|
|
| (4 intermediate revisions by the same user not shown) |
| Line 18: |
Line 18: |
|
| |
|
| ==[[Pancreatic fistula overview|Overview]]== | | ==[[Pancreatic fistula overview|Overview]]== |
| A [[pancreatic]] [[fistula]] is an abnormal connection between the epithelialized surfaces of the [[pancreatic duct]] and adjacent or distant structures, [[organs]] or [[cavities]].
| |
|
| |
| Clinical criteria defined by the International Study Group for [[Pancreatic]] [[Fistula]] (ISGPF) is a measurable [[Drain (surgery)|drain]] output containing [[pancreas]]-derived [[enzyme]] [[amylase]] which is greater than three times the upper limit of the normal serum level measured on or after postoperative day three.
| |
|
| |
| A revised grading for [[pancreatic]] [[fistula]] was proposed by ISGPF, according to which [[pancreatic]] [[fistula]] is graded either into a new category which involve an [[asymptomatic]] leakage from the [[pancreas]] called [[biochemical]] leak (BL), or Grade B including patients who undergo [[surgical procedures]] such as [[percutaneous]] or [[endoscopic]] drainage or [[angiographic]] procedures in order to promote the healing of [[fistula]] and Grade C including patients with [[organ failure]] requiring reoperations and [[mortality]] as a result of complication from [[pancreatic]] [[fistula]].
| |
|
| |
|
| ==[[Pancreatic fistula historical perspective|Historical Perspective]]== | | ==[[Pancreatic fistula historical perspective|Historical Perspective]]== |
| There is no historical significance associated with pancreatic fistula.
| |
|
| |
|
| ==[[Pancreatic fistula classification|Classification]]== | | ==[[Pancreatic fistula classification|Classification]]== |
| [[Pancreatic]] [[fistula]] can be classified anatomically as;
| |
|
| |
| *[[Internal]] [[fistula]]: The [[pancreatic duct]] communicates with [[internal organs]] or [[body cavity]] such as [[Pleural cavity|pleural]] or [[peritoneal]] [[cavity]].
| |
|
| |
| *External [[fistula]]: The [[pancreatic duct]] communicates with the [[skin]], otherwise known as pancreaticocutaneous [[fistula]].<ref name="pmid18053844">{{cite journal| author=Morgan KA, Adams DB| title=Management of internal and external pancreatic fistulas. | journal=Surg Clin North Am | year= 2007 | volume= 87 | issue= 6 | pages= 1503-13, x | pmid=18053844 | doi=10.1016/j.suc.2007.08.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18053844 }} </ref>
| |
|
| |
| Pancreatic fistula can also be classified based on the [[anatomy]] of the [[pancreatic duct]] and the location of [[injury]] as;
| |
|
| |
| *Type 1 [[pancreatic]] [[fistula]]: Involves [[injury]] to the [[pancreatic]] [[parenchyma]] with leakage from the [[distal]] part of the [[pancreatic duct]] or the side branches.
| |
| *Type 2 [[pancreatic]] [[fistula]]: Involves [[injury]] to and leak from the main [[pancreatic duct]].
| |
| *Type 3 [[pancreatic]] [[fistula]]: Occurs as a result of [[proximal]] or [[distal]] [[pancreatectomy]].<ref name="pmid28780610">{{cite journal| author=Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M | display-authors=etal| title=Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification. | journal=Dig Dis Sci | year= 2017 | volume= 62 | issue= 10 | pages= 2648-2657 | pmid=28780610 | doi=10.1007/s10620-017-4697-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28780610 }} </ref>
| |
|
| |
| [[Pancreatic]] [[fistula]] is classified into two categories on the basis of [[clinical]] manifestations, [[complications]] and severity by the ISGPF as;
| |
|
| |
| *[[Biochemical]] [[pancreatic]] [[fistula]]: This category includes fistula with no significant [[clinical]] [[symptoms]].
