Infected walled-off pancreatic necrosis with gastric varices and no safe transgastric window
A 51-year-old man with gallstone pancreatitis 5 weeks ago develops fever of 39.1°C, white cell count 21 × 10^9/L and hypotension requiring noradrenaline. CT shows a 12 cm walled-off necrosis in the lesser sac extending into the left paracolic gutter. The collection abuts the posterior gastric wall, but there are prominent gastric varices and splenic vein thrombosis; the stomach is surrounded by varices. Percutaneous transperitoneal access would cross the stomach or colon. A left flank approach is possible, but the collection is deep and there is ascites. He is on meropenem, albumin 24 g/L, platelets 72 × 10^9/L and INR 1.5. The surgical team proposes open necrosectomy. The patient is obese (BMI 38) and has type 2 diabetes. You are asked whether percutaneous drainage is feasible and what approach you would use.
1. Outline the step-up management strategy for infected necrotising pancreatitis and decide whether this patient should undergo immediate open necrosectomy, percutaneous drainage or endoscopic drainage.
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This is infected necrotising pancreatitis with organ failure. The modern approach is the step-up strategy: organ support, antibiotics and drainage first, followed by minimally invasive necrosectomy only if drainage fails. Immediate open necrosectomy carries high mortality and should be avoided unless there is an absolute indication such as abdominal compartment syndrome or bowel ischaemia. Endoscopic transmural drainage is usually attractive for a retrogastric collection, but here the prominent gastric varices make transmural puncture hazardous. Percutaneous drainage is therefore the preferred first step, using a retroperitoneal route if possible. If no safe percutaneous window exists, a multidisciplinary discussion should consider EUS-guided drainage with variceal assessment, laparoscopic or retroperitoneal drainage, or a combined approach in a specialist centre.
2. Which percutaneous route would you choose and why? Include image guidance, drain size and how you would avoid varices and colon.
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Choose a left flank retroperitoneal approach under CT and ultrasound guidance, staying posterior to the colon and lateral to the spleen, and avoiding the stomach and known varices. Use colour Doppler to map varices and choose a trajectory that does not cross them. The collection is deep, so a coaxial technique with a fine needle, guidewire and serial dilatation is safer than a direct large-bore puncture. Place a 12–14 Fr locking drain initially; if the necrosis is thick, consider a second drain or a larger 16 Fr drain. Avoid a transperitoneal route through the stomach or colon because of the risk of fistula and peritonitis. If no safe window is found, do not force a drain; escalate to a specialist multidisciplinary team.
3. What would you do if the patient remains septic after 72 hours despite drainage?
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First check the drain: is it in the collection, is it blocked or displaced, and is there undrained necrosis? Review the CT and consider upsizing or adding a second drain, preferably by the same retroperitoneal route. Send cultures and review antibiotics with microbiology. If drainage is adequate but sepsis persists, proceed to minimally invasive necrosectomy - for example video-assisted retroperitoneal debridement or percutaneous necrosectomy - rather than open laparotomy. The step-up approach does not mean waiting indefinitely; failure to improve after 72 hours is a trigger for escalation. Reassess organ support and nutritional status, and involve surgery, gastroenterology and critical care. Open necrosectomy is reserved for failed minimally invasive approaches or complications such as perforation or bleeding.