management of pancreatic fistulas
TRANSCRIPT
Management of Pancreatic fistulas
Surgical Clinics of North America June 2013
Introduction
• Definition: Leakage of pancreatic fluid as a result of pancreatic duct obstruction.
• Iatrogenic• Non- Iatrogenic
• Non iatrogenic• Acute or chronic pancreatitis – alcohol/
gallstones.
• 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.
• Definition: drain output of any volume on or after postoperative day 3 with an amylase greater than 3 times the serum level.
Internal fistulas.
• Pancreatitis.• Can present as– Pancreatic ascites.– Pancreaticopleural fistula.
External fistulas.
• Pancreaticocutaneous fistula.
• Percutaneous drainage of pseudocyst/collection.
• Pancreatic debridement.• Pancreatic resection.
Initial management.
1. Control pancreatic secretions• CT/USG guided drain placement. • Antibiotics2. 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.
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
Definitive management.
• 70-82 % close spontaneously.• Often nil per oral is the only management
required.
• Octreotide.– Inhibits exocrine secretion.–No effect on closure rate.–Reduces output and improves fistula
control.
• Fibrin glue.– Injection of fibrin through drain or
radiologically.– Effective in low – output pancreatic fistulas.
• 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.
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.
• 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
Treatment of post-procedural fistulas.
Following • Percutaneous drainage of pseudocyst.• Operative debridement of acute pancreatitis.• Operative pancreatic injury.• Pancreatic resection.
• 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.
• 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.
• After pancreatic resection.• Leak from divided edge/ pancreatic
anastomosis.• 20 % incidence after
pancreaticoduodenectomy and distal pancreatectomy.
• Management – conservative with drains
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.
• Thank you