| |
| *Clinically relevant [[pancreatic]] [[fistula]]: This category includes [[fistulas]] under grade B and C, which shows significant clinical [[symptoms]] and require surgical [[interventions]], re-surgeries and can complicate into [[organ failure]] and death.<ref name="pmid31840199">{{cite journal| author=Jiang L, Ning D, Chen X| title=Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions. | journal=Front Med | year= 2020 | volume= 14 | issue= 3 | pages= 251-261 | pmid=31840199 | doi=10.1007/s11684-019-0727-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31840199 }} </ref>
| |
|
| |
|
| ==[[Pancreatic fistula pathophysiology|Pathophysiology]]== | | ==[[Pancreatic fistula pathophysiology|Pathophysiology]]== |
| The [[pathophysiology]] of [[pancreatic]] [[fistula]] involves the disruption of the [[pancreatic duct]] either from an [[iatrogenic]] insult, underlying [[inflammatory process]] or [[trauma]]. The disruption of the [[pancreatic duct]] causes gradual loss of the integrity of the tissue resulting in the leakage of the [[pancreatic]] [[fluid]] which induces [[inflammation]] and erosions, thereby leading to the formation of abnormal connections between the [[duct]] and the surrounding structures.<ref name="pmid29588609">{{cite journal| author=Nahm CB, Connor SJ, Samra JS, Mittal A| title=Postoperative pancreatic fistula: a review of traditional and emerging concepts. | journal=Clin Exp Gastroenterol | year= 2018 | volume= 11 | issue= | pages= 105-118 | pmid=29588609 | doi=10.2147/CEG.S120217 | pmc=5858541 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29588609 }} </ref><ref name="pmid21672661">{{cite journal| author=Hackert T, Werner J, Büchler MW| title=Postoperative pancreatic fistula. | journal=Surgeon | year= 2011 | volume= 9 | issue= 4 | pages= 211-7 | pmid=21672661 | doi=10.1016/j.surge.2010.10.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21672661 }} </ref>
| |
|
| |
|
| ==[[Pancreatic fistula causes|Causes]]== | | ==[[Pancreatic fistula causes|Causes]]== |
| [[Pancreatic]] [[fistula]] can result from different types of insults such as;<ref name="pmid24650171">{{cite journal| author=Larsen M, Kozarek R| title=Management of pancreatic ductal leaks and fistulae. | journal=J Gastroenterol Hepatol | year= 2014 | volume= 29 | issue= 7 | pages= 1360-70 | pmid=24650171 | doi=10.1111/jgh.12574 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24650171 }} </ref><ref name="pmid28040257">{{cite journal| author=Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M | display-authors=etal| title=The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. | journal=Surgery | year= 2017 | volume= 161 | issue= 3 | pages= 584-591 | pmid=28040257 | doi=10.1016/j.surg.2016.11.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28040257 }} </ref>
| |
|
| |
| *[[Iatrogenic]]: External [[pancreatic]] [[fistula]] is most commonly [[iatrogenic]] in [[etiology]]. [[Trauma]] to the [[duct]] during [[surgery]] such as [[pancreaticoduodenectomy]], [[distal]] [[pancreatectomy]], during [[endoscopic]] intervention, [[extraction]] of a [[biopsy]] sample, [[pancreatic]] [[resection]] or as a complication of drainage of [[pancreatic pseudocyst]].
| |
| *Non-iatrogenic: Includes [[pathology]] of the [[gland]] such as [[acute]] or [[chronic pancreatitis]] or [[trauma]] to the [[abdominal]] structures or [[organs]] leading to [[fistula]] formation.
