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| ==[[Pancreatic fistula overview|Overview]]== | | ==[[Pancreatic fistula overview|Overview]]== |
| A [[pancreatic]] [[fistula]] is an abnormal connection between the epithelialized surfaces of the [[pancreatic duct]] and adjacent or distant structures, [[organs]] or [[cavities]].
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| Clinical criteria defined by the International Study Group for [[Pancreatic]] [[Fistula]] (ISGPF) is a measurable [[Drain (surgery)|drain]] output containing [[pancreas]]-derived [[enzyme]] [[amylase]] which is greater than three times the upper limit of the normal serum level measured on or after postoperative day three.
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| A revised grading for [[pancreatic]] [[fistula]] was proposed by ISGPF, according to which [[pancreatic]] [[fistula]] is graded either into a new category which involve an [[asymptomatic]] leakage from the [[pancreas]] called [[biochemical]] leak (BL), or Grade B including patients who undergo [[surgical procedures]] such as [[percutaneous]] or [[endoscopic]] drainage or [[angiographic]] procedures in order to promote the healing of [[fistula]] and Grade C including patients with [[organ failure]] requiring reoperations and [[mortality]] as a result of complication from [[pancreatic]] [[fistula]].
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| ==[[Pancreatic fistula historical perspective|Historical Perspective]]== | | ==[[Pancreatic fistula historical perspective|Historical Perspective]]== |
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| ==[[Pancreatic fistula classification|Classification]]== | | ==[[Pancreatic fistula classification|Classification]]== |
| [[Pancreatic]] [[fistula]] can be classified anatomically as;
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| *[[Internal]] [[fistula]]: The [[pancreatic duct]] communicates with [[internal organs]] or [[body cavity]] such as [[Pleural cavity|pleural]] or [[peritoneal]] [[cavity]].
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| *External [[fistula]]: The [[pancreatic duct]] communicates with the [[skin]], otherwise known as pancreaticocutaneous [[fistula]].
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| Pancreatic fistula can also be classified based on the [[anatomy]] of the [[pancreatic duct]] and the location of [[injury]] as;
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| *Type 1 [[pancreatic]] [[fistula]]: Involves [[injury]] to the [[pancreatic]] [[parenchyma]] with leakage from the [[distal]] part of the [[pancreatic duct]] or the side branches.
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| *Type 2 [[pancreatic]] [[fistula]]: Involves [[injury]] to and leak from the main [[pancreatic duct]].
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| *Type 3 [[pancreatic]] [[fistula]]: Occurs as a result of [[proximal]] or [[distal]] [[pancreatectomy]].
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| [[Pancreatic]] [[fistula]] is classified into two categories on the basis of [[clinical]] manifestations, [[complications]] and severity by the ISGPF as;
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| *[[Biochemical]] [[pancreatic]] [[fistula]]: This category includes fistula with no significant [[clinical]] [[symptoms]].
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| *Clinically relevant [[pancreatic]] [[fistula]]: This category includes [[fistulas]] under grade B and C, which shows significant clinical [[symptoms]] and require surgical [[interventions]], re-surgeries and can complicate into [[organ failure]] and death.
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| ==[[Pancreatic fistula pathophysiology|Pathophysiology]]== | | ==[[Pancreatic fistula pathophysiology|Pathophysiology]]== |
| The [[pathophysiology]] of [[pancreatic]] [[fistula]] involves the disruption of the [[pancreatic duct]] either from an [[iatrogenic]] insult, underlying [[inflammatory process]] or [[trauma]]. The disruption of the [[pancreatic duct]] causes gradual loss of the integrity of the tissue resulting in the leakage of the [[pancreatic]] [[fluid]] which induces [[inflammation]] and erosions, thereby leading to the formation of abnormal connections between the [[duct]] and the surrounding structures.
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| ==[[Pancreatic fistula causes|Causes]]== | | ==[[Pancreatic fistula causes|Causes]]== |
| [[Pancreatic]] [[fistula]] can result from different types of insults such as;
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| *[[Iatrogenic]]: External [[pancreatic]] [[fistula]] is most commonly [[iatrogenic]] in [[etiology]]. [[Trauma]] to the [[duct]] during [[surgery]] such as [[pancreaticoduodenectomy]], [[distal]] [[pancreatectomy]], during [[endoscopic]] intervention, [[extraction]] of a [[biopsy]] sample, [[pancreatic]] [[resection]] or as a complication of drainage of [[pancreatic pseudocyst]].
