Endoscopic treatment of pancreatic fistulas

Abstract

Aims: Pancreatic fistula is a serious complication of acute and chronic pancreatitis or pancreatic trauma and surgery. Its management is still controversial. Patients and methods: 8 patients with pancreatic fistula were treated endoscopically over a period of 5 years. 5 patients were presented with pancreatic ascites following pancreatic tail resection (2 cases), nephrectomy (1 case), blunt abdominal trauma (1 case) and necrosectomy due to acute necrotic pancreatitis (1 case). In 1 patient pancreatic ascites and left pleural effusion developed after splenectomy and in 1 patient pleural effusion occurred as a complication of chronic pancreatitis; 1 patient had an external fistula associated with pancreatic tail pseudocyst following distal pancreatectomy. The level of amylase in the aspirated fluids were consistently elevated. The mean fistula output volume was 150ml/day. ERCP identified leaks. Dual or pancreatic sphincterotomy, pancreatic stent or nasopancreatic drain placement was performed to lower the pancreatic duct pressure and bypass the ductal disruption. Results: Dual or pancreatic sphincterotomy was effective for the 5 patients in whom the ductal injury originated from the tail of the pancreas and hence could not be bypassed (splenectomy, nephrectomy, abdominal trauma, two postoperative fistulas). These patients had no strictures in the main pancreatic duct. Their fistulas closed within 3 weeks, except for one patient whose fistula closed after 12 weeks. Pancreatic stent or nasopancreatic drain placement was performed in 3 patients with chronic pancreatitis and main pancreatic duct stricture to bypass the disruption. Only in one of the patients it was effective, leading to closure of the fistula. Endoscopic therapy was unsuccessful in 2 patients in spite of pancreatic stent, enteral nutrition and use of octreotide. They required surgery. There was no serious complication or procedure-related mortality. Conclusion: Endoscopic treatment is an effective and safe method for pancreatic fistulas, especially for patients without strictures in the main pancreatic duct.