Surgery for necrotizing acute pancreatitis: surgical approach, morbidity and challenges encountered: experience from a tertiary care hepatopancreatobiliary unit in Sri Lanka

Background: Infected pancreatic necrosis (IPN) remains a life-threatening complication of acute pancreatitis. While minimally invasive "step-up" strategies are now standard, their implementation in resource-limited settings is often constrained by availability of interventional radiology, advanced endoscopy, and intensive care support. This study describes management pathways, morbidity, and outcomes of surgically treated IPN in a tertiary hepatopancreatobiliary (HPB) unit operating under such limitations. Methods: A retrospective analysis of prospectively maintained data was performed on patients who underwent surgical necrosectomy for IPN between 2015 and 2021. Management followed a step-up philosophy where feasible, incorporating antibiotics, image-guided or endoscopic drainage, and delayed surgery. Clinical characteristics, interventions, complications, and outcomes were analysed descriptively. Results: = 2). All patients ultimately required open necrosectomy due to persistent sepsis or failure of less invasive measures. Early morbidity was substantial, with organ failure occurring in 83.3%, including acute respiratory distress syndrome in 66.6%. Clinically relevant postoperative pancreatic fistula occurred in 50%, and incisional hernia developed in all patients during follow-up. Median ICU and hospital stays were 17.3 and 58.5 days respectively. There was one mortality (16.6%). Conclusion: In resource-limited environments, the step-up approach to IPN is frequently constrained by service availability rather than intent. Open necrosectomy remains an essential salvage strategy when minimally invasive interventions are unavailable or unsuccessful, but is associated with significant morbidity. Careful patient selection, delayed intervention, and multidisciplinary management are critical to achieving acceptable outcomes.