| |
|
| |
|
| ==[[Pancreatic fistula differential diagnosis|Differentiating Pancreatic fistula from other Diseases]]== | | ==[[Pancreatic fistula differential diagnosis|Differentiating Pancreatic fistula from other Diseases]]== |
| [[Differential diagnosis]] of a [[pancreatic]] [[fistula]] may include evaluation for:<ref name="pmid25893120">{{cite journal| author=Cochrane J, Schlepp G| title=Acute on chronic pancreatitis causing a highway to the colon with subsequent road closure: pancreatic colonic fistula presenting as a large bowel obstruction treated with pancreatic duct stenting. | journal=Case Rep Gastrointest Med | year= 2015 | volume= 2015 | issue= | pages= 794282 | pmid=25893120 | doi=10.1155/2015/794282 | pmc=4381724 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25893120 }} </ref>
| |
|
| |
| #[[Chronic liver disease]] leading to [[abdominal]] [[ascites]]
| |
| #[[Renal failure]]
| |
| #[[Heart failure]]
| |
| #[[Malignancy]]
| |
| #Conditions leading to [[pleural effusion]] such as [[malignancy]], [[trauma]] and [[infections]]
| |
| #[[Pancreatitis]]
| |
| #[[Retroperitoneal bleeding]]
| |
| #[[Bowel ischemia]]
| |
|
| |
|
| ==[[Pancreatic fistula epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Pancreatic fistula epidemiology and demographics|Epidemiology and Demographics]]== |
| [[Pancreatic]] [[fistula]] is a known complication following [[surgical resection]] of the [[pancreas]]. The [[incidence rate]] varies from as low as 5% in high volume centers to as high as 26%.<ref name="pmid24019766">{{cite journal| author=Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M| title=Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. | journal=Case Rep Gastroenterol | year= 2013 | volume= 7 | issue= 2 | pages= 332-9 | pmid=24019766 | doi=10.1159/000354136 | pmc=3764947 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24019766 }} </ref> [[Acute]] [[fluid]] collection is recorded in up to 40% patients with [[acute pancreatitis]], out of which some cases develops true [[pancreatic]] [[fistula]] depending upon the severity of the insult.<ref name="pmid24650171">{{cite journal| author=Larsen M, Kozarek R| title=Management of pancreatic ductal leaks and fistulae. | journal=J Gastroenterol Hepatol | year= 2014 | volume= 29 | issue= 7 | pages= 1360-70 | pmid=24650171 | doi=10.1111/jgh.12574 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24650171 }} </ref> Post-operative [[pancreatic]] [[Fistula|fistulae]] can affect 13% to 41% of patients after [[pancreatic]] [[resection]], making it a known source of [[morbidity]] and [[mortality]]. [[Pancreatic]] [[fistula]] can lead to certain severe [[complications]] if not addressed on time, as it carries a [[mortality]] risk of 25% in patients with grade C [[pancreatic]] [[fistula]]. The overall [[mortality rate]] is 1%. The [[incidence]] of [[pancreatic]] [[fistula]] varies depending on the type of [[pancreatic]] [[resection]] as it can be as low as 3% following a [[pancreatic]] head [[resection]] to as high as 30% after [[distal]] [[pancreatectomy]].<ref name="pmid29588609">{{cite journal| author=Nahm CB, Connor SJ, Samra JS, Mittal A| title=Postoperative pancreatic fistula: a review of traditional and emerging concepts. | journal=Clin Exp Gastroenterol | year= 2018 | volume= 11 | issue= | pages= 105-118 | pmid=29588609 | doi=10.2147/CEG.S120217 | pmc=5858541 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29588609 }} </ref><ref name="pmid21672661">{{cite journal| author=Hackert T, Werner J, Büchler MW| title=Postoperative pancreatic fistula. | journal=Surgeon | year= 2011 | volume= 9 | issue= 4 | pages= 211-7 | pmid=21672661 | doi=10.1016/j.surge.2010.10.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21672661 }} </ref>
| |
|
| |
|
| ==[[Pancreatic fistula risk factors|Risk Factors]]== | | ==[[Pancreatic fistula risk factors|Risk Factors]]== |
| According to [[Fistula]] Risk Scoring (FRS) system, the risk factors for the development of [[pancreatic]] [[fistula]] depends upon:
| |
|
| |
| *Texture of the [[gland]]: Soft texture of the [[gland]] is identified as a predictive risk factor.
| |
| *[[Pathology]]: [[Carcinoma]] of the [[duodenum]], [[ampulla]], [[cystic duct]] and [[islet cell]] carries high risk for [[fistula]] development compared to the [[glandular]] [[carcinoma]] such as [[pancreatic]] [[Ductal carcinoma|ductal]] [[adenocarcinoma]] or [[chronic pancreatitis]].
| |
| *[[Diameter]] of the [[pancreatic duct]]: Small [[pancreatic duct]] diameter <3mm is identified as a risk factor for the development of [[fistula]] formation, specifically a diameter of <1mm carries a high risk.
