Pancreatic fistulas

Abstract

Pancreatic fistula is defined as an abnormal communication between the pancreatic ductal system and adjacent or remote epithelial surfaces containing pancreas-derived, enzyme-rich fluid. The cause of this abnormal communication is pancreatic ductal leak (pancreatic leak). The leak may originate from the major pancreatic duct or from side branches. Pancreatic leaks develop in the course of acute or chronic disease or manifest as iatrogenic complications. Pancreatic fistula may complicate the course of acute or chronic pancreatitis, blunt or penetrating abdominal trauma, pancreatic injury caused during pancreatectomy, gastrectomy, splenectomy, or other surgical procedures performed at the vicinity. Leaking pancreatic juice initially forms a peripancreatic fluid collection, which later evolves to either internal or external fistula. Internal fistulas include pancreatic ascites, pancreatic pseudocysts, and high amylase pleural effusion. Sometimes, the collection erodes into neighboring hollow viscera, leading to pancreatico-splanchnic (gastric, enteric, colonic, bladder) fistula. External fistulas develop after a tract to the skin is formed. This occurs either spontaneously or more frequently after a drain is placed, be it percutaneous or surgical. The present chapter will mainly focus on external, postoperative fistulas. A small leak from a side branch will usually heal fast and uneventfully. On the other hand, a persistent main pancreatic duct disruption leads to significant consequences and prolonged morbidity. The traditional treatment algorithm encompasses conservative treatment, including drainage, antibiotics, bowel rest, nutritional, fluid, and electrolyte support. This approach is effective with most low-volume leaks. Traditionally, surgical treatment is considered as the treatment of choice for persistent or complicated leaks. However, in recent years there is a trend toward aggressive endoscopic treatment as a surgery sparing, minimally invasive approach.