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296 P. Y. Parikh and K. D. Lillemoe
Table 28.2 Fistula risk score for prediction of clinically relevant pancreatic fistula after pancreaticoduodenectomy.
(Adapted from [11])
Risk factor Parameter Points
Pathology Pancreatic adenocarcinomaor pancreatitis 0
Ampullary, duodenal,cystic, islet cell 1
Gland texture Firm 0
Soft 2
Intraoperative blood loss, mL ≤
Pancreatic duct diameter, mm ≥ 5 0
a
Total 0–10 points. 0 points (negligible risk); 1–2 points (low risk); 3–6 points (intermediate risk); 7–10 points (high
risk) to develop clinically relevant postoperative pancreatic fistula
400 0
401–700 1
701–1000 2
> 1000 3
4 1
3 2
2 3
1 4
≤
a
procedure can have an impact on fistula development and have been investigated in numerous
studies. The technique of stump closure after
distal pancreatectomy remains the subject of an
ongoing debate. All approaches including fibrin
glue, sealants, patches, stapler closure, electrocautery, and suture have been tested in numerous
studies. In an analysis by Ferrone et al. of 462
patients, fistula rates were 19–31 % considering
all approaches without significant advantages for
any method [14]. The recently completed DISPACT trial included 352 patients that were randomly assigned to a stapler or hand-sewn closure
of the pancreatic remnant. Both groups showed
identical fistula rates of 30 and 36 % on postoperative day 7 and 30, respectively [15].
The role of splenic preservation on fistula
development is also controversial. An analysis
of 211 patients by Shoup et al. showed that splenectomy was associated with a higher risk for
clinically-relevant fistula [16]. In contrast to this
publication, the two large series by Kleeff et al.
including 302 patients and by Lillemoe et al. with
235 patients, failed to confirm splenectomy as an
independent risk factor for fistula development
[17, 18].
In recent years, laparoscopic distal pancreatectomy for benign as well as malignant disorders
has gained acceptance. In a multicenter study
of 96 laparoscopic distal pancreatectomies, the
overall fistula rate was 17 % [19]. In contrast, a
meta-analysis published in 2009 which included
28 studies, found an overall fistula rate of 29 %
[20]. When compared to the open approaches in a
multicenter study of 142 laparoscopic versus 200
open resections, a rather high fistula rate (26 %
laparoscopic vs. 32 % open) was reported [21].
Currently, there is no evidence supporting the
laparoscopic procedure over the open procedure
with regard to postoperative fistula development.
Duodenum-Preserving Pancreatic Head Resection/Lateral Pancreaticojejunostomy
Duodenum-preserving pancreatic head resection
(DPPHR) and lateral pancreaticojejunostomy
(Puestow procedure) are the procedures used
in the surgical treatment of chronic pancreatitis. These patients usually show a fibrotic tissue
texture which facilitates surgical tissue handling
and is associated with a reduced risk for anastomotic leak. Although all of these procedures require anastomotic suture line of extensive length,
the fistula rates are low ranging from 0 to 6 %
[22]. There are no clear advantages with regard
to fistula development for any of the common
DPPHR modifications (Frey or Beger) or the
Puestow procedure which supports the fact that
fistula development is mainly dependent on the
fibrotic pancreatic texture, not on the surgical
29728 Persistent Pancreatic Fistula
technique or the extent of resected tissue in these
procedures.
Pancreatic Pseudocyst Drainage/ Pancreatic Necrosectomy
Acute necrotizing pancreatitis is the most severe
and potentially life-threatening form of acute
pancreatitis. As many cases involve infection of
the necrotic tissue, almost all will require percutaneous drainage of peripancreatic fluid collections or a surgical procedure for the debridement
of necrosis (necrosectomy) (Fig.
