What Is a Pancreatic Fistula?

After the pancreatic duct is ruptured, the pancreatic fluid leaks from non-physiological channels is called pancreatic fistula. It is one of the serious complications of acute and chronic pancreatitis and abdominal surgery, especially after pancreatic surgery and trauma. Pancreatic fistula is divided into extrapancreatic fistula and intrapancreatic fistula. Those who flow out of the body are called extrapancreatic fistula, and those who flow into the digestive tract are called pancreatic fistula. With the increase of acute necrotizing pancreatitis, pancreatic trauma, and pancreatic surgery, the incidence of pancreatic fistula also increases. The treatment of pancreatic fistula is more difficult. If it is not handled properly, it may easily cause serious complications such as bleeding, infection, and even death. Prevention of pancreatic fistula and proper treatment of pancreatic fistula that has already occurred are still problems that pancreatic surgery requires continuous efforts to solve.

Basic Information

Visiting department: General surgery
Common locations: pancreas
Common causes: Pancreatic trauma, acute necrotizing pancreatitis, catheter damage due to pancreatic surgery, etc.

Common symptoms: Mild pancreatic fistula may be asymptomatic in the early stage, and severe pancreatic fistula may have obvious tenderness in the abdomen, tachycardia, shortness of breath, and peritonitis in the presence of infection.

Causes of pancreatic fistula

Pancreatic trauma

Is the most common cause of pancreatic fistula. Mainly due to: After pancreatic damage, especially pancreatic contusion, laceration or crush injury caused by blunt injury, when the pancreas is debrided or repaired, the remaining damaged pancreatic tissue can continue to necrosis after operation, once it is involved Pancreatic duct, pancreatic fistula occurs; pancreatic fistula is still prone to occur if the pancreatic duct is damaged after surgery; damage to the large pancreatic duct or main pancreatic duct. Successful, pancreatic fistula is prone to occur. If direct drainage is performed, pancreatic fistula may also occur after operation.

2. Acute necrotizing pancreatitis

Necrosis of pancreatic tissues and pancreatic ducts due to ischemia and enzymatic digestion. Necrotic pancreatic tissues are exposed after surgical removal or spontaneous detachment, or after pancreatic body and tail excision, pancreatic secretion persists due to tissue infection. Outflow from the drainage port, causing pancreatic fistula.

3. Pancreas surgery

All types of pancreatic surgery and interventional procedures may cause pancreatic duct damage and form pancreatic fistula.

Pancreatic fistula classification

1. Extrapancreatic fistula and intrapancreatic fistula

The pancreatic juice flows out of the surface through the abdominal drainage tube or incision as an extrapancreatic fistula. Intrapancreatic fistula includes pancreatic pseudocysts and pancreatic thoracic, ascites, and fistulas between pancreatic ducts and other organs. If pancreatic fluid flows into the abdominal cavity but is surrounded by surrounding organ tissues, an intrapancreatic fistula is formed.

2. High flow fistula and low flow fistula

According to the leakage of pancreatic juice, extrapancreatic fistula was divided into high-flow fistula (> 200ml / d) and low-flow fistula (<200ml / d).

3. Severity

According to the severity of pancreatic fistula, pancreatic fistula is divided into three types: mild asymptomatic, pancreatic fluid drainage <100ml / d; moderate mild clinical symptoms related to delayed drainage (nausea, vomiting, persistent fever) The drainage volume of pancreatic juice is 100-500ml / d; severe clinical symptoms (abdominal abscess, etc.), the drainage volume of pancreatic juice is> 500ml / d, and other therapeutic intervention is needed.

Clinical manifestations of pancreatic fistula

Mild pancreatic fistula may only show elevated amylase in the drainage fluid in the early stage without other symptoms. Severe pancreatic fistula often manifests as early tenderness in the abdomen, tachycardia, shortness of breath, or mild irritability in the patient, peritonitis in the presence of infection, and amylase in the drainage fluid is often significantly increased. Loss of a large amount of pancreatic juice containing water, electrolytes and proteins, if not replenished in time, can cause dehydration and disturbance of electrolyte balance, as well as digestion and absorption of nutrients, manifested as wasting and malnutrition. Excessive loss of alkaline pancreatic juice can cause metabolic acidosis. The skin around the fistula is eroded and eroded, causing ulcers and even bleeding. It can also heal the skin of the fistula before pancreatic fistula due to poor drainage, forming a pseudopancreatic cyst

Pancreatic fistula

1.Determination of amylase in drainage fluid

The determination of amylase concentration in the drainage fluid is an important criterion for judging pancreatic fistula, but most of the plasma amylase concentration in the pancreatic fistula shows a normal range.

2.B-ultrasound

It can be used to explore the shape of the pancreas, the presence of peripancreatic effusion, and the presence of pancreatic cysts, and as a preliminary examination of the pancreatic and bile duct systems.

3.CT, MRI examination

You can further check the pancreas and pancreatic ducts for deformation, the presence of peripancreatic effusion and cysts, especially for the relationship between pancreatic ducts and the site of pancreatic fluid leakage or cysts.

4. Retrograde pancreaticobiliary ductography (ERCP)

Pancreaticobiliary angiography can directly observe the location and scope of pancreatic duct rupture and the anatomical relationship between pancreatic duct and fistula, especially the etiology and classification of pancreatic fistula.

Pancreatic fistula treatment

The general treatment principles are adequate drainage, control of infections, prevention of corrosive bleeding, correction of water and electrolyte disturbances, and nutritional support. With aggressive non-surgical treatment, most pancreatic fistulas can heal themselves.

Full drainage

Sufficient and smooth drainage is the most important and important measure for the treatment of pancreatic fistula after surgery. The most important thing is the management of the drainage tube. If the drainage is smooth after the operation, there is not much problem even if pancreatic fistula occurs. The leaked pancreatic fluid can be drawn out from the drainage tube, and it will not accumulate elsewhere and cause bacterial proliferation and corrosive bleeding.

2. Controlling infection

The main cause of infection during pancreatic fistula is poor drainage, which can be repeatedly punctured and catheterized under ultrasound or CT guidance. Patients with extrapancreatic fistula with local infection should also pay attention to the rational application of antibiotics.

3. Prevention and treatment of corrosive bleeding

Pancreatic fistula with intra-abdominal hemorrhage is the most dangerous situation. Once pancreatic fistula occurs, we must attach great importance to the prevention and treatment of intra-abdominal hemorrhage.

4. Correct water and electrolyte disorders

Through blood biochemical monitoring, according to the blood sodium concentration, an appropriate amount of 3% sodium chloride can be added, and more can be corrected in time. Severe hypokalemia can be corrected by micropump supplementation of potassium chloride through the central vein.

5. Nutrition support

Pancreatic fistula can provide total parenteral nutrition support at an early stage, and after recovery of intestinal function, efforts should be made to restore enteral nutrition support. Enteral nutrition is best administered via the jejunum, as it avoids further stimulation of the pancreas.

6. Surgical treatment

After effective drainage and corresponding non-surgical treatment, pancreatic fistula self-healing rate is higher. If the above treatments have not been cured, and the time is more than 3 months, surgical treatment is feasible.