STANFORD MULTIDISCIPLINARY SEMINARS Getting the Dead Out: Modern Treatment Strategies for Necrotizing Pancreatitis Monica M. Dua • David J. Worhunsky • Sabina Amin • John D. Louie • Walter G. Park • George Triadafilopoulos • Brendan C. Visser Ó Springer Science+Business Media New York 2014 Case Presentation and Evolution A 21-year-old male was brought to the emergency department with severe abdominal pain and vomiting. Low-grade fever and epigastric tenderness were noted on examination; laboratory values included a WBC of 11 K/lL and elevated amylase and lipase to 1,593 and [ 3,000 U/L, respectively. A CT scan was interpreted as showing an enlarged and ill-defined pancreas with hetero- geneous parenchymal enhancement, consistent with pan- creatitis. Several peripancreatic fluid collections extended bilaterally to the para-renal spaces, left para-colic gutter, and pelvis (Fig. 1). An ultrasound of the gallbladder was normal with no gallstones visualized. The patient had no other contributory past medical or social history. He was admitted to the medical service and initially developed a systemic inflammatory response (SIRS) to his idiopathic pancreatitis, with fever, tachycardia, and a white count peak to 16 K/lL. After several days of intravenous fluid resuscitation and bowel rest, he improved and was dis- charged home 10 days later tolerating a regular diet. One week after discharge, the patient returned for an outpatient visit where he reported intermittent low-grade fevers and decreased appetite; he was able to tolerate only 50–60 % of his meals. Three days later (20 days after initial episode of pancreatitis), he returned to the emer- gency department for severe abdominal pain, vomiting, and dehydration. He was febrile and tachycardic with repeat CT scan interpreted as showing extensive pancreatic and peripancreatic necrosis, with acute necrotic collections (ANCs) extending to the spleen and tracking along the left paracolic gutter and retroperitoneum (Fig. 2). Bilateral pulmonary emboli were noted on CT scan, including an embolus within the right main pulmonary artery. A trans- thoracic echocardiogram demonstrated resultant right heart strain, and he was taken immediately to interventional radiology for thrombectomy and catheter-directed throm- bolytic therapy; however, toward the end of the procedure, the patient suffered cardiogenic shock and cardiac arrest requiring resuscitative efforts and extracorporeal mem- brane oxygenation (ECMO). He had ensuing coagulopathy, and a hematocrit drop to 18 % that prompted a CT angiogram. Interval hemorrhage into the peripancreatic fluid collection was noted with no identifiable source; therefore, no intervention was required beyond transfusion. Ultimately, the patient spent the next 6 weeks in the hos- pital recovering. With respect to his necrotizing pancrea- titis, although it was anticipated that intervention would likely be required for the extensive necrosis, given his recent cardiac events and clinical improvement over the hospitalization, treatment was deferred as long as the patient was asymptomatic and tolerating a regular diet, in order to maximize his nutritional status and his clinical status. Two weeks after discharge, he returned to the surgery clinic reporting fevers to 102 °F and left flank pain. A CT scan (11 weeks after initial episode of pancreatitis) dem- onstrated interval development of gas within the fluid M. M. Dua Á D. J. Worhunsky Á B. C. Visser (&) Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA 94305, USA e-mail: bvisser@stanford.edu S. Amin Á J. D. Louie Department of Radiology, Stanford University Medical Center, Stanford, CA 94305, USA W. G. Park Á G. Triadafilopoulos Department of Medicine, Stanford University Medical Center, Stanford, CA 94305, USA 123 Dig Dis Sci DOI 10.1007/s10620-014-3153-z