28.1a, b
). In
acute necrotizing pancreatitis, the pancreatic duct
often disrupted by the necrosis, results in creation
of a pseudocyst or either a sterile or an infected
collection consisting of pancreatic juice and necrotic tissue. Any procedures to address these
fluid collections by external drainage will result
in an external pancreatic fistula.
Howard et
al. have classified
external pancreatic fistulas anatomically into end and side
fistulas. Side fistulas can be further classified as
postoperative and inflammatory [23]. End external pancreatic fistulas are leaks from the pancreatic duct which have no continuity with the gastrointestinal tract. The most common anatomic
configuration in these is the “disconnected duct
syndrome” due to necrosis of the midpancreatic
body along with the ductal epithelium, with no
communication between the external pancreatic fistula and the proximal pancreatic duct.
The distal remnant of the pancreas is an isolated
pancreatic segment draining only via the fistula.
All such end fistulas will require either internal
drainage or resection in order to close.
A pancreatic fistula following percutaneous
drainage of a pseudocyst occurs approximately
15 % of the time [23]. Persistent drainage is often
the result of an obstructing stricture within the
main pancreatic duct, causing the pressure within the duct to be abnormally high. Patients with
pancreatic necrosis secondary to acute pancreatitis often present with pancreatic duct disruption.
At the time of the initial surgery, the goal is to debride all necrotic tissue and perform wide drainage. Most duct disruptions go on to seal with time
and drainage, however 10–56
% continue to
have
persistent drainage that may require more definitive management [24].
Other Pancreatic Resections
Middle segmental pancreatic resections are
tissue-sparing procedures usually employed for
benign pancreatic neoplasms. Current literature
reporting results from nearly 300 patients, reports
fistula rates between 10 and 40 % with most series having rates higher than 25 % [25, 26]. This
high rate is explained by the existence of two cut
pancreatic surfaces, which are either closed by an
anastomosis or by duct/parenchyma closure comparable to distal resections.
Tumor enucleations of the pancreas represent
another type of resection with a rather high reported fistula incidence. In a 61-patient study by
Crippa et al. fistula incidence was 23 %, while
smaller series report fistula rates of approximately
Fig. 28.1 a Patient with infected pancreatic necrosis. b Same patient after operative debridement and drainage of
pancreatic necrosis
298 P. Y. Parikh and K. D. Lillemoe
40 % [27, 28]. Despite these rather high overall
fistula rates, associated complications are low in
all studies. Grade C fistulas range between 0 and
4 %, showing that enucleation-associated fistula
are rare and treated by drainage without further
specific therapy.
The pancreatic fistula after operative trauma
is usually isolated to the tail of the pancreas following splenectomy, left nephrectomy/adrenalectomy, and mobilization of the splenic flexure
during colectomies. Reported fistula rates range
from 0 to 2 % after these operations [27].
Prevention of Pancreatic Fistula
Given the frequency of pancreatic fistulas following pancreatic resection, extensive research
has been employed to prevent the occurrence of
pancreatic fistula. The strategies include pharmacologic manipulation, modifications and refinements in surgical technique regarding pancreatic anastomosis, pancreatic anastomotic stents,
and perianastomotic drainage post pancreatic
resection.
Octreotide, a synthetic somatostatin analogue
inhibits pancreatic exocrine secretion. The use
of octreotide and its analogues to prevent postoperative fistula is an approach which has been
used since the 1990s [29, 30]. Despite 20 years of
clinical use and evaluation in numerous studies,
a recent Cochrane meta-analysis concluded that
evidence is still lacking to give clear guidelines
[31]. While early randomized controlled trials
(RCTs) favored the use of octreotide and showed
a 50 % reduction of fistula rates, these findings
were not confirmed in later studies [30, 32, 33].
From these results, it was concluded and supported by the Cochrane review that routine use of
octreotide was not indicated, but should be used
in a risk-dependent manner in a presumed “critical” anastomoses due to soft pancreatic tissue
texture. Although the overall fistula rates have
been reduced, somatostatin analogues failed to
reduce the incidence of clinically relevant (grade
B/C) fistula or re-operation rates and mortality.
