When Step-Up Escalates: Infected Necrotizing Pancreatitis with Colonic Ischemia Requiring Staged Reconstruction

Background

Infected necrotizing pancreatitis carries substantial morbidity and is usually managed with a step-up strategy, beginning with drainage and reserving surgery for patients who fail less invasive therapy. Progressive sepsis and bowel complications may require earlier operative source control.

Case Presentation

A 25-year-old woman developed severe gallstone pancreatitis complicated by acute hypoxemic respiratory failure and acute kidney injury. She underwent laparoscopic cholecystectomy and was later readmitted with fever, dyspnea, leukocytosis, persistent abdominal pain, and an enlarging pancreatic fluid collection. Endoscopic ultrasound-guided cystogastrostomy with placement of a lumen-apposing metal stent was performed for drainage. Despite this, her condition worsened, raising concern for infected pancreatic necrosis. Exploratory laparotomy revealed extensive infected necrotic pancreatic tissue with colonic involvement. Pancreatic debridement, left hemicolectomy, splenectomy, and temporary abdominal closure with negative-pressure therapy were performed. Because bowel viability remained a concern, a planned re-exploration was undertaken. At the second operation, the laparotomy packs were removed and the bowel was reassessed. New ischemia of the transverse colon was identified, requiring transverse colectomy with stapled transverse-to-sigmoid colocolostomy. After washout and drain placement, definitive fascial closure was achieved. She remained in the intensive care unit on mechanical ventilation with ongoing management by surgery, gastroenterology, pulmonary/critical care, and infectious disease. Follow-up imaging showed interval improvement of the pancreatic collection.

Discussion

This case demonstrates how severe necrotizing pancreatitis can progress despite appropriate endoscopic drainage. The development of colonic ischemia changed the clinical problem from one of drainage alone to one requiring operative source control. Planned re-exploration was particularly important because it allowed reassessment of bowel viability and recognition of ischemia that had evolved after the initial operation.

Conclusion

The step-up approach remains appropriate for infected necrotizing pancreatitis, but it should not delay surgery when sepsis persists, or bowel ischemia develops. In selected patients, temporary abdominal closure with planned re-exploration can provide time for physiologic stabilization, repeated assessment of bowel viability, and safer delayed reconstruction.