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Pancreatic drainage should be avoided in the early phase of the disease (first two weeks) and should be optimally delayed for four weeks when a mature wall has developed. Drainage of infected WON is effective in 35–70% of cases without the need for an additional necrosectomy [11,17].

Figure 14.2 CT scan of a patient with infected walled‐off necrosis after placement of a transgastric lumen apposing metal stent (short arrows) and a 7 Fr tube deep in the collection for local antibiotic infusion (long arrows).

Source: courtesy of J.E. Domínguez‐Muñoz.

Drainage of infected necrosis can be performed either endoscopically (endoscopic ultrasound guided) or percutaneously (CT guided). If drainage fails to treat infected necrosis, endoscopic drainage is followed by endoscopic necrosectomy, and percutaneous drainage is followed by laparoscopic necrosectomy according to the step‐up approach. Both approaches have been shown to be equally effective in terms of major complications or death, although the endoscopic approach is associated with less pancreatic fistulas and shorter hospital stay [17].

Based on a previously reported theoretical approach to local infusion of antibiotics for infected pancreatic necrosis [21], we have recently developed a protocol that combines local antibiotic therapy delivered via a single‐pigtail 7–8.5 Fr naso‐cystic tube with systemic antibiotics and endoscopic drainage for infected WON (Figure 14.2). This method may reduce the need for necrosectomy by increasing the antibiotic concentration in the necrotic tissue. The efficacy of this approach should be tested in randomized controlled trials.

Figure 14.3 Step‐up approach for the management of infected pancreatic necrosis. EUS, endoscopic ultrasound.

Although evidence favoring either metal or plastic stents for EUS‐guided endoscopic drainage of infected WON is lacking [35], lumen apposing metal stents (LAMS) are generally preferred in order to facilitate endoscopic necrosectomy if needed [36]. LAMS should be removed as soon as the collection resolves in order to minimize the risk of complications, mainly bleeding, migration, and stent occlusion [37].

Together with anatomical factors (location and extent of the necrosis), the decision about whether to drain infected WON endoscopically or percutaneously should be based on clinical expertise. In addition, the combination of percutaneous and endoscopic drainage should be considered for patients with WON that extends into the paracolic gutters and pelvis [36].