• Beiyuan Zhang, Tao Gao, Yan Wang, Hao Zhu, Song Liu, Ming Chen, Wenkui Yu, and Zhanghua Zhu.
• Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China.
• Medicine (Baltimore). 2023 Mar 17; 102 (11): e33288e33288.

RationaleComplete removal of necrosis is critical for treating patients with severe acute pancreatitis (SAP) presenting infection of pancreatic necrosis (IPN). Frequently used mini-invasive methods include the surgical step-up approach suitable for necrosis extending laterally, whereas the endoscopic step-up approach is suitable for medial necrosis. However, in patients with extensive IPN, either approach alone usually has limited treatment effects.Patient ConcernsWe describe a case series of combined mini-invasive step-up approach for treating extensive IPN.DiagnosesPatients were diagnosed with SAP and had extensive IPN.InterventionsSeven patients with SAP and extensive IPN were enrolled. All patients underwent a combined step-up approach comprising 4 steps: percutaneous catheter drainage, continuous negative pressure irrigation (CNPI), percutaneous endoscopic necrosectomy (PEN), and transgastric necrosectomy (TN).OutcomesThe median interval from symptom onset to percutaneous catheter drainage and CNPI was 11 days (range, 6-14) and 18 days (range, 14-26), and the median CNPI duration was 84 days (range, 54-116). The median interval from the onset of symptoms to PEN and TN was 36 days (range, 23-42) and 41 days (range, 34-48), respectively, and the median number of procedures was 2 (range, 1-2) for PEN and 3 (range, 2-4) for TN. Only a minor case of abdominal bleeding and a pancreatic-cutaneous fistula were reported, both resolved after conservative treatment. The median length of stay in the intensive care unit was 111 days (range, 73-133); all patients survived.LessonsThis mini-invasive step-up approach shows promising clinical effects and is relatively safe in critically ill patients with extensive IPN and high-risk surgical intervention.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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