de Asunción Background: Approximately 15% of patients with acute pancreatitis (AP) develop the severe form. Treatment of infected necrotizing pancreatitis has changed over the past 20 years and continues to evolve with increasing experience, new techniques, and research. Treatment of Infected necrosis by laparotomy is associated with high morbidity and mortality. The “Step Up Approach” consists of the successive placement of drains of progressively greater caliber, it has demonstrated, since the publication of the PANTER study, its superiority over the classical surgical approach in terms of morbidity. In up to 35% of cases, the episode will be resolved only in this way, in the rest of patients, the pancreatic cell will be debrided. Methods: We present the case of a patient with a diagnosis of severe acute pancreatitis and infected pancreatic necrosis who was managed with the now popular “step up” approach Results: Clinical case: 28-year-old male with dyslipidemic origin (AP), with necrosis pancreatic, peripancreatic collections, and gas in retroperitoneum, treated with TPN, pancreatin (CREON) and antibiotic therapy (Imipenem 20 days and then according to antibiogram). He developed infected necrosis that required drainage with two 12 Fr and 14 Fr pigtails (25th day-hospitalization), with ultrasound-guided access in the right flank and left flank. Catheter replacement and progressive increase in diameter were performed, followed by RPVA necrosectomy following the path of the left pigtail (th day-hospitalization). The evolution was favorable, with progressive withdrawal of drains, and discharge without drains on day 65 of hospitalization. Conclusion: The “Step Up Approach” is the current standard in the treatment of infected pancreatic necrosis, it is effective and safe, avoiding the serious complications of open necrosectomy, with a good recovery of the patient.