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| *Non-iatrogenic: Includes [[pathology]] of the [[gland]] such as [[acute]] or [[chronic pancreatitis]] or [[trauma]] to the [[abdominal]] structures or [[organs]] leading to [[fistula]] formation.
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| ==[[Pancreatic fistula differential diagnosis|Differentiating Pancreatic fistula from other Diseases]]== | | ==[[Pancreatic fistula differential diagnosis|Differentiating Pancreatic fistula from other Diseases]]== |
| [[Differential diagnosis]] of a [[pancreatic]] [[fistula]] may include evaluation for:
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| #[[Chronic liver disease]] leading to [[abdominal]] [[ascites]]
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| #[[Renal failure]]
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| #[[Heart failure]]
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| #[[Malignancy]]
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| #Conditions leading to [[pleural effusion]] such as [[malignancy]], [[trauma]] and [[infections]]
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| #[[Pancreatitis]]
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| #[[Retroperitoneal bleeding]]
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| #[[Bowel ischemia]]
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| ==[[Pancreatic fistula epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Pancreatic fistula epidemiology and demographics|Epidemiology and Demographics]]== |
| Pancreatic fistula is a known complication following surgical resection of the pancreas. The incidence rate varies from as low as 5% in high volume centers to as high as 26%. Acute fluid collection is recorded in up to 40% patients with acute pancreatitis, out of which some cases develops true pancreatic fistula depending upon the severity of the insult. Post-operative pancreatic fistulae can affect 13% to 41% of patients after pancreatic resection, making it a known source of morbidity and mortality. Pancreatic fistula can lead to certain severe complications if not addressed on time, as it carries a mortality risk of 25% in patients with grade C pancreatic fistula. The overall mortality rate is 1%. The incidence of pancreatic fistula varies depending on the type of pancreatic resection as it can be as low as 3% following a pancreatic head resection to as high as 30% after distal pancreatectomy.
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| ==[[Pancreatic fistula risk factors|Risk Factors]]== | | ==[[Pancreatic fistula risk factors|Risk Factors]]== |
| According to Fistula Risk Scoring (FRS) system, the risk factors for the development of pancreatic fistula depends upon:
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| *Texture of the gland: Soft texture of the gland is identified as a predictive risk factor.
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| *Pathology of the gland: Carcinoma of the duodenum, ampulla, cystic duct and islet cell carries high risk for fistula development compared to the glandular carcinoma such as pancreatic ductal adenocarcinoma or chronic pancreatitis.
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| *Diameter of the pancreatic duct: Small pancreatic duct diameter <3mm is identified as a risk factor for the development of fistula formation, specifically a diameter of <1mm carries a high risk.
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| *Intraoperative blood loss: >1000ml is associated with a high risk of fistula formation.
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| *Other risk factors may include male gender, excessive fluid administration during surgery, fasting blood glucose <108 mg/dl and an increase remnant gland volume. Some studies have reported both malnutrition and obesity as risk factors for the development of pancreatic cancer.
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| ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | | ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| History and clinical presentation depends upon the size, location and connection of the pancreatic fistula with the involved organ or cavity.
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| Clinical presentation may range from being asymptomatic to showing a variety of signs and symptoms resulting from fluid accumulation such as nausea, vomiting, hypotension, infection, tachycardia, pain, weight loss, ileus and severe symptoms such as unrelenting pain and sepsis.
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| External pancreatic fistula presents with pancreatic fluid accumulation noticeable on the skin surface.
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| Internal pancreatic fistula may present with ascites or pleural effusion as fluid accumulates within the abdominal or thoracic cavity.
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| Complications arising from a pancreatic fistula are due to the undrained pancreatic fluid accumulation and erosions caused by the enzymatically active substances of the fluid which affects the surrounding tissues. The most commonly observed complications are:
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| #Wound infection and sepsis
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| #Hemorrhage
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| #Internal and/or external fistula
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| #Pancreatic pseudocyst
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| #Delayed gastric emptying
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| #Walled off pancreatic necrosis
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| #Prolongation of the hospital stay
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| #Pancreatic ascites
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| #High amylase pleural effusion
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| #Disconnected duct syndrome
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| #Multisystem involvement eventually leading to multiorgan failure and/or death.
