{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T11:46:07Z","timestamp":1775821567189,"version":"3.50.1"},"reference-count":36,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T00:00:00Z","timestamp":1775779200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Acute pancreatitis is a prevalent pathology with increasing incidence. Despite advances in treatment, some patients still present a severe clinical course with high morbidity and mortality rates. We evaluated the association between implementation of a step-up-based management strategy and clinical outcomes in patients with severe acute pancreatitis (SAP) treated at a tertiary referral center. Method: A retrospective observational study was conducted, including patients treated for SAP at a tertiary care center. Clinical outcomes, including mortality, morbidity, and length of hospital stay, were compared between two periods: Period A (1998\u20132010, classical treatment) and Period B (2011\u20132021, step-up approach). A subanalysis on minimally invasive techniques was also performed for Period B. Results: In total, 116 patients were included (39 Period A; 77 Period B). Pancreatic fistulas were reduced in Period B (15.38% vs. 5.33%; p = 0.088), as was mortality (30.76% vs. 18.67%; p = 0.15). Open surgeries decreased significantly in Period B (71.9% vs. 16.9%; p = 0.043), as did the mean hospital stay (60.5 \u00b1 28 vs. 33.08 \u00b1 28 days; p &lt; 0.001). When comparing endoscopy management versus Video-Assisted Retroperitoneal Debridement (VARD), the rate of pancreatic fistulas was higher in the VARD group (0% vs. 57.1%; p &lt; 0.01). Patients requiring VARD presented with larger collections (710 cc vs. 1737.9 cc; p = 0.03) and fewer procedures (4.2 \u00b1 2.3 vs. 1.5 \u00b1 0.5; p = 0.002). Conclusions: The step-up management in patients with SAP was associated with a decrease in open surgical approches and length of stay. VARD was performed in patients with higher volume collections and was associated with fewer interventions than patients treated by endoscopic necrosectomy; however, the incidence of pancreatic fistulas was higher.<\/jats:p>","DOI":"10.3390\/jcm15082881","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T09:08:12Z","timestamp":1775812092000},"page":"2881","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Has the Step-Up Approach Improved Prognosis in Severe Necrotizing Acute Pancreatitis?"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3660-8670","authenticated-orcid":false,"given":"Ricardo","family":"Gadea-Mateo","sequence":"first","affiliation":[{"name":"Department of Surgery, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9474-6521","authenticated-orcid":false,"given":"Marina","family":"Garc\u00e9s-Albir","sequence":"additional","affiliation":[{"name":"Department of Surgery, Liver-Biliary and Pancreatic Unit, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9807-4689","authenticated-orcid":false,"given":"Dimitri","family":"Dorcaratto","sequence":"additional","affiliation":[{"name":"Department of Surgery, Liver-Biliary and Pancreatic Unit, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-5286-4218","authenticated-orcid":false,"given":"Georgy","family":"Kadzhaya-Khlystov","sequence":"additional","affiliation":[{"name":"Department of Surgery, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vicente","family":"Sanchiz","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elena","family":"Mu\u00f1oz-Forner","sequence":"additional","affiliation":[{"name":"Department of Surgery, Liver-Biliary and Pancreatic Unit, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rosana","family":"Villagrasa","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6756-9707","authenticated-orcid":false,"given":"Isabel","family":"Mora-Oliver","sequence":"additional","affiliation":[{"name":"Department of Surgery, Liver-Biliary and Pancreatic Unit, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elisabetta","family":"Casula","sequence":"additional","affiliation":[{"name":"Department of Radiology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mar","family":"Juan-Diaz","sequence":"additional","affiliation":[{"name":"Critical Care Unit, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6228-3462","authenticated-orcid":false,"given":"Pablo","family":"Navarro-Cort\u00e9s","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jorge","family":"Guijarro-Rosaleny","sequence":"additional","affiliation":[{"name":"Department of Radiology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isabel","family":"Pascual-Moreno","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hospital Cl\u00ednico Universitario of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luis","family":"Sabater","sequence":"additional","affiliation":[{"name":"Department of Surgery, Liver-Biliary and Pancreatic Unit, Hospital Cl\u00ednico Universitario of Valencia, Biomedical Research Institute INCLIVA, University of Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"De Madaria, E., and