Pancreatic fistula: Difference between revisions
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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: | |||
Texture of the gland: Soft texture of the gland is identified as a predictive risk factor. | |||
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. | |||
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. | |||
Intraoperative blood loss: >1000ml is associated with a high risk of fistula formation.<ref name="pmid29588609">{{cite journal| author=Nahm CB, Connor SJ, Samra JS, Mittal A| title=Postoperative pancreatic fistula: a review of traditional and emerging concepts. | journal=Clin Exp Gastroenterol | year= 2018 | volume= 11 | issue= | pages= 105-118 | pmid=29588609 | doi=10.2147/CEG.S120217 | pmc=5858541 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29588609 }} </ref> | |||
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.<ref name="pmid30170457">{{cite journal| author=Ke Z, Cui J, Hu N, Yang Z, Chen H, Hu J | display-authors=etal| title=Risk factors for postoperative pancreatic fistula: Analysis of 170 consecutive cases of pancreaticoduodenectomy based on the updated ISGPS classification and grading system. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 35 | pages= e12151 | pmid=30170457 | doi=10.1097/MD.0000000000012151 | pmc=6392812 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30170457 }} </ref><ref name="pmid30212577">{{cite journal| author=Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM| title=Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. | journal=PLoS One | year= 2018 | volume= 13 | issue= 9 | pages= e0203841 | pmid=30212577 | doi=10.1371/journal.pone.0203841 | pmc=6136772 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30212577 }} </ref> | |||
==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | ||
Revision as of 10:40, 17 March 2021
| Pancreatic fistula | |
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Pancreatic fistula Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Pancreatic fistula On the Web |
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American Roentgen Ray Society Images of Pancreatic fistula |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
A pancreatic fistula is an abnormal connection between the epithelialized surfaces of the pancreatic duct and adjacent or distant structures, organs or cavities. Clinical criteria defined by the International Study Group for Pancreatic Fistula (ISGPF) is a measurable 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. 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.
Historical Perspective
Classification
Pancreatic fistula can be classified anatomically as;
- Internal fistula: The pancreatic duct communicates with internal organs or body cavity such as pleural or peritoneal cavity.
- External fistula: The pancreatic duct communicates with the skin, otherwise known as pancreaticocutaneous fistula.
Pancreatic fistula can also be classified based on the anatomy of the pancreatic duct and the location of injury as;
- Type 1 pancreatic fistula: Involves injury to the pancreatic parenchyma with leakage from the distal part of the pancreatic duct or the side branches.
- Type 2 pancreatic fistula: Involves injury to and leak from the main pancreatic duct.
- Type 3 pancreatic fistula: Occurs as a result of proximal or distal pancreatectomy.
Pancreatic fistula is classified into two categories on the basis of clinical manifestations, complications and severity by the ISGPF as;
- Biochemical pancreatic fistula: This category includes fistula with no significant clinical symptoms.
- 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.
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.
Causes
Pancreatic fistula can result from different types of insults such as;
- 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.
- 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.
Differentiating Pancreatic fistula from other Diseases
Differential diagnosis of a pancreatic fistula may include evaluation for:
- Chronic liver disease leading to abdominal ascites
- Renal failure
- Heart failure
- Malignancy
- Conditions leading to pleural effusion such as malignancy, trauma and infections
- Pancreatitis
- Retroperitoneal bleeding
- Bowel ischemia
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%.[1] 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.[2] 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.[3][4]
Risk Factors
According to Fistula Risk Scoring (FRS) system, the risk factors for the development of pancreatic fistula depends upon: Texture of the gland: Soft texture of the gland is identified as a predictive risk factor. 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. 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. Intraoperative blood loss: >1000ml is associated with a high risk of fistula formation.[3] 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.[5][6]
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | ERCP | Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
Case Studies
- ↑ Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M (2013). "Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center". Case Rep Gastroenterol. 7 (2): 332–9. doi:10.1159/000354136. PMC 3764947. PMID 24019766.
- ↑ Larsen M, Kozarek R (2014). "Management of pancreatic ductal leaks and fistulae". J Gastroenterol Hepatol. 29 (7): 1360–70. doi:10.1111/jgh.12574. PMID 24650171.
- ↑ 3.0 3.1 Nahm CB, Connor SJ, Samra JS, Mittal A (2018). "Postoperative pancreatic fistula: a review of traditional and emerging concepts". Clin Exp Gastroenterol. 11: 105–118. doi:10.2147/CEG.S120217. PMC 5858541. PMID 29588609.
- ↑ Hackert T, Werner J, Büchler MW (2011). "Postoperative pancreatic fistula". Surgeon. 9 (4): 211–7. doi:10.1016/j.surge.2010.10.011. PMID 21672661.
- ↑ Ke Z, Cui J, Hu N, Yang Z, Chen H, Hu J; et al. (2018). "Risk factors for postoperative pancreatic fistula: Analysis of 170 consecutive cases of pancreaticoduodenectomy based on the updated ISGPS classification and grading system". Medicine (Baltimore). 97 (35): e12151. doi:10.1097/MD.0000000000012151. PMC 6392812. PMID 30170457.
- ↑ Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM (2018). "Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy". PLoS One. 13 (9): e0203841. doi:10.1371/journal.pone.0203841. PMC 6136772. PMID 30212577.