Finally, postoperative octreotide administration
for postoperative fistula has failed to show any
improvement in the rate of fistula closure [34].
Despite the lack of effect on fistula closure rate,
the octreotide may help lower fistula output and
make fistula control easier. Recently, a singlecenter, randomized, double-blind trial was published showing pasireotide, a new somatostatin
analogue, decreased the rate of clinically significant postoperative pancreatic fistula, leak, or
abscess [35]. While the initial results are promising, further studies need to be conducted to prove
whether pasireotide is beneficial.
Modifications in surgical technique to prevent pancreatic fistula have been evaluated for
decades with conflicting results. Following a
pancreaticoduodenectomy, there has been an
ongoing debate of whether a pancreaticogastrostomy or pancreaticojejunostomy has a lower
postoperative fistula rate. Within each of these
techniques, several different technical modifications, including single or double layer sutures,
invagination and purse-string sutures have been
compared with regard to the surgical complications and especially postoperative fistula frequency. Unfortunately, there have been no level
1 evidence-supported techniques that have been
universally adopted. Following distal pancreatectomy, there are numerous studies comparing
sutures, staplers, patches, fibrin glue, and sealants to handle the distal stump of the pancreatic
remnant that have been reported [13, 14], and no
convincing evidence exists to support the superiority of any one technique.
The placement of pancreatic duct stents and
the potential role in prevention of postoperative
pancreatic fistula has been investigated for both
right and left pancreatic resections. The principle
of internal drainage of the pancreatic duct following pancreaticoduodenectomy to achieve a diversion of the pancreatic secretion from the suture
site has been hypothesized; however, the stent
may also cause problems via irritation of the duct
and the suture lines as well as the obstruction
or migration. In available studies, the outcome
shows a great deal of variability. Earlier studies
demonstrated a beneficial effect of anastomotic
stenting in lowering the postoperative pancreatic
fistula rate [36, 37]. A randomized trial by Poon
et al. among 120 patients, which used long stents
29928 Persistent Pancreatic Fistula
across the pancreaticjejunostomy anastomosis
and drained externally, showed that the stented
group had a significantly lower pancreatic fistula
rate compared to the nonstented group (6.7 vs.
20 %, respectively) [37]. Despite these encouraging results, the technique has not been universally adopted. In contrast, the largest randomized
study, published in 2006 by Winter et al., which
used short internalized stents (6 cm long plastic
pediatric feeding tube) included 234 patients who
underwent pancreaticoduodenectomy with stent
= 115) or
( n
without stent ( n
= 119)
placement
into the pancreatic duct [38]. Winter showed an
overall fistula rate of 7.6
(stent), concluding no benefit
% (no stent) vs. 11.3 %
for stenting of the
pancreatic duct. The most recent study, published
in 2012 by Sachs et
had an intraoperatively pancreaticojejunal
al. where 59/444 patients
stent
placed actually had greater rates of critically
relevant postoperative pancreatic fistula, major
complications, greater length of stay, and total
costs [39].
There are very few studies analyzing the effect of preoperative or intraoperative stents in
the distal pancreatectomy setting. In a 23-patient
collective, Fischer et
al. described a prophylactic intraoperative transampullary stent placement
as an open surgical procedure that resulted in a
significant reduction in postoperative pancreatic fistula rates [40]. However, Okamoto et
al.
observed a stent-related morbidity of 57 %, including pancreatitis and stent obstruction [41
Reider et
al. had no
postoperative pancreatic fis-
].
tula in stented patients; however, in this study a
sphincterotomy was performed in addition to the
placement of preoperative stents prior to distal
pancreatectomy [42].
