From “step-up” to “step-jump”: a leap-forward intervention for infected necrotizing pancreatitis

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From “step-up” to “step-jump”: a leap-forward intervention for infected necrotizing pancreatitis

Acute pancreatitis (AP) can range from a mild, self-resolving condition to a life-threatening emergency—but its most dangerous form, infected necrotizing pancreatitis (INP), carries a mortality rate of up to 30% due to sepsis and organ failure. For decades, surgeons relied on open surgery to remove dead pancreatic tissue, but a “step-up” approach—starting with minimally invasive drainage before moving to surgery—has become the gold standard. Yet new research suggests this one-size-fits-all strategy isn’t right for everyone.

Writing in the Chinese Medical Journal, a team from the Department of Pancreas Center at the First Affiliated Hospital with Nanjing Medical University (Dongya Huang, Qiang Li, Zipeng Lu, Kuirong Jiang, Junli Wu, Wentao Gao, Bin Xiao, and Yi Miao) argues for a “step-jump” alternative: skipping minimally invasive steps and going straight to surgery for select INP patients.

The rise of the step-up approach—and its limits

The landmark PANTER trial (2010), a Dutch multicenter study, established the step-up strategy as the standard of care. It found that starting with image-guided percutaneous catheter drainage (PCD) or endoscopic intervention—only moving to minimally invasive surgery if needed—was as effective as open necrosectomy (surgical removal of dead tissue) but caused fewer complications like organ failure, hernias, or diabetes. Long-term follow-up (2019) confirmed these benefits: step-up patients had lower rates of pancreatic insufficiency and diabetes over 7 years.

But the trial had critical flaws. For one, it didn’t separate patients by the type of necrotic tissue: “wet” necrosis (liquefied, responsive to drainage) vs. “dry” necrosis (solid, requiring debridement). Thirty-five percent of step-up patients got better with PCD alone—signaling their necrosis was mostly wet—but some wet necrosis patients in the open surgery group got unnecessary large operations. The trial also didn’t account for surgeon experience (a key factor in surgical outcomes) and found no difference in mortality between groups. Its small sample size further limits how broadly results can be applied.

When step-up fails: The case for “step-jump”

For some patients, strict adherence to step-up can be deadly. A 2020 case report (Burek et al) described a patient who followed the step-up protocol but died of severe sepsis—delayed surgery let infection spiral out of control. Another study (Harfouche et al, 2020) found patients who failed drainage had higher mortality and worse outcomes than those who got surgery first, especially if they had high illness scores (measured by the Acute Physiology and Chronic Health Enquiry II). And when patients “step up” to open surgery after minimally invasive attempts, they’re often sicker and face worse post-op complications (Maatman et al, 2020).

This is where “step-jump” comes in. For patients with widespread dry necrosis or who aren’t improving with drainage, skipping PCD and going straight to surgery could save time—and lives. Open necrosectomy lets surgeons thoroughly remove dead tissue in one procedure, which is critical for stopping sepsis. It’s not a return to risky early surgery: delayed open surgery (after 28 days) by experienced teams is safe. A Massachusetts General Hospital study found just 5.1% mortality for delayed open surgery vs. 20.3% for early surgery. And a 2020 study (Cao et al) found a one-step laparoscopy-assisted approach had fewer procedures and shorter hospital stays than step-up—with no higher risk of complications or death.

Minimally invasive isn’t always better

Critics might argue minimally invasive care is always superior, but data don’t support that. A Japanese multicenter study (2020) found no mortality difference between secondary open surgery and minimally invasive treatment. The key is experience: open surgery remains safe when performed by teams that handle many pancreatic cases. The tendency to label all minimally invasive care as “better” ignores the reality that some patients need the thoroughness of open necrosectomy—especially those with widespread necrosis.

The future: Personalized care for INP

The step-up approach works for many, but step-jump should be an option for those where minimally invasive care would delay life-saving surgery. The core issue is individualization: INP varies widely in severity, necrotic tissue type, and patient health—one strategy can’t fit all. Future research needs to build clinical prediction models to match patients to the right approach, ensuring no one misses their window for recovery.

For now, the message is clear: INP treatment should be as unique as the patient. The step-up approach is a game-changer for many, but step-jump offers a critical lifeline for those who need it.

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