Pancreatic fistula

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Pancreatic fistula
MeSH D010185

Pancreatic fistula Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pancreatic fistula from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

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Laboratory Findings

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ERCP

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Case #1

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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

There is no historical significance associated with pancreatic fistula.

Classification

Pancreatic fistula can be classified anatomically as;

Pancreatic fistula can also be classified based on the anatomy of the pancreatic duct and the location of injury as;

Pancreatic fistula is classified into two categories on the basis of clinical manifestations, complications and severity by the ISGPF as;

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.[4][5]

Causes

Pancreatic fistula can result from different types of insults such as;[6][7]

Differentiating Pancreatic fistula from other Diseases

Differential diagnosis of a pancreatic fistula may include evaluation for:

  1. Chronic liver disease leading to abdominal ascites
  2. Renal failure
  3. Heart failure
  4. Malignancy
  5. Conditions leading to pleural effusion such as malignancy, trauma and infections
  6. Pancreatitis
  7. Retroperitoneal bleeding
  8. 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%. 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.

Risk Factors

According to Fistula Risk Scoring (FRS) system, the risk factors for the development of pancreatic fistula depends upon:

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.

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.

External pancreatic fistula presents with pancreatic fluid accumulation noticeable on the skin surface.

Internal pancreatic fistula may present with ascites or pleural effusion as fluid accumulates within the abdominal or thoracic cavity.

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:

  1. Wound infection and sepsis
  2. Hemorrhage
  3. Internal and/or external fistula
  4. Pancreatic pseudocyst
  5. Delayed gastric emptying
  6. Walled off pancreatic necrosis
  7. Prolongation of the hospital stay
  8. Pancreatic ascites
  9. High amylase pleural effusion
  10. Disconnected duct syndrome
  11. Multisystem involvement eventually leading to multiorgan failure and/or death.

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.

Diagnosis

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.

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.

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. Pancreatic fluid amylase level will be >1000 u/dl.

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:

  1. 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.
  2. Grade B or C pancreatic fistula:
  • 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.
  • 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.

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.

Case Studies

Case #1

References

  1. Morgan KA, Adams DB (2007). "Management of internal and external pancreatic fistulas". Surg Clin North Am. 87 (6): 1503–13, x. doi:10.1016/j.suc.2007.08.008. PMID 18053844.
  2. Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M; et al. (2017). "Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification". Dig Dis Sci. 62 (10): 2648–2657. doi:10.1007/s10620-017-4697-5. PMID 28780610.
  3. Jiang L, Ning D, Chen X (2020). "Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions". Front Med. 14 (3): 251–261. doi:10.1007/s11684-019-0727-3. PMID 31840199.
  4. 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.
  5. 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.
  6. 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.
  7. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M; et al. (2017). "The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After". Surgery. 161 (3): 584–591. doi:10.1016/j.surg.2016.11.014. PMID 28040257.