Pancreatic fistula surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Patients with expanding peripancreatic fluid on abdominal imaging or with persistent symptoms undergo endoscopic therapy via endoscopic retrograde cholangiopancreatography (ERCP) as it is a preferred approach towards the management of a symptomatic pancreatic fistula due to its diagnostic as well as therapeutic value. A transpapillary pancreatic stent is placed during ERCP and/or a pancreatic sphincterectomy is done. If no improvement is seen or endoscopic therapy is not feasible, the patient may receive surgical treatment. Surgical treatment depends upon the location of the fistula where the duct is disrupted, the size of the peripancreatic fluid collection, presence of vascular thrombosis, tissue necrosis and history of previous interventions. Surgical treatment may involve the drainage of pancreatic pseudocyst if indicated, which is often associated with chronic pancreatic fistula. Other options may include fistulojejunostomy, pancreatic resection and decompression of the pancreatic duct with pancreatojejunostomy.
Surgery
- Most of the pancreatic fistula are reported to close spontaneously with supportive care. However, if patient develops symptoms such as abdominal discomfort, fever and chills, abdominal imaging should be done to evaluate the peripancreatic fluid expansion. Patients with expanding peripancreatic fluid on abdominal imaging or with persistent symptoms undergo endoscopic therapy via endoscopic retrograde cholangiopancreatography (ERCP) as it is a preferred approach towards the management of a symptomatic pancreatic fistula due to its diagnostic as well as therapeutic value. A transpapillary pancreatic stent is placed during ERCP and/or a pancreatic sphincterectomy is done.
- If no improvement is seen or endoscopic therapy is not feasible, the patient may receive surgical treatment. Most of the patients presenting with a biochemical leak are asymptomatic and are managed with conservative approach using supportive care, however, patients with Grade B or C pancreatic fistula may need surgery if not improved with medical therapy.[1]
- Surgical treatment depends upon the location of the fistula where the duct is disrupted, the size of the peripancreatic fluid collection, presence of vascular thrombosis, tissue necrosis and history of previous interventions.[2]
- Surgical treatment may involve the drainage of pancreatic pseudocyst if indicated, which is often associated with chronic pancreatic fistula.
- Other options may include fistulojejunostomy, pancreatic resection and decompression of the pancreatic duct with pancreatojejunostomy.
- 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.[3][4]
References
- ↑ 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.
- ↑ Hackert T, Werner J, Büchler MW (2011). "Postoperative pancreatic fistula". Surgeon. 9 (4): 211–7. doi:10.1016/j.surge.2010.10.011. PMID 21672661.
- ↑ Bressan AK, Wahba M, Dixon E, Ball CG (2018). "Completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy: a systematic review and qualitative synthesis of the literature". HPB (Oxford). 20 (1): 20–27. doi:10.1016/j.hpb.2017.08.036. PMID 28978403.
- ↑ Smits FJ, Molenaar IQ, Besselink MG, Busch OR, van Eijck CH, van Santvoort HC; et al. (2018). "Management of postoperative pancreatic fistula after pancreatoduodenectomy: high mortality after completion pancreatectomy: Reply to: Bressan et al. completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy". HPB (Oxford). 20 (12): 1223. doi:10.1016/j.hpb.2018.05.015. PMID 29941289.