Perforations and Fistulas of the Gastrointestinal Tract in Patients with Necrotizing Pancreatitis: A Nationwide Prospective Analysis

Abstract

Introduction: Perforation and fistula of the gastrointestinal (GI)-tract may occur in necrotizing pancreatitis. Data from large unselected patient populations on the incidence, risk factors, clinical outcomes and treatment are lacking. Methods: We performed a post-hoc analysis of 896 patients with necrotizing pancreatitis, prospectively included in 23 Dutch hospitals (2005-2015). Multivariable logistic regression was used to explore risk factors and to adjust for confounders in comparing clinical outcomes of patients with or without perforation and fistula of the GI-tract. Results: GI-tract perforations and fistulas were identified in 139 (16%) patients, mostly in the duodenum (40%) and colon (64%). Independent risk factors were highest C-reactive protein within 48-hours after admission (OR 1.20 [95%-CI 1.02–1.41]), organ-failure in the first week (OR 2.81 [95%-CI 1.80–4.39]) and infected necrosis before diagnosis (OR 1.81 [95%-CI 1.11–2.97]). GI-tract perforation and fistula were associated with poor clinical outcomes, especially when the colon was affected. This is exemplified by an increase in prolonged ICU-stays (OR 6.64 [95%-CI 13.02–15.18]) and more invasive interventions (OR 4.54 [95%-CI 1.82-13.19]). Perforations and fistulas of the stomach and duodenum were treated conservatively in 66% and surgically in 8%. Colon perforations and fistulas were treated conservatively in 27% and surgically in 57%. Conclusions: Perforations and fistulas of the GI-tract occur in one in six patients with necrotizing pancreatitis and poorly affects clinical outcomes, especially colon perforations and fistulas. Risk factors are C-reactive protein within 48 hours, early organ-failure and infected necrosis. Overall, more than half of the patients are treated conservatively.