Mart\u00ednez Sempere, J.F. (2011). Pancreatitis aguda. Asociaci\u00f3n Espa\u00f1ola de Gastroenterolog\u00eda. Tratamiento de las Enfermedades Gastroenterol\u00f3gicas, AEG.","DOI":"10.1016\/S0210-5705(11)70014-0"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1053\/j.gastro.2016.01.039","article-title":"Double Trouble in Acute Pancreatitis","volume":"150","author":"Sharma","year":"2016","journal-title":"Gastroenterology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1731","DOI":"10.1053\/j.gastro.2015.08.045","article-title":"Burden of Gastrointestinal, Liver, and Pancreatic Diseases in the United States","volume":"149","author":"Peery","year":"2015","journal-title":"Gastroenterology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/S0140-6736(14)60649-8","article-title":"Acute pancreatitis","volume":"386","author":"Lankisch","year":"2015","journal-title":"Lancet"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1111\/j.1477-2574.2009.00072.x","article-title":"National Hospital volume in acute pancreatitis: Analysis of the nationwide inpatient sample 1998\u20132006","volume":"11","author":"Singla","year":"2009","journal-title":"Hpb"},{"key":"ref_6","unstructured":"Mart\u00edn P\u00e9rez, E., Sabater Ort\u00ed, L., and S\u00e1nchez-Bueno, F. (2018). Pancreatitis aguda: Definici\u00f3n, etiolog\u00eda, diagn\u00f3stico y clasificaci\u00f3n pron\u00f3stica. Cirug\u00eda Biliopancre\u00e1tica: Gu\u00edas Cl\u00ednicas de la Asociaci\u00f3n Espa\u00f1ola de Cirujanos, Ar\u00e1n Ediciones. [2nd ed.]."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"200","DOI":"10.4240\/wjgs.v9.i10.200","article-title":"Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit","volume":"9","author":"Aparna","year":"2017","journal-title":"World J. Gastrointest. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1400","DOI":"10.1038\/ajg.2013.218","article-title":"American College of Gastroenterology Guideline: Management of Acute Pancreatitis","volume":"108","author":"Tenner","year":"2013","journal-title":"Am. J. Gastroenterol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Yu, L., Xie, F., Luo, L., Lei, Y., Huang, X., Yang, X., Zhu, Y., He, C., Li, N., and He, W. (2023). Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis. BMC Gastroenterol., 23.","DOI":"10.1186\/s12876-023-02651-4"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/S0140-6736(17)32404-2","article-title":"Endoscopic or surgical step-up approach for infected necrotising pancreatitis: A multicentre randomised trial","volume":"391","author":"Bakker","year":"2018","journal-title":"Lancet"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Bhatti, U.F., and Alam, H.B. (2019). A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis. 50 Landmark Papers Every Acute Care Surgeon Should Know, CRC Press.","DOI":"10.1201\/9780429316944-36"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1445","DOI":"10.1007\/s11605-022-05285-1","article-title":"Contemporary Intervention in Necrotizing Pancreatitis: Improved Understanding Changing Practice","volume":"26","author":"McGuire","year":"2022","journal-title":"J. Gastrointest. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1097\/SLA.0000000000001407","article-title":"Outcomes from minimal access retroperitoneal and open pancreatic necrosectomy in 394 patients with necrotizing pancreatitis","volume":"263","author":"Gomatos","year":"2016","journal-title":"Ann. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1627","DOI":"10.1007\/s11605-013-2266-6","article-title":"Surgical Versus Nonsurgical Treatment of Infected Pancreatic Necrosis: More Arguments to Change the Paradigm","volume":"17","author":"Pascual","year":"2013","journal-title":"J. Gastrointest. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1136\/gutjnl-2012-302779","article-title":"Classification of acute pancreatitis\u20142012: Revision of the Atlanta classification and definitions by international consensus","volume":"62","author":"Banks","year":"2013","journal-title":"Gut"},{"key":"ref_16","first-page":"e83020","article-title":"Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review","volume":"17","author":"Sahu","year":"2025","journal-title":"Cureus"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"S748","DOI":"10.1016\/j.hpb.2019.10.1473","article-title":"The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After","volume":"21","author":"Marchegiani","year":"2019","journal-title":"Hpb"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1097\/00000658-198710000-00015","article-title":"Management of infected pancreatitis necrosis by open drainage","volume":"206","author":"Bradley","year":"1987","journal-title":"Ann. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1097\/00000658-198903000-00004","article-title":"Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results","volume":"209","author":"Beger","year":"1989","journal-title":"Ann. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Besselink, M.G., Van Santvoort, H.C., Nieuwenhuijs, V.B., Boermeester, M.A., Bollen, T.L., Buskens, E., Dejong, C.H., van Eijck, C.H., van Goor, H., and Hofker, S.S. (2006). Minimally invasive \u201cstep-up approach\u201d versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): Design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg., 6.","DOI":"10.1186\/1471-2482-6-6"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A New Method of Classifying Prognostic in Longitudinal Studies: Development","volume":"40","author":"Charlson","year":"1987","journal-title":"J. Chronic Dis."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1053\/j.gastro.2021.09.043","article-title":"Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis","volume":"162","author":"Iannuzzi","year":"2022","journal-title":"Gastroenterology"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1001\/archsurg.2010.178","article-title":"Safety and Efficacy of Video-Assisted Retroperitoneal Debridement for Infected Pancreatic Collections","volume":"145","author":"Horvath","year":"2010","journal-title":"Arch. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1136\/gutjnl-2016-313341","article-title":"Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: A pooled analysis of individual data for 1980 patients","volume":"67","author":"Hollemans","year":"2018","journal-title":"Gut"},{"key":"ref_25","first-page":"e70470","article-title":"Role of Necrosectomy in Necrotizing Pancreatitis: A Narrative Review","volume":"16","author":"Vaidya","year":"2024","journal-title":"Cureus"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1055\/s-0033-1344027","article-title":"Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study","volume":"45","author":"Yasuda","year":"2013","journal-title":"Endoscopy"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1016","DOI":"10.1053\/j.gastro.2018.10.045","article-title":"Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients with Necrotizing Pancreatitis","volume":"156","author":"Hollemans","year":"2019","journal-title":"Gastroenterology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1254","DOI":"10.1053\/j.gastro.2011.06.073","article-title":"A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome","volume":"141","author":"Bakker","year":"2011","journal-title":"Gastroenterology"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1053\/j.gastro.2018.11.031","article-title":"An Endoscopic Transluminal Approach, Compared with Minimally Invasive Surgery, Reduces Complications and Costs for Patients with Necrotizing Pancreatitis","volume":"156","author":"Bang","year":"2019","journal-title":"Gastroenterology"},{"key":"ref_30","first-page":"471","article-title":"An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: A systematic review and meta-analysis","volume":"111","author":"Hu","year":"2019","journal-title":"Rev. Esp. Enfermedades Dig."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1002\/bjs.5546","article-title":"Feasibility of minimally invasive approaches in patients with infected necrotizing pancreatitis","volume":"94","author":"Besselink","year":"2007","journal-title":"Br. J. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1186\/s40001-023-01030-9","article-title":"Minimal-access video-assisted retroperitoneal and\/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: Initial experience from a prospective single-arm study","volume":"28","author":"Wei","year":"2023","journal-title":"Eur. J. Med. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1177\/000313481307900434","article-title":"Video-assisted laparoscopic d\u00e9bridement for retroperitoneal pancreatic collections: A reliable step-up approach","volume":"79","year":"2013","journal-title":"Am. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Olsen, G.A., Schmidt, P.N., Hadi, A., Prahm, A.P., Werge, M.P., Roug, S., Schefte, D.F., Lauritsen, M.L., Hansen, E.F., and Novovic, S. (2025). Accelerated vs Step-Up Endoscopic Treatment for Pancreatic Walled-Off Necrosis: A Randomized Controlled Trial (ACCELERATE). Clin. Gastroenterol. Hepatol., in press.","DOI":"10.1016\/j.cgh.2025.08.007"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1001\/jamasurg.2022.5695","article-title":"Contemporary Surgical Management of Pancreatic Necrosis","volume":"158","author":"Maurer","year":"2023","journal-title":"JAMA Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1994","DOI":"10.1053\/j.gastro.2019.01.269","article-title":"Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach","volume":"156","author":"Trikudanathan","year":"2019","journal-title":"Gastroenterology"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/2881\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T10:47:24Z","timestamp":1775818044000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/2881"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,10]]},"references-count":36,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15082881"],"URL":"https:\/\/doi.org\/10.3390\/jcm15082881","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,10]]}}}