The routine use of intraperitoneal drains following elective pancreatic surgery remains an
area of debate regarding whether drains prevent
or exacerbate pancreatic fistulas. The first randomized trial to investigate the impact of intraperitoneal drain use reported by Conlon et
randomized 179 patients following
pancreatico-
al.
duodenectomy and distal pancreatectomy to intraperitoneal drain placement or surgery without
drains [43]. This study demonstrated that patients
in the drainage group were more likely to have
an intra-abdominal abscess, collection, or fistula compared to patients without drains. More
recently, Bassi et al. randomized patients who
were at low risk for leak based on drain amylase
level < 5000 U/L on postoperative day 1 to early
drain removal (postoperative day 3) or late drain
removal (≥ postoperative day 5) [44]. The trial
reported a significant reduction in pancreatic fistulas (using the ISGPF definition) in early drain
removal group versus the late drain removal
group 1.8–26.3 %. While these studies show
that drains may not be necessary, most surgeons
routinely still use postoperative drains and have
not changed their clinical practice. Recently, a
randomized multicenter trial was conducted to
further evaluate the necessity of drains after pancreaticoduodenectomy [45]. There were no differences between the drain and no-drain cohorts
in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, or operative
technique. Pancreaticoduodenectomy without
intraperitoneal drainage was associated with an
increase in the number of patients with complications, number of complications per patient, and
the severity of complications. The no-drain cohort also had a higher incidence of gastroparesis,
intra-abdominal fluid collection, intra-abdominal
abscess, and severe diarrhea. Furthermore, patients in the no-drain group more often required
postoperative percutaneous drains and had a prolonged hospital stay. The Data Safety Monitoring Board stopped the study early because of the
increased mortality from 3 to 12
% in the
patients
undergoing pancreaticoduodenectomy without
intraperitoneal drainage. Thus, most surgeons
feel that this level 1 evidence provides strong
support for routine drainage following pancreaticoduodenectomy. This same study continues
to determine the necessity of drains for patients
after distal pancreatectomy.
Complications of Pancreatic Fistula
Multiple studies have demonstrated that patients
with pancreatic leak have a significant increase
in secondary complications compared to patients without leak [8, 46]. Commonly observed
300 P. Y. Parikh and K. D. Lillemoe
complications are mainly caused by undrained
infected pancreatic fluid collections. Pancreatic
fluid is an enzymatically active and aggressive
substance that may cause erosion of the surrounding tissue, organs, and blood vessels. This
can lead into leakage from other adjacent anastomoses or bowel (particularly in patients with
pancreatic necrosis) causing a biliary, gastric, or
enteric leak.
Postoperative hemorrhage associated with a
pancreatic leak is one for the most dreaded complications following major pancreatic resections.
The pancreatic enzymes in combination with infection can cause erosion of the gastroduodenal
artery or splenic artery stump or from an arterial
pseudoaneurysm resulting in significant bleeding
requiring immediate therapy. This complication
usually occurs after the first week after the surgery and in most cases with what appears to be
adequate drainage of the pancreatic leak. Management is guided by the patient’s clinical status and hemodynamic stability. In general, most
patients should be approached via angiographic
embolization or arterial stenting to provide the
best outcomes [47]. Patients who are hemodynamically unstable may require operative reexploration and packing and then angiographic
control. A high index of suspicion should be
maintained because postoperative hemorrhage is
associated with significant risk.
The occurrence of pancreatic fluid collections
due to a pancreatic leak is also a potential cause
of ongoing abdominal sepsis that can lead to generalized systematic organ failure. Percutaneous
drainage of the fluid collections by interventional
radiology and broad spectrum antibiotic therapy
are as important as supportive ICU therapy in
these patients.
An important aspect of the pancreatic fistula
complications is the economic impact from the
prolonged treatment. The longer duration of hospital stay is an important factor that increases
treatment costs. The average hospital stay in uncomplicated resections is usually 6–8 days, but
can increase to 25–40 days in cases of fistula
development, especially with type B or C fistula [46]. The associated treatment costs in these
patients are 4–5 times higher than in patients
without fistulas, highlights the socio-economic
dimension of the health care system [8].