| |
| *Intraoperative blood loss: >1000ml is associated with a high risk of [[fistula]] formation.
| |
| *Other risk factors may include male gender, excessive fluid administration during surgery, [[Fasting plasma glucose|fasting]] [[blood]] [[glucose]] <108 mg/dl and an increase remnant [[gland]] volume. Some studies have reported both [[malnutrition]] and [[obesity]] as risk factors for the development of [[pancreatic cancer]].
| |
|
| |
|
| ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | | ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| History and clinical presentation depends upon the size, location and connection of the [[pancreatic]] [[fistula]] with the involved [[Organ (anatomy)|organ]] or [[cavity]].
| |
|
| |
| Clinical presentation may range from being [[asymptomatic]] to showing a variety of [[Signs and Symptoms|signs]] and [[symptoms]] resulting from fluid accumulation such as [[nausea]], [[vomiting]], [[hypotension]], [[infection]], [[tachycardia]], [[pain]], [[weight loss]], [[ileus]] and severe symptoms such as unrelenting [[pain]] and [[sepsis]].
| |
|
| |
| External [[pancreatic]] [[fistula]] presents with [[pancreatic]] [[fluid]] accumulation noticeable on the [[skin]] surface.
| |
|
| |
| [[Internal]] [[pancreatic]] [[fistula]] may present with [[ascites]] or [[pleural effusion]] as fluid accumulates within the [[abdominal]] or [[thoracic]] cavity.
| |
|
| |
| Complications arising from a [[pancreatic]] [[fistula]] are due to the undrained [[pancreatic]] [[fluid]] accumulation and erosions caused by the enzymatically active substances of the fluid which affects the surrounding [[tissues]]. The most commonly observed complications are:
| |
|
| |
| #[[Wound]] [[infection]] and [[sepsis]]
| |
| #[[Hemorrhage]]
| |
| #[[Internal]] and/or external [[fistula]]
| |
| #[[Pancreatic pseudocyst]]
| |
| #[[Delayed gastric emptying]]
| |
| #[[Walled off pancreatic necrosis]]
| |
| #Prolongation of the hospital stay
| |
| #[[Pancreatic]] [[ascites]]
| |
| #High [[amylase]] [[pleural effusion]]
| |
| #Disconnected [[duct]] [[syndrome]]
| |
| #Multisystem involvement eventually leading to [[multiorgan failure]] and/or death.
| |
|
| |
| [[Pancreatic]] [[fistula]] that are less severe are reported to heal in a duration of 4-6 weeks with conservative management only. 80% of the external [[fistula]] and 50-65% of the [[internal]] [[fistula]] are reported to close eventually with conservative measures which involve stabilization of the patient with supportive therapies. However, [[pancreatic]] [[fistula]] can lead to significant [[morbidity]] if not addressed on time. Surgical intervention provides resolution of the [[fistula]] with a 90-92% success rate.
| |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
|
| |
|
| ===History and clinical presentation:=== | | ===History and clinical presentation:=== |
| A [[pancreatic]] [[fistula]] with leakage of fluid can be diagnosed in some cases with typical history and clinical presentation, such as patient presenting with [[pancreatitis]] followed by recurrence, persistent symptoms or post [[pancreatic]] [[resection]] fluid drainage with increase amylase level. However, most cases are far more challenging which require [[imaging]] techniques and examination of the fluid samples withdrawn from the leak to help diagnose the [[fistula]].
| |
|
| |
|
| ===Imaging:=== | | ===Imaging:=== |
| The imaging techniques used to confirm the diagnosis of [[pancreatic]] [[fistula]] may include [[abdominal]] [[ultrasound]], [[Computed tomography|CT-scan]] of the [[abdomen]], pancreatogram, [[endoscopic retrograde cholangiopancreatography]] (ERCP), [[magnetic resonance cholangiopancreatography]] (MRCP) and [[fine needle aspiration]] of the fluid using [[endoscopic ultrasound]] (EUS). [[ERCP]] can be used for both diagnosis and therapeutic purposes such as placement of [[stent]] during the procedure to facilitate the closure of [[fistula]].
