Pancreatic Fistula - An Overview

Introduction

An abnormal or surgically made connecting passage from one organ surface to the other organ is called a fistula. In the case of a pancreatic fistula, there is a connection from the epithelium of the pancreatic duct to the other surface. These are categorized based on the underlying disease process and immediate cause, and anatomically, they can be internal or external. Treatment of the pancreatic fistula can be done either by supportive therapy or surgical management.

What Is a Pancreatic Fistula?

The pancreatic fistula is a connection forming between the ductal epithelium of the pancreas and the epithelium surface elsewhere. This can occur due to disruption or discontinuity in the pancreatic duct, which can lead to leakage of the fluid, causing erosion and resulting in pancreatic fistulas.

What Are the Types of Pancreatic Fistula?

Following are the types of pancreatic fistula:

• Internal Pancreatic Fistula: Disruption of the pancreatic duct can be seen, which ultimately results in communication with the pleural and peritoneal cavities.

• External Pancreatic Fistula: It is also called a pancreaticocutaneous fistula. It communicates between the pancreatic duct and the skin, leading to pancreatic fluid drainage.

What Are the Causes of Pancreatic Fistula?

Causes of the pancreatic fistula can be divided into

• Iatrogenic Causes - Iatrogenic causes include trauma during surgery or biopsy of the mass in the pancreas, resection of the pancreas, trauma during the endoscopic intervention, or the presence of pancreatic pseudocysts in which the pancreatic fluid is collected. Almost all cases of external pancreatic fistulas arise due to iatrogenic causes.

• Non-Iatrogenic Causes - Causes that are not related to any kind of trauma or defect are called non-iatrogenic causes. Such causes include trauma to the abdomen and pancreatitis, which can be acute or chronic.

What Are the Symptoms of Pancreatic Fistula?

The patient can either be asymptomatic or symptomatic.

• Abdominal pain.

• Vomiting.

• Nausea.

• Lack of appetite.

• Weight loss.

• Distended abdomen.

• Difficulty in defecation or urination.

• Gastrointestinal symptoms.

• Ascites (abdominal distension).

• Dyspnea.

• Wheezing.

• Cough.

• Chest pain.

• Fistula openings in the skin can present with skin wounds.

• Dehydration.

• Malnourishment.

• Fever.

What Is the Diagnosis for Pancreatic Fistula?

• Imaging techniques: Imaging studies should be carried out to differentiate dyspnea from abdominal pain.

• Chest X-Ray: It is a quick imaging technique that can provide information about the underlying conditions.

• Computerized Tomography: Abdominal pain can be evaluated using a CT scan. This detects the collection of fluids and pancreatic changes. It shows a disadvantage of the pancreatic fistula that cannot be evaluated properly.

• Magnetic Resonance Cholangiopancreatography: A precise picture of the duct of the pancreas can be provided

• Endoscopic Retrograde Cholangiopancreatography: A site where there is a disruption in the duct and the complete anatomy of the fistula can be detected using this method.

• Fistulography: The location of the site of the fistula and other anatomic structures can be visualized.

• Laboratory Evaluation: Certain laboratory tests are advised.

• Blood Examination: Complete blood picture, levels of lipase and amylase, and the complete metabolic panel are evaluated. The complete metabolic panel includes aspartate, aminotransferase, bilirubin, albumin, and calcium levels. All the samples are evaluated to characterize the etiology of the pancreatic fistula.

What Is the Treatment for Pancreatic Fistula?

Both operative and nonoperative management of pancreatic fistulas can be advised.

Management of the pancreatic fistula before any treatment intervention involves controlling the fistula and maintaining proper nutrition.

Supportive care includes the following:

• Controlling the secretion of the pancreas is done by administering somatostatin analogs or keeping the patient temporarily on parenteral nutrition.

• Correction of electrolyte and fluid abnormalities should be done to prevent a condition called metabolic acidosis (disturbance in the pH and increase in the acidic content in the blood).

• The external area of the fistula is prevented from any further damage.

Operative or surgical care includes the following:

Endoscopy Therapy: The placement of a pancreatic stent is done to enhance the secretions of the pancreas and promote their flow through an internal drainage route.

This reduces the flow of the secretions through the fistula tract, and the fistula is facilitated for closure. In cases where endoscopy therapy fails, operative management is necessary.

Surgical Approach: This approach depends on the anatomy of the duct and the site of the fistula.

• Pancreaticojejunostomy: A process which is done in large duct diseased patients.

• Caudal Pancreatectomy: Injury at the tail of the pancreas can be treated with this surgical procedure.

• Distal Pancreatectomy: This approach is followed when there is an injury in the body of the pancreas, including the drainage of the fluid.

Recurrence of the pancreatic fluid can occur, which is treated using percutaneous drains.

What Is the Prognosis for Pancreatic Fistula?

When the pancreatic fistulas are not treated or addressed properly, symptoms can be severe. Moderately severe pancreatic fistulas are managed using supportive and conservative approaches. The success rate of resolution of pancreatic fistulas can be high when managed with surgical intervention. Fistulas that develop after the surgery can be resolved in nearly two months. A fatality of nearly ten percent is also reported.

What Are the Complications of Pancreatic Fistula?

Following are the complications of pancreatic fistulas.

• Pancreatic Necrosis - It is also known as pancreatic abscess, which can be seen as fluid accumulation in computed tomography.

• Pseudocyst Formation - Formation of pseudocyst can occur due to disruption of the ductal wall.

• Sepsis - It is a medical emergency in which the blood is infected, and the organs supplied with the blood are all infected.

• Pleural Effusion of the Pancreas - Leakage of pancreatic enzymes leading to the formation of a fistula.

• Intra-Abdominal Hemorrhage - It is a type of bleeding that occurs in the peritoneal cavity (the cavity present between organs and lining of the abdominal wall.

• Pancreatic Ascites - It is a rarely occurring complication that leads to continuous leakage into the peritoneum.

Conclusion

Pancreatic fistula can be managed with the help of a multidisciplinary team approach, including surgeons, primary care doctors, nutritionists, wound care nurses, radiologists, and gastroenterologists. Proper coordination and communication are necessary to obtain a positive outcome of the treatment. A better prognosis is obtained through surgical intervention, lowering the risks of complications. Symptoms should be noted concerning the development of pancreatic fistula, and treatment should be provided.