Management of Pancreatic fistulas

Surgical Clinics of North America June 2013

Introduction

• Definition: Leakage of pancreatic fluid as a result of pancreatic duct obstruction.

• Iatrogenic• Non- Iatrogenic

• Non iatrogenic• Acute or chronic pancreatitis – alcohol/

gallstones.

• Iatrogenic pancreatic fistulas.– Operative trauma.– ERCP.

• Mostly the tail of pancreas• Splenic operation.• Left renal/ adrenal operations.• Mobilization of splenic flexure.• Following resection of a portion of pancreas.

• Definition: drain output of any volume on or after postoperative day 3 with an amylase greater than 3 times the serum level.

Internal fistulas.

• Pancreatitis.• Can present as– Pancreatic ascites.– Pancreaticopleural fistula.

External fistulas.

• Pancreaticocutaneous fistula.

• Percutaneous drainage of pseudocyst/collection.

• Pancreatic debridement.• Pancreatic resection.

Initial management.

1. Control pancreatic secretions• CT/USG guided drain placement. • Antibiotics2. Nutrition.• Correct electrolyte imbalance. (Significant loss of

Na/HCO3-)• Total parenteral nutrition. – minimizes protein

loss and pancreatic enzyme secretion.• Enteral feeding – preferably naso-jejunal tube.

Evaluating the pancreatic duct.

• CT• MRCP – delineates the sides of ductal

disruption , stones and strictures.• Secretion stimulation MRCP.• ERCP – visualizing pancreatic duct –

therapeutic interventions – sphincterotomy, stenting, nasobiliary drainage.

• Fistulogram

Definitive management.

• 70-82 % close spontaneously.• Often nil per oral is the only management

required.

• Octreotide.– Inhibits exocrine secretion.–No effect on closure rate.–Reduces output and improves fistula

control.

• Fibrin glue.– Injection of fibrin through drain or

radiologically.– Effective in low – output pancreatic fistulas.

• Endoscopic therapy.• ERCP with stenting or sphincterotomy.• Reduces pressures in pancreatic duct.• Closure rates as high as 82%.• Stenting for duct disruption.

ERCP Conservative management.

84% closure rate 75% closure rate.71 days 120 days.

Operative management.

• Reserved for failure of other methods.• Duct decompression via lateral pancreatico-

jejunostomy – pancreatic duct > 7 mm• Distal pancreatectomy – injury in body or tail

without duct dilatation.

• Disconnected duct syndrome.• Acute pancreatic necrosis with autolysis of part

of pancreatitis.• Supportive care and drainage.• Tail duct disruption – distal pancreatectomy• Neck duct disruption – drainage till fibrous

fistula tract is formed followed by fistula enterostomy with Roux-en-y jejunal loop.

• ?Distal pancreatectomy for neck disruption

Treatment of post-procedural fistulas.

Following • Percutaneous drainage of pseudocyst.• Operative debridement of acute pancreatitis.• Operative pancreatic injury.• Pancreatic resection.

• Associated with pseudocyst drainage – Incidence - 15%–Due to increase in pressure in MPD due to

stricture.– ERCP and stenting/ sphincterotomy.–Operative intervention if no resolution

within 6 weeks.

• After debridement of pancreatic necrosis–Conservative management with drainage.– ERCP and decompression of pancreatic

duct.• After operative trauma.– Usually resolve spontaneously in absence of

stricture.– Distal pancreatectomy.

• After pancreatic resection.• Leak from divided edge/ pancreatic

anastomosis.• 20 % incidence after

pancreaticoduodenectomy and distal pancreatectomy.

• Management – conservative with drains

Risk factors after resection• Pancreatic duct size.• Pancreatic texture.• male gender.• Jaundice.• cardiovascular disease.• operative time.• intraoperative blood loss.• type of pancreatico-digestive anastomosis .• hospital volume.• surgeon’s experience.

• Thank you