Pancreatic fistula natural history, complications and prognosis: Difference between revisions
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*[[Anterior]] disruption of a [[Pancreatic pseudocyst|pseudocyst]] or a [[pancreatic duct]] leads to leakage of [[pancreatic]] secretions into the free [[peritoneal cavity]], leading to [[pancreatic]] [[ascites]]. If the duct is disrupted posteriorly, the secretions leak through the [[retroperitoneum]] into the [[mediastinum]] via the [[aortic]] or [[esophageal]] [[hiatus]].<ref>{{cite journal | author=Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD | title=Internal pancreatic fistulas: pancreatic ascites and pleural effusions | journal=Ann Surg | year=1976 | pages=587-93 | volume=184 | issue=5 | id=PMID 984927}}</ref><ref name="pmid984927">{{cite journal| author=Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD| title=Internal pancreatic fistulas: pancreatic ascites and pleural effusions. | journal=Ann Surg | year= 1976 | volume= 184 | issue= 5 | pages= 587-93 | pmid=984927 | doi=10.1097/00000658-197611000-00009 | pmc=1345487 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=984927 }}</ref> | *[[Anterior]] disruption of a [[Pancreatic pseudocyst|pseudocyst]] or a [[pancreatic duct]] leads to leakage of [[pancreatic]] secretions into the free [[peritoneal cavity]], leading to [[pancreatic]] [[ascites]]. If the duct is disrupted posteriorly, the secretions leak through the [[retroperitoneum]] into the [[mediastinum]] via the [[aortic]] or [[esophageal]] [[hiatus]].<ref>{{cite journal | author=Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD | title=Internal pancreatic fistulas: pancreatic ascites and pleural effusions | journal=Ann Surg | year=1976 | pages=587-93 | volume=184 | issue=5 | id=PMID 984927}}</ref><ref name="pmid984927">{{cite journal| author=Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD| title=Internal pancreatic fistulas: pancreatic ascites and pleural effusions. | journal=Ann Surg | year= 1976 | volume= 184 | issue= 5 | pages= 587-93 | pmid=984927 | doi=10.1097/00000658-197611000-00009 | pmc=1345487 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=984927 }}</ref> | ||
*Once in the [[mediastinum]], the secretions can either be contained in a [[mediastinal]] [[pseudocyst]], lead to [[enzymatic]] [[mediastinitis]], or, more commonly, leak through the [[pleura]] to enter the chest and form a [[chronic]] [[pancreatic]] [[pleural effusion]].<ref name="pmid2755944">{{cite journal| author=Iacono C, Procacci C, Frigo F, Andreis IA, Cesaro G, Caia S | display-authors=etal| title=Thoracic complications of pancreatitis. | journal=Pancreas | year= 1989 | volume= 4 | issue= 2 | pages= 228-36 | pmid=2755944 | doi=10.1097/00006676-198904000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2755944 }}</ref><ref>{{cite journal | author= | *Once in the [[mediastinum]], the secretions can either be contained in a [[mediastinal]] [[pseudocyst]], lead to [[enzymatic]] [[mediastinitis]], or, more commonly, leak through the [[pleura]] to enter the chest and form a [[chronic]] [[pancreatic]] [[pleural effusion]].<ref name="pmid2755944">{{cite journal| author=Iacono C, Procacci C, Frigo F, Andreis IA, Cesaro G, Caia S | display-authors=etal| title=Thoracic complications of pancreatitis. | journal=Pancreas | year= 1989 | volume= 4 | issue= 2 | pages= 228-36 | pmid=2755944 | doi=10.1097/00006676-198904000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2755944 }}</ref><ref name="pmid13064942">{{cite journal| author=SMITH EB| title=Hemorrhagic ascites and hemothorax associated with benign pancreatic disease. | journal=AMA Arch Surg | year= 1953 | volume= 67 | issue= 1 | pages= 52-6 | pmid=13064942 | doi=10.1001/archsurg.1953.01260040055008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13064942 }}</ref> | ||
*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:<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="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> | *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:<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="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> | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Clinical presentation may range from being asymptomatic to showing a variety of 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 following a pancreatic fistula may include 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.