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| Pancreatic fistula that are less severe are reported to heal in a duration of 4-6 weeks with conservative management only. 80% of the external fistula and 50-65% of the internal fistula are reported to close eventually with conservative measures which involve stabilization of the patient with supportive therapies. However, pancreatic fistula can lead to significant morbidity if not addressed on time. Surgical intervention provides resolution of the fistula with a 90-92% success rate.
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| ==Diagnosis== | | ==Diagnosis== |
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| ===History and clinical presentation:=== | | ===History and clinical presentation:=== |
| A pancreatic fistula with leakage of fluid can be diagnosed in some cases with typical history and clinical presentation, such as patient presenting with pancreatitis followed by recurrence, persistent symptoms or post pancreatic resection fluid drainage with increase amylase level. However, most cases are far more challenging which require imaging techniques and examination of the fluid samples withdrawn from the leak to help diagnose the fistula.
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| ===Imaging:=== | | ===Imaging:=== |
| The imaging techniques used to confirm the diagnosis of pancreatic fistula may include abdominal ultrasound, CT-scan of the abdomen, pancreatogram, endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) and fine needle aspiration of the fluid using endoscopic ultrasound (EUS). ERCP can be used for both diagnosis and therapeutic purposes such as placement of stent during the procedure to facilitate the closure of fistula.
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| ===Laboratory tests:=== | | ===Laboratory tests:=== |
| Fluid samples collected via thoracentesis, paracentesis or fluid collected via percutaneous drainage from an external fistula can be analyzed for amylase level, which helps solidify the diagnosis of pancreatic cancer. Complete blood count is necessary to check for any ongoing infection or hemorrhage. Complete metabolic panel including inflammatory markers, serum electrolytes, liver function tests, calcium, albumin, amylase and lipase should be sent to laboratory for evaluation. Furthermore, pancreatic fistula leak presenting as ascites or pleural effusion should be analyzed for fluid protein, albumin, lactate dehydrogenase, glucose, gram cultures and total cell count. To differentiate the ascites or pleural fluid from pancreatic fluid the fluid amylase level will be >1000 u/dl.
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| ==Treatment== | | ==Treatment== |
| Treatment of a pancreatic fistula includes early recognition of the problem which is the key to careful management in order to prevent the consequent complications. Management of pancreatic fistula requires a multidisciplinary team which includes interventional radiologists, endoscopy specialist and surgeons and include the following steps:
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| #Biochemical leak: Patients with biochemical leak are clinically asymptomatic with an amylase rich pancreatic fluid drain and can be managed conservatively. Patients should be kept under observation with close monitoring for signs of complications in order to avoid its progression to clinically relevant pancreatic fistula. The drain placed intraoperatively are usually kept to support the spontaneous closure of the fistula. Drainage output and inflammatory markers such as C-reactive protein and leucocyte count are regularly monitored to prevent fluid collections that may lead to life threatening sequalae.
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| #Grade B or C pancreatic fistula:
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| *Non-Surgical approach: Primary management involves treatment with non-surgical minimally invasive catheter drain placement. Imaging techniques such as CT-scan in combination with interventional drain placement can help resolve peri-pancreatic fluid collection that went unrecognized and developed eventually. Antibiotic treatment is given to prevent abdominal infections. One life threatening condition that may complicate a grade B or C fistula is hemorrhage of a nearby vessel by the enzymatically active pancreatic fluid, which can be promptly evaluated with the help of CT-angiogram to identify the location of the bleeding vessel and can be managed via angiographic placement of a stent or embolization.
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| *Surgical management: Conditions which requires urgent evacuation of large amount of blood that cannot be attained with minimally invasive techniques necessitates surgical interventions which include emergency laparotomy, intra-abdominal lavage and drainage of infected fluid collections widely. Conditions which involves necrosis, life threatening sepsis or complicated pancreatic fistula may require the resection of the remnant pancreas.
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| Supportive care which is proven beneficial for both biochemical leaks and patients who develop sepsis and/or hemorrhage as a complication of pancreatic fistula include stabilizing the patient, pancreatic secretion control, nil per oral by ideally starting temporary parenteral nutrition and correction of the fluid and electrolytes abnormalities. Somatostatin analogs such as octreotide are used commonly to control the pancreatic secretion, however no significant benefit is observed with its use in patients with already established pancreatic fistula.
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| ==Case Studies==
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| [[Pancreatic fistula case study one|Case #1]]
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| [[Category:Organ disorders]] | | [[Category:Organ disorders]] |
| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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| | ==References== |
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| | [[category:Gastroenterology]] |