Management of Pancreatic Fistula
Regardless of the cause or the location of the pancreatic fistula, the steps required for treatment of
a clinically relevant pancreatic fistula are similar.
First, stabilization of patients and medical optimization are the crucial steps. Drainage of collections and insuring operatively placed drains are
adequately controlling the fistula output to control sepsis that is mandatory. In cases with sepsis
or high output fistulas, the patient is made “nil
per os” (NPO) and parenteral nutrition is considered necessary. Only then should the nature of
pancreatic duct injury be investigated and definitive management of the fistula be addressed.
Initial Management
The type of initial management needed for patients depends on the type of classified fistula and
severity of symptoms. A clinically uncomplicated postoperative Grade A fistula can usually be
managed by drainage alone, via intraoperatively
placed drains which are still in situ and kept as
long as necessary. Usually within 2–4 weeks,
one sees spontaneous closure of the fistula. Fistula output volume and inflammatory parameters
including white blood cell (WBC) should be
monitored to avoid unrecognized fluid collections causing infectious complications despite
continuing drainage.
In patients without drains or if drains have
already been removed, patients with a pancreatic leak will display symptoms of pain, fever,
nausea/vomiting, and other signs of sepsis. Initial management of patients with symptomatic
(Grade B or C) pancreatic fistula requires control of the pancreatic secretions. A control can be
accomplished with percutaneous drains placed
under computed tomography (CT) or ultrasound
guidance (Fig. 28.2a, b). Broad spectrum antibiotics are administered to treat the likely infected
fluid and to avoid ongoing abdominal sepsis.
Using this method, fistulas often resolve within
a 2–6 week period.
30128 Persistent Pancreatic Fistula
Fig. 28.2 a Large fluid collection present on postoperative day 7 after open distal pancreatectomy. b Same patient after
the fluid collection has been drained percutaneously by interventional radiology (Grade B fistula)
Further management after control of the collection and antibiotics include getting the patient
medically optimized. Patients with pancreatic
fistula are at risk for having significant nutritional and electrolyte imbalances, especially significant loss of sodium and bicarbonate caused
by pancreatic exocrine secretions. Patients with
pancreatic fistulas often have significant nausea,
anorexia, and the inability to tolerate oral intake.
Furthermore, since most pancreatic fistulas occur
in the postoperative period, some degree of malnutrition is usually present. Thus, depending on
the severity of the pancreatic fistula, patients will
require total parenteral nutrition (TPN) in an effort to overcome their catabolic state. The TPN
provides the benefit of minimizing protein loss
while decreasing pancreatic secretions from the
lack of pancreatic stimulation; however, the risks
include potential line sepsis, electrolyte and glucose abnormalities, and cholestatic injury to the
liver. Enteral feeding should be initiated as early
as possible because of simpler administration,
cost-effectiveness, and the ability to maintain
mucosal barrier function. Ideally, the tube feeds
should be delivered in a postpyloric location via a
nasojejunal feeding tube. However, studies show
no benefit of postpyloric feeding over gastric
feeding or even oral intake if tolerated by the patient [48, 49].
In contrast, grade C fistulas require more aggressive therapies. The most life-threatening of
this uncontrolled fistula is erosional bleeding
from enzymatic digestion of nearby vascular
structures. Bleeding often begins with a “sentinel bleed” which is self-limited and not associated with hemodynamic changes. However,
some patients may present with massive bleeding acutely without any warning event. The common algorithm is a contrast-enhanced CT scan
to visualize the site of bleeding and associated
collections, followed by arterial angiography of
the visceral segment. This treatment is successful
in stopping the bleeding in 80 % of patients [47].
