Pancreatic Duct Leak

Pancreatic duct leak is disruption of the main or a branch pancreatic duct with escape of pancreatic juice into the retroperitoneum or peritoneal cavity. It causes collections, pseudocysts, pancreatic ascites and pleural effusions.

Causes are acute necrotising pancreatitis (the commonest), chronic pancreatitis, trauma and pancreatic surgery (pancreatic fistula occurs in 10% to 30% after pancreatoduodenectomy). Disconnected duct syndrome is the complete form of the leak.

Pathophysiology.

Necrosis or injury breaks the duct wall, and pancreatic enzymes digest surrounding tissue. The leak persists while duct pressure is higher than that of the surrounding space.

Abdominal pain and distension, fever, a mass, ascites, pleural effusion with dyspnoea, and leakage of fluid through a drain or wound.

Red flags.

• Sepsis from an infected collection.
• Bleeding from a drain or wound.
• Respiratory compromise from effusion.

Fluid amylase over 1,000 units/L (usually over 5,000) with protein over 30 g/L, in a drain, ascites or pleural fluid, confirms the leak. Magnetic resonance cholangiopancreatography with secretin shows duct disruption and the collection. Endoscopic retrograde cholangiopancreatography shows the leak and treats it. CT shows collections.

Differential diagnosis.

• Bile leak.
• Chylous ascites.
• Infected necrosis.
• Pancreatic cancer with necrosis.
• Tuberculous or malignant ascites.

Give bowel rest with nutrition by the nasojejunal or oral route, drain symptomatic or infected collections, and bridge the leak with a transpapillary stent (5 to 10 French) placed by endoscopic retrograde cholangiopancreatography, which closes 70% to 90% of partial leaks. Complete disconnection needs long term transmural drainage or surgery.

• Octreotide (limited evidence): 100 micrograms subcutaneously three times daily for 7 to 14 days; maximum 600 micrograms daily; monitor glucose, gallstones and heart rate; reduce in severe renal impairment.
• Pancrelipase (when feeding orally): 40,000 to 50,000 lipase units with each main meal; maximum 10,000 lipase units/kg daily; monitor stool and weight.
• Piperacillin-tazobactam (infected collection): 4.5 g IV every 6 hours for 7 to 14 days after drainage; maximum 18 g daily; monitor renal function and counts; reduce for creatinine clearance under 40 mL/min.

Monitoring. Drain output and amylase each day; imaging at 4 to 6 weeks; nutritional status each week.

Referral and escalation. Pancreatic endoscopy, interventional radiology and pancreatic surgery.