Walled-off pancreatic necrosis: a staged multidisciplinary step-up approach

Walled-off pancreatic necrosis (WOPN) is a rare complication of pancreatitis. We present the case of a woman in her eighties admitted for diffuse abdominal pain. She had a palpable abdominal mass and the CT scan showed necrosis throughout the tail of the pancreas, a peripancreatic and retrogastric hydroaerial collection (19cm of diameter) and a calculus in the main biliary duct, thus establishing a diagnosis of emphysematous necrotising obstructive pancreatitis. A step-up approach was decided, first with removal of the biliary calculus, followed by a waiting period of 4 weeks in which the patient was under intravenous antibiotics. At re-evaluation, the CT scan showed a smaller and more organised collection, bounded by a wall, defining WOPN. At this stage, transgastric drainage via echoendoscopy was attempted, without success, followed by percutaneous CT-guided drainage, also with little effect. Surgical necrosectomy was then executed, as a final step, with a successful outcome.