Introduction Surgical drains are crucial in postoperative management to prevent complications such as fluid collections and abscess formation. However, they carry risks like migration or erosion into adjacent organs, leading to serious consequences like gastric outlet obstruction. This case highlights the complexities of managing a surgical drain eroding into the duodenum following interventions for gallstone pancreatitis.

Case Description A 76-year-old male with a history of benign prostatic hyperplasia, hypertension, gastroesophageal reflux disease, and recent gallstone pancreatitis presented to the ED with persistent vomiting and intolerance to oral intake. Initial assessment showed tachycardia, hypotension, and hypoxemia. He had undergone a laparoscopic cholecystectomy converted to open subtotal cholecystectomy and pancreatic necrosectomy 50 days earlier, with a Jackson-Pratt (JP) drain placed for purulent fluid management. He presented with worsening symptoms, including abdominal pain, purulent JP drain output, and a 30-pound weight loss. Severe protein-calorie malnutrition was noted, and total parenteral nutrition (TPN) was started. Lab findings indicated anemia of chronic disease. CT imaging revealed gastric dilation, duodenal narrowing, and wall thickening suggesting gastric outlet obstruction from postoperative sequelae or pancreatitis inflammation. Additional findings included esophagitis, walled-off necrosis, and infected collections around the pancreas. Endoscopies on days 3 and 10 identified severe esophagitis and JP drain migration into the duodenum, causing obstruction. The drain was repositioned, resolving the obstruction and allowing diet progression. By day 14, an upper GI study confirmed no duodenal leaks, enabling a transition to a regular diet and discharge on day 16.

Discussion This case underscores the complexities of managing surgical drain complications following extensive interventions for severe gallstone pancreatitis. The patient's history and surgical interventions predisposed him to drain-related complications due to extensive tissue manipulation and inflammatory responses. Endoscopic interventions were crucial for repositioning the drain and resolving the obstruction, highlighting advanced endoscopic techniques' evolving role. Despite advancements, drain migration remains a concern, emphasizing the need for vigilant postoperative monitoring and early intervention. The patient's malnutrition and anemia added complexity to his recovery, with TPN playing a crucial role in optimizing outcomes. Recent studies advocate for minimally invasive techniques for necrotizing pancreatitis, showing improved outcomes and reduced complications. Early intervention in pancreatic fluid collections may improve outcomes without increasing morbidity, challenging previous delayed intervention paradigms. This case emphasizes conservative management and interdisciplinary teamwork in achieving favorable outcomes. Standardized protocols for prevention, early detection, and optimal management are crucial, along with continued research to refine techniques and establish evidence-based guidelines for high-risk scenarios.