Journey through necrotizing pancreatitis - presentation, walled-off necrosis complicated by hemorrhage and infection, transgastric drainage, and resolution
This case is a long and complex journey, and I hope by the end you feel as relieved for the patient as I do!
Sequence of events with key comments:
Day 1-3: necrotizing pancreatitis involving > 50%, which become strikingly more apparent on day 3
Day 30: formation of walled off necrosis
Day 35: hemorrhage, resulting in enlarging collections
Day 90-93: enlarging WON with increasing inflammation and possible air on MRI, concerning for infection.
Day 95-100: percutaneous transgastric drainage of WON. This is a fascinating technique that was extremely effective. Why it works: (a) any leakage of the cyst contents around the drain goes right into the stomach, and (b) following drain removal, if there is persistent communication of the drained collection with the pancreatic duct (as was likely by the pancreatic tail), it has a fistulous tract into the stomach mimicking a surgical cystogastrostomy, preventing the formation of a pancreaticocutaneous fistula1. Perhaps surprisingly, the patients can eat with this in place!
Day 125: temporary conversion of the drain into a gastrostomy tube, in order to allow the gastrostomy tract to mature prior to tube removal.