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G. Tsiotos J. Tsiaoussis
Pancreatic
and Intestinal Fistulas
Modern Management of NP
and its Implications
Since it has been recognized that the early peak of
mortality in the biphasic mortality pattern of NP is
due to the overwhelming systemic inflammatory response syndrome (SIRS; not sepsis), whereas the later
second peak is due to sepsis, two major components
of modern management have emerged: (1) very aggressive hemodynamic, ventilatory, metabolic, and
nutritional support and avoiding operative treatment
in the early phase, and (2) delayed operative treatment
(where necessary) for as long as possible. This approach, which has been substantiated by cornerstone
clinical studies [2,3] and is now the preferred management strategy in patients with NP [4], has led to
optimized hemodynamics early after NP, much fewer
reoperations for debridement (usually just one), essentially no gauze packing, and placement of fewer
drains. As will be discussed in detail below, these factors have substantially decreased the incidence of NP/
IF.
Pathogenesis
Although the pathogenesis of PF/IF is multifactorial,
the most common factor in their development is the
presence of pancreatic parenchymal necrosis, as this
results in the disruption of small or large pancreatic
ducts with subsequent extravasation of exocrine secretions into the retroperitoneum [5]. Operative necrosectomy and local drainage allow for external
egress of these extravasated secretions and the potential for a pancreaticocutaneous fistula. The concurrent pancreatic and peripancreatic inflammatory
process may also lead to stenosis of the pancreatic
ducts, which represents a substantial element for the
chronicity of fistulas. The importance of pancreatic
parenchymal necrosis as the main risk factor in the
pathogenesis of PF is stressed by the finding in one
study that all patients who developed pancreaticocu-
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Autodigestion
Autodigestion of adjacent organs as a cause of IF in
the course of NP has more of a theoretical background.
According to this hypothesis, the extravasated exocrine secretions may result in transmural necrosis of
the stomach and small intestine in a way similar to
peripancreatic fat necrosis. This concept for the development of gastrointestinal tract fistulas seems much
less likely because, unlike fat, the stomach and small
intestine have a much better vascular supply and,
thus, associated protective mechanisms [6].
G. Tsiotos J. Tsiaoussis
Pressure Necrosis
Another iatrogenic mechanism of fistula formation
may be from pressure necrosis of a segment of bowel
from an adjacent drain and such a mechanism could
Chapter 25
reflect the late development of certain colonic, smallbowel, or gastric fistulas. To avoid this, the peripancreatic drains should not be positioned directly on the
duodenum or ascending colon when placed from the
patients right side, or on the descending colon when
placed from the left side. The ideal placement of the
drains is behind the splenic flexure of the colon and
below the lower pole of the spleen, thereby exiting the
abdominal wall in the left anterior axillary line. Also,
large, hard, stiff sump drains should be avoided as an
additional means of prevention of gastrointestinal fistula.
Minimally invasive techniques (percutaneous or
endoscopic drainage) and minimally invasive surgery
(retroperitoneoscopic debridement) are alternatives
to open surgery in select cases, promising lower morbidity including lower incidence of PF [10]. These innovations have not been popularized yet and only a
small number of series (with highly selected patients)
have been published [11]. With the currently available
experience, laparoscopy-assisted necrosectomy might
be followed by a higher trend for significant injuries
to intra-abdominal viscera including a higher incidence of PF/IF, as has been reported (2060%) [9].
Pancreatic Fistulas
Definition and Incidence
The lack of a widely accepted definition of this complication in the setting of NP has contributed in part
to the major discrepancy in its reported incidence
among published series. Criteria such as amylase level
in the excreted fluid, daily output of the fistula, and
its duration vary among studies. Despite the varying
definitions, a PF can be conceptualized anatomically
as an abnormal communication between a pancreatic
duct (major or minor) and the skin (pancreaticocutaneous fistula or external fistula), or between the pancreatic duct and peritoneal or pleural cavity, or another hollow viscus (internal fistula). Because of its
clinical significance we will deal with external fistulas in this chapter. The presence of infected NP (versus sterile NP) seems to favor the development of PF,
as PF is far more common (up to 76%) in the former
group [6,12].
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Management
PFs are quite often complicated by fluid and electrolyte abnormalities, malnutrition, skin erosion, and
less often hemorrhage and sepsis. The initial management of PF is conservative and its fundamental principles are the following:
1. Provision of optimal drainage to avoid intra-abdominal fluid collections.
2. Maintenance of fluid and electrolyte balance.
3. Treatment of local infection.
4. Optimization of nutritional status by parenteral or
preferably enteral feeding.
5. Skin care.
An additional appealing line of PF management is the
reduction of pancreatic secretion (and thus PF output) by possible administration of octreotide. The
role of octreotide in the prevention and the treatment
of PF has been studied in the postpancreatectomy setting (for tumor or chronic pancreatitis), but not in the
NP setting. It is fair to note that five of nine prospective randomized studies demonstrate a favorable effect of octreotide over placebo, whereas the remaining four did not [14]. Again, all nine studies included
patients who had undergone an elective pancreatic
operation and not patients with PF in the context of
NP. Our experience with the use of octreotide in an
effort to accelerate the closure of inflammatory PF
has not been encouraging [6]. It seems unlikely that
G. Tsiotos J. Tsiaoussis
this issue will be definitively resolved in the near future; today, the use of octreotide in this setting is not
evidence-based and should be reserved for use only
within a clinical protocol.