An operative intervention should be considered
when bleeding control cannot be achieved interventionally or when further complications seem
to be likely. Most times, the evacuation of clot
and packing may be all that can be accomplished,
although an effort should be made to ligate the
bleeding vessel if visualized. In such cases, after
gaining stability, embolization may still be the
optimal management of the arterial disruption.
The need for completion pancreatectomy is a
very rare event after a pancreaticoduodenectomy
for bleeding complications [50].
Grade C fistula where there are multiple undrained fluid collections that cannot be accessed
by interventional procedures and have extensive
intra-abdominal sepsis, should also be considered for operative intervention. These patients
should have extensive lavage of the abdominal
cavity and wide drainage of the anastomoses to
achieve best control for the critically ill patient.
An emergency resection or completion pancreatectomy after a pancreaticoduodenectomy may
be beneficial if there is minimal remnant and
302 P. Y. Parikh and K. D. Lillemoe
extensive enzymatic digestion that cannot be
widely drained. In most cases, completion pancreatectomy which is used as a salvage procedure
is associated with higher perioperative mortality
greater than 50 % and results in the severe morbidity of brittle diabetes [51]. Resection of the
pancreatic head to control complicated fistula
after distal pancreatectomy is not necessary, as
these fistula can usually always be managed nonoperatively.
Delineation of Pancreatic Duct
After the initial steps to drain collections, control sepsis, and address nutrition, patience is appropriate as many fistulas will close spontaneously. If a fistula persists, the location and extent
of pancreatic duct injury should be identified.
Identification of the ductal disruption will help
dictate the need for further intervention including
surgical management. The first diagnostic study
usually is a CT scan to assess for and drain any
fluid collections and possible evaluation of a dilated obstructed pancreatic duct (Fig. 28.3). To
further evaluate the pancreatic duct, a magnetic
resonance cholangiopancreatography (MRCP) is
a valuable noninvasive tool. MRCP can delineate
the sites of ductal disruption and identify other
findings, such as pancreatic stones or ductal strictures. The standard MRCP can be combined with
a secretin stimulation MRCP, which is useful in
the diagnosis of chronic pancreatitis by stimulat-
ing the pancreas to produce exocrine secretions
while performing the imaging. Another noninvasive technique to define the pancreatic ductal
pathology is injection of an existing drain which
should visualize the pancreatic duct at the site of
leakage (Fig. 28.4).
ERCP has the benefit of visualizing the pancreatic duct while at the same time providing
potentially therapeutic interventions, including
sphincterotomy, stenting, and nasobiliary drainage; however, ERCP does require conscious
sedation and carries the risk of duodenal perforation and/or pancreatitis. Endoscopic studies
after pancreaticoduodenectomy can be technically very difficult. Thus, the main indication for
ERCP would be after distal pancreatectomy or in
fistulas after pancreatitis.
In cases of fistulas after pancreatitis, the criteria for the diagnosis of disconnected duct syndrome include: ERCP evidence of main pancreatic duct cutoff or discontinuity with the inability
of accessing or cannulating the upstream pancreatic duct; CT scan evidence of viable pancreatic
tissue upstream from the pancreatic duct cutoff or
discontinuity and a nonhealing pancreatic fistula,
pseudocyst, or fluid collection despite a course
of conservative medical management [52]. Other
authors suggest criteria should include necrosis
Fig. 28.3 Patient with persistent pancreatic fistula that
shows upstream viable pancreas and a dilated pancreatic
duct
Fig. 28.4 Fistulogram through the drain showing con-
nection to downstream pancreatic duct draining into duodenum
30328 Persistent Pancreatic Fistula
of at least 2 cm of pancreas, viable pancreatic
tissue upstream from the site of the necrosis and
extravasation of contrast material injected into
the main pancreatic duct at pancreatography [53].