Natural History, Complications, and Prognosis
Natural History
History and clinical presentation depends upon the size, location and connection of the pancreatic fistula with the involved organ or cavity.[1][2]
Clinical presentation may range from being asymptomatic to showing a variety of 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.[3]
- Internal pancreatic fistula may present with ascites or pleural effusion as fluid accumulates within the abdominal or thoracic cavity.[2]
Complications
- Anterior disruption of a pseudocyst or a pancreatic duct leads to leakage of pancreatic secretions into the free peritoneal cavity, leading to pancreatic ascites. If the duct is disrupted posteriorly, the secretions leak through the retroperitoneum into the mediastinum via the aortic or esophageal hiatus.[4][5]
- Once in the mediastinum, the secretions can either be contained in a mediastinal pseudocyst, lead to enzymatic mediastinitis, or, more commonly, leak through the pleura to enter the chest and form a chronic pancreatic pleural effusion.[6][7]
- 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:[8][9]
- 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.
Prognosis
- 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.[10][11]
References
- ↑ Pratt WB, Callery MP, Vollmer CM (2009). "The latent presentation of pancreatic fistulas". Br J Surg. 96 (6): 641–9. doi:10.1002/bjs.6614. PMID 19434658.
- ↑ 2.0 2.1 Fulcher AS, Capps GW, Turner MA (1999). "Thoracopancreatic fistula: clinical and imaging findings". J Comput Assist Tomogr. 23 (2): 181–7. doi:10.1097/00004728-199903000-00004. PMID 10096323.
- ↑ Schoch A, Rivory J, Monneuse O, Nargues N, Ponchon T, Pioche M (2020). "EUS-guided detection and internal drainage of an open pancreaticocutaneous fistula after acute necrotizing pancreatitis". Endoscopy. 52 (8): E284–E285. doi:10.1055/a-1099-8998. PMID 32052403 Check
|pmid=value (help). - ↑ Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD (1976). "Internal pancreatic fistulas: pancreatic ascites and pleural effusions". Ann Surg. 184 (5): 587–93. PMID 984927.
- ↑ Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD (1976). "Internal pancreatic fistulas: pancreatic ascites and pleural effusions". Ann Surg. 184 (5): 587–93. doi:10.1097/00000658-197611000-00009. PMC 1345487. PMID 984927.
- ↑ Iacono C, Procacci C, Frigo F, Andreis IA, Cesaro G, Caia S; et al. (1989). "Thoracic complications of pancreatitis". Pancreas. 4 (2): 228–36. doi:10.1097/00006676-198904000-00012. PMID 2755944.
- ↑ SMITH EB (1953). "Hemorrhagic ascites and hemothorax associated with benign pancreatic disease". AMA Arch Surg. 67 (1): 52–6. doi:10.1001/archsurg.1953.01260040055008. PMID 13064942.
- ↑ Nahm CB, Connor SJ, Samra JS, Mittal A (2018). "Postoperative pancreatic fistula: a review of traditional and emerging concepts". Clin Exp Gastroenterol. 11: 105–118. doi:10.2147/CEG.S120217. PMC 5858541. PMID 29588609.
- ↑ Larsen M, Kozarek R (2014). "Management of pancreatic ductal leaks and fistulae". J Gastroenterol Hepatol. 29 (7): 1360–70. doi:10.1111/jgh.12574. PMID 24650171.
- ↑ Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M (2013). "Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center". Case Rep Gastroenterol. 7 (2): 332–9. doi:10.1159/000354136. PMC 3764947. PMID 24019766.
- ↑ Alexakis N, Sutton R, Neoptolemos JP (2004). "Surgical treatment of pancreatic fistula". Dig Surg. 21 (4): 262–74. doi:10.1159/000080199. PMID 15308865.