Pancreatic Fistula

Pancreatic fistula is an abnormal communication between the pancreatic ductal system and another epithelial surface or cavity, with leakage of amylase rich fluid.

• Most are postoperative (pancreatoduodenectomy, distal pancreatectomy, enucleation) with rates of 10 to 30%.
• Other causes: acute necrotising pancreatitis, trauma, percutaneous drainage of collections, chronic pancreatitis.
• ISGPS definition and grades (postoperative pancreatic fistula): drain fluid amylase more than 3 times the upper serum limit, plus clinical impact.
  • Biochemical leak (no clinical impact).
  • Grade B: change in management (drain retained beyond 3 weeks, percutaneous drainage, antibiotics, nutritional support).
  • Grade C: reoperation, organ failure, death.
• Risk factors: soft gland texture, small duct (under 3 mm), high BMI, high risk pathology (ampullary, duodenal, cystic tumours), intraoperative blood loss.
• Complications: intra-abdominal abscess, sepsis, haemorrhage (pseudoaneurysm), delayed gastric emptying.

• Fever, abdominal pain, ileus, wound infection, tachycardia, high drain output of turbid fluid, gastric emptying delay.
• Sentinel bleed (small haemorrhage via drain) precedes catastrophic haemorrhage from erosion of the gastroduodenal or hepatic artery stump.
• External fistula presents with persistent drain output of pancreatic fluid (over 10 mL/day amylase rich).
• Internal fistulas cause ascites, pleural effusion, or pancreaticoenteric communication.

• Drain fluid amylase on postoperative day 1 and 3 (over 3 times serum amylase confirms).
• CT with oral and IV contrast: collections, fluid tracts, pseudoaneurysm.
• Fistulography (sinogram) or MRCP (with secretin) delineating the tract and duct.
• ERCP to identify main duct disruption.
• Inflammatory markers (CRP at day 3 over 150 mg/L predicts fistula or infection), white count, blood cultures.
• CT angiography for suspected haemorrhage or pseudoaneurysm.

• Drainage: maintain well positioned drains; remove when amylase is low and output is minimal; percutaneous drainage of undrained collections under imaging.
• Nutritional support: enteral nutrition (nasojejunal or jejunostomy) or parenteral nutrition for high output fistula.
• Octreotide 100 micrograms SC three times daily or somatostatin analogues; benefit in reducing fistula rate perioperatively is debatable, but used for established fistula.
• Antibiotics for infection (piperacillin tazobactam 4.5 g every 6 hours; meropenem 1 g every 8 hours); culture guided.
• Endoscopic transpapillary pancreatic duct stenting with sphincterotomy for persistent fistula; EUS guided drainage for internal collections.
• Management of haemorrhage: angiographic embolisation or covered stent placement; surgery for failure.
• Reoperation for uncontrolled sepsis or necrosis: drainage, completion pancreatectomy, anastomosis revision.
• Prevention: technique modifications (duct to mucosa anastomosis, pancreatic stent), pancreatic duct occlusion, drain management, early drain removal, avoidance of fluid overload.
• Most grade B fistulas heal within 6 to 8 weeks.