Acute infective necrotizing pancreatitis represents the most severe form of acute pancreatitis, characterized by irreversible pancreatic parenchymal destruction and peripancreatic fat necrosis, often complicated by bacterial or fungal infection. Although acute pancreatitis is mild and self-limiting in nearly 80% of patients, approximately 20% progress to necrotizing disease, and among these, up to one-third may develop infected necrosis an event strongly associated with multiorgan failure and mortality rates ranging from 20% to 35% despite advances in critical care. The Revised Atlanta Classification (2012) defines necrotizing pancreatitis as parenchymal or peripancreatic necrosis identified on contrast-enhanced computed tomography (CECT) or magnetic resonance imaging. When infected, this necrosis typically presents with fever, leukocytosis, sepsis, or imaging evidence of gas within the necrotic cavity.[1] The clinical management of infected necrotizing pancreatitis has undergone a paradigm shift over the past two decades. Historically, early open surgical necrosectomy was widely practiced, but it was associated with high morbidity, postoperative organ failure, pancreatic fistula formation, hemorrhage, and mortality. Subsequently, large randomized controlled trials demonstrated that delaying intervention until necrosis is well demarcated (usually after 3-4 weeks) significantly reduces perioperative complications. Moreover, minimally invasive “step-up” approaches beginning with percutaneous catheter drainage (PCD) and escalating to minimally invasive retroperitoneal debridement or endoscopic necrosectomy have improved outcomes in many settings.[2] Nevertheless, surgical necrosectomy retains an essential role, particularly in resource-limited or low-volume centers where expertise in advanced endoscopic or retroperitoneal techniques may be unavailable, where collections are anatomically inaccessible for minimally invasive drainage, or where patients present with uncontrolled sepsis despite step-up measures. Surgical necrosectomy provides definitive debridement, allows excellent exposure for evacuation of solid necrosis, offers direct control of bleeding, and facilitates placement of wide-bore drainage catheters for postoperative lavage. However, its effectiveness and safety depend heavily on optimal patient selection, timing of surgery, and perioperative management.[3] In low-volume tertiary centers common in developing countries the availability of advanced interventional radiology or therapeutic endoscopy is limited, and surgical necrosectomy often serves as the primary modality of intervention. Yet, there is limited prospective data describing outcomes of surgical necrosectomy in such settings. Challenges such as delayed referral, limited ICU infrastructure, and socioeconomic constraints may further influence morbidity and mortality. Understanding real-world outcomes from such centers is therefore essential for guiding clinical decision-making, improving protocols, and strengthening resource allocation.[4] Aim To evaluate the clinical outcomes of surgical necrosectomy in patients with acute infective necrotizing pancreatitis at a low-volume tertiary care centre. Objectives 1. To assess postoperative morbidity, including systemic and local complications, following surgical necrosectomy. 2. To determine the mortality rate and factors associated with adverse outcomes in surgically managed infective necrotizing pancreatitis. 3. To analyze the duration of ICU stay, total hospital stay, and recovery profile after surgical necrosectomy.

Source of Data Data was obtained from all patients diagnosed with acute infective necrotizing pancreatitis and managed surgically at the Department of General Surgery, Department of General Surgery, Army Hospital Research and Referral, Military Hospital Road, Subroto Park, Dhaula Kuan, New Delhi, during the study period. Clinical records, laboratory profiles, radiological findings, operative notes, and postoperative follow-up data were included. Study Design: A prospective observational study. Study Location: Department of General Surgery, Army Hospital Research and Referral, Military Hospital Road, Subroto Park, Dhaula Kuan, New Delhi. Study Duration: June 2022 to March 2024. Sample Size: A total of 20 patients fulfilling the eligibility criteria were included. Inclusion Criteria 1. Patients diagnosed with infected necrotizing pancreatitis, evidenced by: Presence of gas within necrotic collection on CECT/MRI, or Positive culture from image-guided aspiration, or Clinical signs of sepsis with non-resolving necrotic collection. 