Definitive Treatment of Pancreatic Fistula
After the anatomy of the pancreatic duct and the
location of the injury have been identified, definitive management of a long standing persistent
pancreatic fistula can then be considered. Studies
show that 70–82 % of pancreatic fistula will close
spontaneously without the need for operative intervention [54]. Simply making patients NPO
and reducing pancreatic stimulation will result
in resolution of the pancreatic fistula. However,
long-standing persistent pancreatic fistula that
last longer than 6 weeks will require further intervention.
Patients that are medically stable who have a
persistent pancreatic fistula with output less than
100 cc a day and no intra-abdominal collection
can have slow drain removal. This process begins
with removing suction from the drain bulb, followed by downsizing of the drainage catheter via
interventional radiology. Slow incremental withdrawal of the drain should be performed while
monitoring drain output.
Recently, fibrin glue has been used to obliterate the fistula tract. This technique involves
injection of fibrin glue either under radiographic
guidance or through a previously placed drainage tract. Studies of this technique are limited,
but in small case series, it has been shown to be
successful treatment option for patients with lowoutput pancreatic fistulas [55].
The use of ERCP in the evaluation and definitive treatment of a persistent pancreatic fistula
after distal pancreatectomy should be considered.
In patients with a persistent pancreatic fistula despite adequate drainage and medical optimization, an ERCP with sphincterotomy or stenting
can be performed to promote fistula closure.
Closure rates as high as 82 % have been reported
[56]. In general, endoscopic transpapillary stenting is considered helpful in the management of
external pancreatic fistulas and side fistulas. Similarly, endoscopic drainage can be useful in the
management of internal pancreatic fistulas causing pancreatic ascites. In necrotizing pancreatitis
patients who have a pancreatic duct disruption,
an endoscopic stent to bridge the disruption has a
success rate of more than 50 % [57]. However, a
recent multicenter series for patients with necrotizing pancreatitis comparing endoscopic transpapillary stenting versus conservative treatment
failed to show a significant improvement in the
fistula closure rate (84 vs. 75 %) or in time to closure (71 vs120 days) [58]. Despite these results,
an endoscopic stenting should be considered for
long-term persistent pancreatic fistulas and attempted where favorable anatomy is present.
Recent studies have investigated the role of
endoscopic therapies for management of the
disconnected duct syndrome, but with limited
results. However, other studies have found that
patients may temporarily improve with endoscopic therapy, but will still often go on to require surgical intervention. In patients who may
not be considered surgical candidates or who refuse surgery, a rendezvous technique using endoscopic ultrasound guided access to the distal duct
and standard ERCP may be employed to bridge
the gap.
Operative Management of Pancreatic Fistula
The operative management of pancreatic fistulas
remains an important component of their treatment, but is generally reserved in patients where
conservative or endoscopic procedures have
failed. Surgery may prove necessary in patients
who are unable to have endoscopic or interventional therapies secondary to postsurgical anatomy or who have an inability to cannulate the
pancreatic duct, a significant ductal stricture, or
a very large defect. The type of surgical intervention proposed for patients varies on the location
304 P. Y. Parikh and K. D. Lillemoe
of ductal injuries, the severity of fistula, and the
underlying pathology.
The most common indication for surgical intervention is in patients with complicated
pancreatitis who have a persistent pancreatic fistula after percutaneous drainage of a pancreatic
pseudocyst, operative debridement of acute pancreatic necrosis, a disconnected duct syndrome,
or recurrent manifestations of chronic pancreatitis of the distal gland. Patients who present
with a large pancreatic duct (7 mm or greater)
are generally managed with duct decompression,
usually via a lateral pancreaticojejunostomy. If
pancreatic pseudocyst is present, this area should
be incorporated into the anastomosis with a cyst
gastrostomy or cyst jejunostomy. In some clinical situations, the pseudocyst can be successfully managed with endoscopic drainage into
the stomach or duodenum [59]. Patients with a
pancreatic duct injury isolated to the body or tail
of the pancreas are often best served by a distal
pancreatectomy, resecting only the area of the
pancreas beyond the disruption.
