Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

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OBJECTIVE:To present our experience in the management of patients with infected pancreatic necrosis without drainage.METHODS:The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed.RESULTS:We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died.CONCLUSIONS:In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

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Four months after giving birth to her third child, a 24-year-old woman had a copper T intrauterine device (IUD) inserted, without any discomfort. One month later, confirmatory ultrasound demonstrated that the device was correctly positioned. Six months later, the patient presented with a missed menstrual cycle, and a transvaginal ultrasound identified a gestational sac but the IUD was not seen. Cesarean delivery was subsequently performed because of cephalopelvic disproportion; the IUD was not found and it was presumed to have been expelled prior to conception. Three months later, the patient presented with pain in her left hip joint, and an X-ray revealed the IUD in her lower abdomen.The patient underwent diagnostic laparoscopy and the IUD string was located protruding from the sigmoid colon. The contour of the IUD could be visualized when the string was pulled (Fig. 1). Surgeons were unable to perform an intraoperative colonoscopy, which would have allowed the IUD to be pulled through the colon, without bowel preparation. Because the patient had minimal symptoms, it was decided not to remove the involved portion of the sigmoid colon. The IUD string was cut off to try to avoid adhesion formation and minimize the risk of perforation.The patient was subsequently prepared for colonoscopy but the IUD could not be visualized. The device probably dissected the colon wall 0020-7292/$ -see front matter