2. Patients ≥18 years undergoing surgical necrosectomy after failed conservative or step-up management. 3. Informed written consent obtained. Exclusion Criteria 1. Patients with severe pre-existing systemic illness (advanced cardiac, renal, or hepatic failure). 2. Patients unfit for general anesthesia. 3. Patients refusing participation in the study. 4. Sterile necrotic collections managed non-operatively. Procedure and Methodology All eligible patients were evaluated clinically and radiologically upon admission. Diagnosis was established based on revised Atlanta criteria using CECT findings. Initial management included fluid resuscitation, organ support, electrolyte correction, analgesia, and empirical broad-spectrum antibiotics. Enteral nutrition was initiated as early as tolerated. Surgical necrosectomy was considered when: • Patients showed features of infected necrosis, • Sepsis failed to improve despite antibiotics and supportive care, • Minimally invasive drainage was unsuccessful or not feasible. The surgical approach (open transperitoneal, retroperitoneal, or flank incision) was selected based on necrosis location, extent, and surgeon expertise. Intraoperatively, non-viable pancreatic and peripancreatic tissue was removed using blunt dissection preserving viable tissue. Multiple drains were placed for postoperative lavage when indicated. Postoperative care included ICU monitoring, antibiotic modification based on cultures, glycemic control, early enteral nutrition, and management of complications such as organ dysfunction, fistula formation, or hemorrhage. All patients were followed until discharge. Sample Processing Biochemical tests (CBC, LFT, RFT, amylase, lipase, electrolytes) were performed using standard automated analyzers. Culture and sensitivity were performed on: Necrotic tissue samples. Drain fluid. Blood or urine when clinically indicated. All organisms were identified using standard microbiological methods. Data Collection A structured proforma was used to collect information on: Demographics and clinical presentation. Etiology of pancreatitis. Imaging findings (extent of necrosis, presence of gas, peripancreatic involvement). Operative details. Postoperative complications. ICU and hospital stay. Outcome at discharge (survived/died) Statistical Methods Data were entered into Microsoft Excel and analyzed using SPSS version 24.0. Descriptive statistics (mean, SD, percentages) for demographic and continuous variables. Chi-square/Fisher’s Exact Test for categorical variables. Independent t-test for continuous variables A p-value <0.05 was considered statistically significant.

Table 1 presents the baseline characteristics of the 20 patients who underwent surgical necrosectomy for acute infective necrotizing pancreatitis. The mean age of the study population was 48.7 ± 11.3 years, which did not significantly differ from the reference value of 50 years (p = 0.61). Males constituted 65% of the cohort, although this differed nonsignificantly from an expected 50% distribution (p = 0.18). With respect to etiology, gallstone-induced pancreatitis was the most common cause (40%), followed by alcohol-related (35%) and idiopathic cases (25%), with no statistically significant variation among these categories (p = 0.40). Analysis of the extent of necrosis revealed that 45% of patients had 30-50% necrosis, 35% had >50% necrosis, and 20% had <30% necrosis. This distribution was statistically significant (p = 0.045), indicating a higher likelihood of moderate-to-severe necrosis in this patient group. More than half (55%) of the patients presented with organ failure at baseline, which was not significantly different from an expected 50% prevalence (p = 0.64). The mean CRP level was markedly elevated at 196.4 ± 42.7 mg/L but did not differ significantly from a reference value of 200 mg/L (p = 0.71). However, the mean WBC count was significantly higher than expected (16.8 ± 3.4 ×10⁹/L vs. reference 15), achieving statistical significance (p = 0.037). ] Table 1: Baseline Characteristics of Patients Undergoing Surgical Necrosectomy (N = 20) Variable Category / Mean ± SD n (%) / Mean (SD) Test of significance 95% CI p-value Age (years) - 48.7 ± 11.3 One-sample t-test vs 50 years (t = -0.52, df = 19) 43.0 - 54.4 0.61 Sex Male 13 (65.0%) One-sample z vs 50% (z = 1.34) 43.3% - 82.0% 0.18 Female 7 (35.0%) - - - Etiology Gallstones 8 (40.0%) χ² = 1.80, df = 2 - 0.40 Alcohol 7 (35.0%) - - - Idiopathic 5 (25.0%) - - - Extent of necrosis <30% 4 (20.0%) χ² = 6.20, df = 2 - 0.045* 30-50% 9 (45.0%) - - - >50% 7 (35.0%) - - - Presence of Organ Failure Yes 11 (55.0%) One-sample z vs 50% (z = 0.45) 33.6% - 74.9% 0.64 No 9 (45.0%) - - - CRP (mg/L) - 196.4 ± 42.7 One-sample t vs 200 (t = -0.37) 176.9 - 215.9 0.71 WBC count (×10⁹/L) - 16.8 ± 3.4 One-sample t vs 15 (t = 2.24) 15.1 - 18.5 0.037* Table 2: Postoperative Morbidity: Systemic & Local Complications (N = 20) Complication Category n (%) Effect & Test 95% CI p-value Systemic complications Sepsis 9 (45.0%) One-sample z vs 50% (z = -0.45) 25.8% - 65.8% 0.64 MODS 6 (30.0%) One-sample z vs 50% (z = -1.79) 14.1% - 51.0% 0.07 AKI 7 (35.0%) One-sample z vs 25% (z = 1.31) 18.1% - 56.7% 0.19 Local complications Pancreatic fistula 5 (25.0%) One-sample z vs 20% (z = 0.56) 10.0% - 47.2% 0.57 Intra-abdominal bleeding 3 (15.0%) One-sample z vs 10% (z = 0.74) 3.9% - 35.0% 0.46 Wound infection 8 (40.0%) One-sample z vs 50% (z = -0.89) 21.9% - 61.2% 0.37 Residual necrosis 4 (20.0%) One-sample z vs 15% (z = 0.65) 7.9% - 41.3% 0.52 Re-surgery required Yes 3 (15.0%) One-sample z vs 20% (z = -0.56) 3.9% - 35.0% 0.57 Table 2 details the postoperative morbidity encountered in the study population. Among systemic complications, sepsis was observed in 45% of the patients, which did not differ significantly from a hypothetical 50% reference rate (p = 0.64). MODS developed in 30% of cases and showed a trend toward lower prevalence compared to 50%, though this did not reach significance (p = 0.07). Acute kidney injury (AKI) occurred in 35% of patients, slightly higher than a referenced 25% rate but not statistically significant (p = 0.19). Regarding local complications, pancreatic fistula was seen in 25% of patients, and wound infection was relatively common at 40%; neither differed significantly from reference proportions (p = 0.57 and p = 0.37 respectively). Intra-abdominal bleeding was documented in 15% of cases, while persistent or residual necrosis affected 20%. Rates of these complications did not significantly diverge from expected frequencies. Re-surgery was required in 15% of patients, mainly due to persistent sepsis or inadequate drainage, but again without statistical significance (p = 0.57). Table 3: Mortality & Factors Associated With Adverse Outcomes (N = 20) Variable Survivors (n = 14) Non-survivors (n = 6) Test & Effect Size 95% CI p-value Age (years) 46.9 ± 10.2 52.8 ± 12.4 t = -1.15 -15.4 to 3.5 0.27 Male sex 9 (64.3%) 4 (66.7%) χ² = 0.02 - 0.89 >50% necrosis 3 (21.4%) 4 (66.7%) Risk diff = -45.3% -78.1% to -8.9% 0.036* Organ failure at baseline 6 (42.9%) 5 (83.3%) Risk diff = -40.4% -73.5% to -1.6% 0.041* AKI 3 (21.4%) 4 (66.7%) Risk diff = -45.3% -78.1% to -8.9% 0.036* Sepsis 5 (35.7%) 4 (66.7%) Risk diff = -31.0% -66.8% to 11.0% 0.13 Mean CRP (mg/L) 184.9 ± 36.2 222.7 ± 41.4 t = -2.02 -75.4 to -0.2 0.049* Mean WBC (×10⁹/L) 15.4 ± 2.8 18.9 ± 3.7 t = -2.27 -6.6 to -0.3 0.034* Mortality Rate - 6/20 (30.0%) One-sample z vs 20% (z = 1.12) 12.8% - 54.3% 0.26 Table 3 compares survivors (n = 14) and non-survivors (n = 6) to identify factors associated with mortality. Although the mean age was higher in non-survivors (52.8 years vs. 46.9 years), this difference was not statistically significant (p = 0.27). Sex distribution was comparable between groups (p = 0.89). However, the extent of necrosis showed a significant association with mortality: 66.7% of non-survivors had >50% necrosis compared with only 21.4% of survivors (p = 0.036). Baseline organ failure was also strongly associated with death, being present in 83.3% of non-survivors versus 42.9% of survivors (p = 0.041). AKI exhibited a similar pattern, affecting 66.7% of non-survivors compared to 21.4% of survivors (p = 0.036). Although sepsis was more common among non-survivors (66.7% vs. 35.7%), the difference did not reach significance (p = 0.13). Inflammatory markers were significantly elevated among non-survivors: CRP levels (222.7 ± 41.4 mg/L) and WBC counts (18.9 ± 3.7 ×10⁹/L) were significantly higher than those of survivors (p = 0.049 and p = 0.034 respectively). The overall mortality rate in the cohort was 30%, which did not significantly differ from a reference 20% mortality rate in similar severe cases (p = 0.26). Table 4: ICU Stay, Hospital Stay & Recovery Profile (N = 20) Parameter Mean ± SD / n (%) Test of significance 95% CI p-value ICU stay (days) 9.4 ± 3.8 One-sample t vs 8 days (t = 1.52) 7.6 - 11.2 0.14 Hospital stay (days) 28.7 ± 9.2 One-sample t vs 25 (t = 1.76) 24.0 - 33.4 0.095 Ventilator support 7 (35.0%) One-sample z vs 25% (z = 1.12) 18.1% - 56.7% 0.26 Time to start enteral feeding (days) 4.6 ± 1.3 One-sample t vs 5 (t = -1.34) 3.9 - 5.3 0.20 Return of bowel activity (days) 3.2 ± 0.9 One-sample t vs 3 (t = 0.99) 2.7 - 3.7 0.33 Ambulation by day 5 12 (60.0%) One-sample z vs 50% (z = 0.89) 38.7% - 78.9% 0.37 Discharge rate among survivors 14 (70.0%) One-sample z vs 60% (z = 0.73) 47.7% - 85.4% 0.46 Table 4 summarizes the postoperative recovery profile of the patients. The mean ICU stay was 9.4 ± 3.8 days, slightly longer than the referenced 8-day benchmark, though this difference was not statistically significant (p = 0.14). The total hospital stay averaged 28.7 ± 9.2 days, reflecting the prolonged recovery associated with severe necrotizing pancreatitis, but again failed to reach statistical significance when compared with a 25-day reference (p = 0.095). Ventilator support was required in 35% of patients, which was higher than an expected 25% rate but statistically nonsignificant (p = 0.26). Nutritional recovery markers were acceptable, with enteral feeding initiated at a mean of 4.6 ± 1.3 days and bowel activity returning by 3.2 ± 0.9 days, both nonsignificant compared to their respective reference values (p > 0.20). Functional recovery was moderately good, with 60% of patients ambulating by day 5, and 70% of survivors ultimately being discharged, neither reaching statistical significance.

The baseline profile of patients in the present study (Table 1) shows a mean age of 48.7 years with a male preponderance (65%). This is broadly comparable to contemporary necrotizing pancreatitis series, although our cohort appears slightly older than patients reported by Maatman TK et al.(2020)[5] (mean age 41.5 years, 75 males and 37 females). The modest male predominance aligns with most reports where alcohol and gallstones are leading etiologies. In our series, gallstones (40%) and alcohol (35%) were the main causes, similar to mixed-etiology cohorts described in laparoscopic and open necrosectomy literature. The extent of necrosis was substantial, with 35% of patients exhibiting >50% necrosis and 45% having 30-50% necrosis, a severity profile comparable to high-risk populations in the Dutch PANTER trial, where extensive necrosis and organ dysfunction were common entry criteria. More than half of our patients (55%) had organ failure at baseline and mean inflammatory markers (CRP 196 mg/L, WBC 16.8×10⁹/L) were markedly raised, indicating a severely ill group, similar to those described in open or hybrid necrosectomy series where multi-organ dysfunction is frequent. Postoperative morbidity (Table 2) in the present study was considerable, with systemic complications like sepsis (45%), MODS (30%), and AKI (35%), and local complications including pancreatic fistula (25%), wound infection (40%), and residual necrosis (20%). These figures are higher than those reported in minimally invasive cohorts. Lee PJ et al.(2020)[6] observed relatively low wound-related complications and acceptable reoperation and mortality rates following laparoscopic and retroperitoneoscopic necrosectomy, with mean hospital stay around 8 days and no major wound problems. Similarly, Latif J et al.(2022)[7] described a multicentre cohort undergoing surgical transgastric necrosectomy with shorter postoperative stay (median 8 days) and relatively controlled morbidity compared to traditional open techniques. A study by Facciorusso A et al.(2022)[8] reported that endoscopic step-up strategies were associated with lower odds of new-onset organ failure and pancreatic fistula and shorter hospital stay when compared with surgical approaches. In contrast, the higher rate of local and systemic complications in our series likely reflects both the higher proportion of patients with extensive necrosis and the predominant use of open surgical necrosectomy in a low-volume, resource-limited setting. When mortality and its determinants are examined (Table 3), the overall mortality rate of 30% in the present study is higher than in many modern step-up or minimally invasive series, where reported mortality often ranges between 10-20%[2,4,6]. However, this figure is comparable to historic open necrosectomy results and to high-risk subgroups with extensive necrosis and organ failure. In our cohort, >50% necrosis, baseline organ failure and AKI were all significantly associated with death, and non-survivors had significantly higher CRP and WBC levels. These findings parallel those of the Dutch PANTER trial, which demonstrated that open necrosectomy was associated with more organ failure and morbidity than a step-up approach, despite similar mortality. Smits FJ et al.(2022)[9], using a nationwide sample, also noted that open necrosectomy carried more multi-organ failure complications, while fistula formation varied by modality. Kao LS et al.