| |
|
| |
|
| ===Laboratory tests:=== | | ===Laboratory tests:=== |
| Fluid samples collected via [[thoracentesis]], [[paracentesis]] or fluid collected via [[percutaneous]] drainage from an external [[fistula]] can be analyzed for [[amylase]] level, which helps solidify the diagnosis of [[pancreatic cancer]]. [[Complete blood count]] is necessary to check for any ongoing [[infection]] or [[hemorrhage]]. Complete metabolic panel including [[inflammatory]] markers, [[Electrolyte|serum electrolytes]], [[liver function tests]], [[calcium]], [[albumin]], [[amylase]] and [[lipase]] should be sent to [[laboratory]] for evaluation. Furthermore, [[pancreatic]] [[fistula]] leak presenting as [[ascites]] or [[pleural effusion]] should be analyzed for fluid [[protein]], [[albumin]], [[lactate dehydrogenase]], [[glucose]], gram cultures and total cell count. [[Pancreatic]] fluid [[amylase]] level will be >1000 u/dl.
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
| Treatment of a [[pancreatic]] [[fistula]] includes early recognition of the problem which is the key to careful management in order to prevent the consequent complications. Management of [[pancreatic]] [[fistula]] requires a multidisciplinary team which includes interventional [[radiologists]], [[endoscopy]] specialist and surgeons and include the following steps:
| |
|
| |
| #[[Biochemical]] leak: Patients with [[biochemical]] leak are clinically [[asymptomatic]] with an [[amylase]] rich [[pancreatic]] fluid drain and can be managed conservatively. Patients should be kept under observation with close monitoring for signs of complications in order to avoid its progression to clinically relevant [[pancreatic]] [[fistula]]. The drain placed intraoperatively are usually kept to support the spontaneous closure of the [[fistula]]. Drainage output and inflammatory markers such as [[C-reactive protein]] and [[leucocyte]] count are regularly monitored to prevent fluid collections that may lead to life threatening sequalae.
| |
| #Grade B or C [[pancreatic]] [[fistula]]:
| |
|
| |
| *Non-Surgical approach: Primary management involves treatment with non-surgical minimally invasive catheter drain placement. [[Imaging]] techniques such as [[Computed tomography|CT-scan]] in combination with interventional drain placement can help resolve peri-[[pancreatic]] fluid collection that went unrecognized and developed eventually. [[Antibiotic]] treatment is given to prevent [[abdominal]] [[infections]]. One life threatening condition that may complicate a grade B or C [[fistula]] is [[hemorrhage]] of a nearby [[vessel]] by the enzymatically active [[pancreatic]] fluid, which can be promptly evaluated with the help of [[CT angiography|CT]]-[[angiogram]] to identify the location of the bleeding vessel and can be managed via [[angiographic]] placement of a [[stent]] or [[embolization]].
| |
| *Surgical management: Conditions which requires urgent evacuation of large amount of blood that cannot be attained with minimally invasive techniques necessitates surgical interventions which include emergency [[laparotomy]], intra-abdominal lavage and drainage of infected fluid collections widely. Conditions which involves [[necrosis]], life threatening [[sepsis]] or complicated pancreatic fistula may require the [[resection]] of the remnant [[pancreas]].
| |
|
| |
| Supportive care which is proven beneficial for both [[biochemical]] leaks and patients who develop [[sepsis]] and/or [[hemorrhage]] as a complication of [[pancreatic]] [[fistula]] include stabilizing the patient, [[pancreatic]] secretion control, nil per oral by ideally starting temporary [[parenteral nutrition]] and correction of the fluid and [[Electrolyte|electrolytes]] abnormalities. [[Somatostatin]] analogs such as [[octreotide]] are used commonly to control the [[pancreatic]] secretion, however no significant benefit is observed with its use in patients with already established [[pancreatic]] [[fistula]].
| |
|
| |
| ==Case Studies==
| |
|
| |
|
| [[Pancreatic fistula case study one|Case #1]]
| |
|
| |
|
| [[Category:Organ disorders]] | | [[Category:Organ disorders]] |