This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and

1. Management of Pancreatic
fistulas
Surgical Clinics of North America June
2013

2. Introduction
• Definition: Leakage of pancreatic fluid as a
result of pancreatic duct obstruction.
• Iatrogenic
• Non- Iatrogenic

3. • Non iatrogenic
• Acute or chronic pancreatitis – alcohol/
gallstones.

4. • 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.

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

6. Internal fistulas.
• Pancreatitis.
• Can present as
– Pancreatic ascites.
– Pancreaticopleural fistula.

7. External fistulas.
• Pancreaticocutaneous fistula.
• Percutaneous drainage of
pseudocyst/collection.
• Pancreatic debridement.
• Pancreatic resection.

8. Initial management.
1. Control pancreatic secretions
• CT/USG guided drain placement.
• Antibiotics
2. 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.

9. 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

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

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

12. • Fibrin glue.
–Injection of fibrin through drain or
radiologically.
–Effective in low – output pancreatic fistulas.

13. • 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.

14. 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.

15. • 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

16. Treatment of post-procedural fistulas.
Following
• Percutaneous drainage of pseudocyst.
• Operative debridement of acute pancreatitis.
• Operative pancreatic injury.
• Pancreatic resection.

17. • 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.

18. • 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.

19. • After pancreatic resection.
• Leak from divided edge/ pancreatic
anastomosis.
• 20 % incidence after
pancreaticoduodenectomy and distal
pancreatectomy.
• Management – conservative with drains

20. 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.

22. • Thank you