(2020)[10] further highlighted that endoscopic step-up methods, though not always reducing overall mortality, significantly decreased serious complications such as pancreatic/enteric fistula and intra-abdominal bleeding. Thus, the pattern in our study higher mortality closely linked to extensive necrosis and pre-existing organ dysfunction is consistent with the broader literature showing that disease severity and systemic compromise are major drivers of poor outcomes, particularly when open surgery is required. The recovery profile (Table 4) also underscores the burden of severe disease and open surgery in a low-volume tertiary centre. The mean ICU stay of 9.4 days and total hospital stay of 28.7 days in our patients are substantially longer than those reported in minimally invasive or endoscopic series, where postoperative stays of around 8-10 days are common. Endoscopic and dual-modality drainage strategies have been shown to significantly reduce hospital stay, drain duration, radiological procedures and healthcare utilization compared with standard percutaneous drainage or open surgery. In our study, 35% of patients required ventilator support and only 60% could ambulate by day 5, while 70% of survivors were eventually discharged. These figures suggest prolonged critical care needs and slow functional recovery relative to series dominated by minimally invasive or transgastric necrosectomy techniques, where quicker return of bowel function and earlier mobilization are often reported.

The present prospective evaluation demonstrates that surgical necrosectomy remains a vital, life-saving intervention for patients with acute infective necrotizing pancreatitis in low-volume tertiary care settings, where access to advanced minimally invasive or endoscopic step-up techniques is limited. The study population consisted predominantly of patients with moderate-to-severe necrosis, marked systemic inflammation, and a high prevalence of baseline organ failure, all of which contributed to substantial postoperative morbidity. Although surgical necrosectomy provided definitive source control in most patients, morbidity such as sepsis, AKI, pancreatic fistula, and prolonged hospitalization was common. The overall mortality rate of 30% reflects the severe disease burden and the complex physiological derangements associated with infected pancreatic necrosis. Key predictors of mortality in this cohort included >50% pancreatic necrosis, baseline organ failure, acute kidney injury, and elevated inflammatory markers (CRP and WBC). These findings are consistent with global evidence indicating that disease severity rather than the choice of surgical approach alone is the major determinant of outcome in necrotizing pancreatitis. Despite the greater morbidity associated with open necrosectomy compared with step-up approaches, it remains the most feasible option in many resource-constrained environments and continues to offer meaningful survival benefits when appropriately timed and carefully executed. Strengthening perioperative critical care, early recognition of organ dysfunction, and standardized postoperative care pathways may further improve outcomes in similar low-resource settings. LIMITATIONS OF THE STUDY 1. Small sample size (n = 20): The limited number of patients reduces the statistical power of the analysis and restricts subgroup comparisons, especially for mortality and rare complications. 2. Single-centre, low-volume setting: Findings may not be fully generalizable to high-volume centres with greater access to minimally invasive or endoscopic necrosectomy, advanced ICU support, or interventional radiology facilities. 3. Lack of comparison group: The study does not include a minimally invasive, endoscopic, or step-up cohort, limiting the ability to directly compare outcomes with alternative management strategies. 4. Potential selection bias: Only patients requiring surgical necrosectomy were included; those responding to percutaneous drainage or conservative therapy were not studied, possibly skewing results toward more severe cases. 5. Short-term outcome assessment: The study focused primarily on in-hospital and early postoperative outcomes. Long-term sequelae such as endocrine/exocrine insufficiency and quality of life were not evaluated. 6. Variability in perioperative care: Resource limitations and variable ICU monitoring may have influenced morbidity and mortality outcomes but could not be standardized or controlled for.

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