Spontaneous closure of a PF should be the primary
therapeutic goal. Compared to postoperative PF, postNP PF tends to have less chances of spontaneous closure (53% vs 86%) and longer duration for those that
do selfresolve (22weeks vs 11weeks) [15]. Although
good nutritional status, optimal drainage, and absence of local and systemic infection certainly provide
a favorable background for spontaneous PF closure,
the single most important factor determining prognosis and dictating definitive management is the pattern of ductal disruption that has given rise to the
development of the PF. Failure of spontaneous closure
is generally due to anatomic factors such as downstream ductal obstruction and disconnected duct
syndrome (isolated pancreatic tail). For example, recognition of an intact pancreatic duct without a downstream ductal obstruction indicates a high possibility
of spontaneous closure. On the contrary, surgery is
necessary when the PF is associated with a leak from
the pancreatic duct that is not joined with the gastrointestinal tract. Indeed, no such PF closed after a
mean of 26weeks of aggressive medical therapy, and
all of these patients required surgical intervention
[15].
In general, when a PF persists for more than
2weeks and its daily output remains essentially unchanged over this period (i.e., without significant,
meaningful decrease), a sinogram should be performed, followed possibly by MRCP. The choice
among further treatment options depends on the specific findings:
Communication of the PF with a Minor (Side)
Pancreatic Duct
Nonoperative management is justified and the chances are that such a PF will eventually close, even after a
few months, provided that the duct drains with no
stenosis (stricture) toward the main pancreatic duct
and to the duodenum.
Communication of the PF with the Main
Pancreatic Duct that has a Proximal Stenosis
Spontaneous closure is unlikely because the pancreatic duct distal to the stricture is preferentially draining to the PF. These patients are ideal for endoscopic
bridging of the proximal and distal parts of the pancreatic duct (traversing the stricture, as well as the
Chapter 25
ductal disruption feeding the PF) and stent placement. Small-diameter (57mm) stents with variable
length across the site of the ductal stricture and disruption may be used. Success rates are high (75100%)
[16,17]. Suboptimal stent placement, stent migration,
or stent occlusion may require repetition of the technique to achieve complete closure of the PF (up to five
stent placements in one patient have been reported for
PF resolution). Interestingly, even when the stent only
traverses the stricture, but does not bridge the site of
ductal leakage, the outcome may be successful [18].
The duration of endoscopic therapy to close the PF
varies from a few days to several weeks, and once it has
been rendered, stents are retrieved after 1014days.
of PF in the vast majority of patients with appropriately defined fistulas and pancreatic ductal anatomy.
However, in the minority in whom this approach fails,
an operation is mandatory. For patients with no disconnected pancreatic segment, a side-to-side pancreaticojejunostomy at the area of the origin of the fistulous tract is usually the optimal operative option.
Intestinal Fistulas
Definition and Incidence
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thus define whether it is duodenum, proximal or distal small bowel, or colon), and will demonstrate the
presence or absence of intestinal stenosis or obstruction distal to the intestinal disruption and the source
of the fistula. A CECT scan should always be performed primarily to rule out an undrained fluid collection that often coexists at the time that the IF is
first diagnosed.
Management
As with PF, the principles of IF management are: provision of excellent drainage, optimization of fluid,
electrolyte, and nutritional status, treatment of local
infection, and skin care. In patients with upper-gut
fistulas, nutrition should be provided either parenterally or enterally distal to the site of the IF using a nasojejunal tube or a tube placed operatively.
A lot of the decision-making regarding further
management depends upon the source of the fistula
(upper gut versus colonic) and on the specific anatomic details of the IF:
1. Every undrained fluid collection seen in CECT
should be well drained by percutaneously placed
tubes under radiologic guidance. This will alleviate
systemic infection and also simplify the fistulous
tract by providing a direct communication between
the intestine and the skin without pooling of intestinal content into the surrounding tissues.
2. The presence of a luminal obstruction or stenosis
distal to the luminal disruption feeding the IF essentially guarantees failure of nonoperative management. On the contrary, absence of a distal stenosis
justifies nonoperative management for long time.
3. The pattern of the fistulous tract is of paramount
importance. Narrow and long fistulas are far more
likely to close spontaneously compared to the wide
and short ones. Prolonged nonoperative management is the preferred option for the former, whereas
it is not justified for the latter.
4. The role of IF output is important and twofold. A
high output (i.e., >200ml/day persistently) may be
first associated with hard-to-maintain electrolyte
balance, and second with distal luminal stenosis
and/or a wider and shorter fistulous tract. It is for
these reasons that a persistently high-output IF is
less likely to close spontaneously.
Provided that no absolute contraindication (i.e., distal
luminal obstruction) is present for nonoperative management, the prognosis of IF is closely related to the
G. Tsiotos J. Tsiaoussis
Chapter 25
Summary
PFs and IFs are notorious complications of NP, but
their incidence has decreased due to the recent change
of management scheme for NP consisting of aggressive initial hemodynamic support and delayed necrosectomy, which has led to a reduction in the number
of reoperations required. Precise delineations of the
fistulous tract in relation to the pancreatic ductal system and the pattern of pancreatic duct disruption dictate the prognosis and the appropriate management
option for a PF. Many PFs close spontaneously, some
require advanced endoscopic intrapancreatic procedures (ductal stent placement), and few require opera-
tive intervention. Most upper-gut fistulas close spontaneously provided that there is no distal intestinal
stenosis, whereas colonic fistulas are generally troublesome, may lead to sepsis, and require urgent operative treatment.
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