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The aim of the percutaneous approach is to improve the patient’s condition and to delay surgery until IPN is well defined (walled‐off necrosis, or WON). Necrosis demarcation facilitates necrosectomy and reduces complications related to drainage and debridement. Although there is some evidence of the safety of drainage placement in the absence of WON, instauration of the necrosis is normally preferred before performing any interventionism, so that it has become the standard practice for some years.

In 1998, Freeny et al. [17] first reported positive results using percutaneous drains inserted under radiological control for initial IPN management. They found that subsequent surgery was avoided in 47% of the cases and sepsis controlled in 74%. Successive studies describe a similar technique, namely inserting computed tomography (CT)‐ or ultrasound‐guided percutaneous drains of 8–28 Fr to evacuate infected peripancreatic collections, combined with antibiotics. Neither the size nor the number of drains seems to affect patient outcomes [18]. Multiple drains may be needed to replace previous ones in order to increase the inserted catheter diameters and saline flushes are often applied at 8‐hour intervals. A recent systematic review of 286 patients found that percutaneous drainage was successful in 44% of the patients without requiring necrosectomy [18], while only 35% of the patients in the PANTER trial had no need for further interventions after this procedure [14]. The clinical response should be assessed 72 hours after placement of the first drain to assess whether a second is required [14]. Similarly, there is no clear consensus on the timing of drainage placement, but most studies recommend the second and third weeks from onset of symptoms, before WON [19]. Questions have been raised about the usefulness of the drain in the early stages of the disease and whether it can prevent later complications such as pancreas fistula or bleeding. In this regard, an ongoing randomized clinical trial (POINTER) is being carried out to determine whether immediate drainage is more effective than postponing intervention [20].

The secondary goal of this strategy is to chart a path for use as a guide when locating the anatomical space to be drained, which is the preliminary step for further procedures, should the conservative treatment fail (see following chapters) [21].