Definitive surgical management is dependent
on the location of the ductal injury. If the ductal
disruption is near the neck of the pancreas, then
these patients are best served by prolonged external drainage of the fistula until a fibrous fistula
can develop. The waiting time between drainage
placement and surgery encountered in the literature is usually 3–6 months [60, 61]. At this time,
a fistula-enterostomy can be performed using a
Roux-en-Y jejunal limb (Fig. 28.5). The success
rate of surgical drainage has been reported to be
as high as 82–100 % in certain series, with minimal complications [62, 63]. However, long-term
failure may occur because of obliteration of the
fistula tract over time. The recurrence rate after
fistulojejunostomy is reported to be around 35 %
and is usually manifested by a pseudocyst formation or the development of diabetes mellitus, as
an indicator of a poorly drained pancreatic remnant [64]. However, fistulojejunostomy to the
site of duct disruption is the operative treatment
for persistent pancreatic ascites.
Another surgical option for a disconnected
duct at the neck of the gland is distal pancreatectomy. However, this option sacrifices a significant amount of otherwise functional pancreatic
parenchyma. A study by Murage et al. showed
equal short- and long-term results when evaluating internal drainage versus distal pancreatectomy for the disconnected left pancreatic remnant.
A pancreatic remnant > 6 cm favored an internal
drainage while the strongest indicator for distal
pancreatectomy was a small pancreatic remnant
and splenic vein thrombosis [62]. However, longterm outcomes of pancreatic function were not
evaluated.
Fig. 28.5 Diagram of Roux-en-Y fistulojejunostomy
Conclusion
Pancreatic fistula is a significant complication
that can occur after all types of pancreatic surgery. The incidence varies from 2 to 50 % depending on the type of procedure. A definition
of postoperative pancreatic fistula has been standardized according to the ISGPF with regard to
clinical symptoms and associated complications.
The management of pancreatic fistula can be
difficult and necessitates a multidisciplinary approach. Basic principles of fistula control/patient
stabilization, delineation of ductal anatomy, and
definitive therapy remain of paramount importance.
30528 Persistent Pancreatic Fistula
Key Points to Avoid Complications
1. High risk conditions such as pancreatic texture, central pancreatic necrosis, and procedures such as tumor enucleation, central pancreatectomy and distal pancreatectomy must
be identified and appropriate measures taken
to prevent and minimize the complications of
pancreatic fistula.
2. Although a number of operative and other
measures have been subjected to randomized
clinical trials to identify approaches to decrease the incidence of fistula after pancreatic
resection of both the head and body/tail of the
pancreas, an experienced surgeon with meticulous operative technique is likely the most
important in prevention.
3. Carefully placed perioperative drains and appropriate postoperative drain management is
the key in minimizing the incidence and complications of pancreatic fistula.
4. Internal rather than external drainage of pancreatic pseudocysts.
Key Points: Diagnosing and/or Managing Complications Either Intra- or Postoperatively
1. All pancreatic fistulas should be defined by
the definitions provided by theISGPF.
2. Early CT scan to assess for and guide drainage
of any fluid collections.
3. Control of pancreatic secretions, broad-spectrum antibiotics for signs of sepsis, and medical optimization of patient with parenteral nutrition.
4. Patience and close observation plus providing
reassurance and counseling to patient that a
majority of fistulas will close spontaneously.
In Type A fistulas, do not intervene or delay
hospital discharge.
5. Delineation of pancreatic duct first by noninvasive techniques like CT scan, MRCP, and/or
drain fistulogram.
6. Depending on reconstructed anatomy, ERCP
may be useful for diagnostic as well therapeu-
tic interventions including sphincterotomy,
stenting, and nasobiliary drainage.
7.
Surgical intervention
should only be considered when all conservative and endoscopic
procedures have failed. A significant period
of time should be allowed before operative
drainage especially following drainage in patients with pancreatic necrosis.
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