Skip to main content
SpringerLink
Log in

Treatment of Pancreatic Leaks and Fistulae

  • Living reference work entry
  • First Online:
Gastrointestinal and Pancreatico-Biliary Diseases: Advanced Diagnostic and Therapeutic Endoscopy

Abstract

Pancreatic fistulae occur as a result of pancreatic duct disruption, most often in the context of pancreatitis, surgery, or trauma. They are categorized as external if they communicate with the skin or internal if they connect with epithelialized spaces within the body, most commonly the peritoneal or pleural cavities, resulting in ascites or pleural effusion, respectively. They are a leading cause of morbidity and mortality in patients post pancreatic surgery, and they are associated with multiple systemic complications independent of their etiology. Conservative treatment aims to decrease pancreatic exocrine secretions and includes nutritional support and somatostatin analogue therapy, yet a significant proportion of patients will not improve without further intervention, which was traditionally surgical. Endoscopic retrograde cholangiopancreatography with transpapillary stenting of the pancreatic duct is now a key part of the treatment algorithm with early data suggesting promising outcomes. This review provides an overview of pancreatic fistula with a focus on endoscopic management.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Alexakis N, Sutton R, Neoptolemos JP (2004) Surgical treatment of pancreatic fistula. Dig Surg 21(4):262–274. https://doi.org/10.1159/000080199

    Article  CAS  PubMed  Google Scholar 

  2. Baker RJ, Bass RT, Zajtchuk R, Strohl EL (1967) External pancreatic fistula following abdominal injury. Arch Surg 95(4):556–566. https://doi.org/10.1001/archsurg.1967.01330160026004

    Article  CAS  PubMed  Google Scholar 

  3. Bakker OJ, van Baal MC, van Santvoort HC, Besselink MG, Poley JW, Heisterkamp J, Bollen TL, Gooszen HG, van Eijck CH, Dutch Pancreatitis Study G (2011) Endoscopic transpapillary stenting or conservative treatment for pancreatic fistulas in necrotizing pancreatitis: multicenter series and literature review. Ann Surg 253(5):961–967. https://doi.org/10.1097/SLA.0b013e318212e901

    Article  PubMed  Google Scholar 

  4. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula D (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13. https://doi.org/10.1016/j.surg.2005.05.001

    Article  PubMed  Google Scholar 

  5. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic S (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 161(3):584–591. https://doi.org/10.1016/j.surg.2016.11.014

    Article  PubMed  Google Scholar 

  6. Bhasin DK, Rana SS, Siyad I, Poddar U, Thapa BR, Sinha SK, Nagi B (2006) Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 21(6):1059–1064. https://doi.org/10.1111/j.1440-1746.2005.04049.x

    Article  PubMed  Google Scholar 

  7. Boerma D, Rauws EA, van Gulik TM, Huibregtse K, Obertop H, Gouma DJ (2000) Endoscopic stent placement for pancreaticocutaneous fistula after surgical drainage of the pancreas. Br J Surg 87(11):1506–1509. https://doi.org/10.1046/j.1365-2168.2000.01573.x

    Article  CAS  PubMed  Google Scholar 

  8. Bracher GA, Manocha AP, DeBanto JR, Gates LK Jr, Slivka A, Whitcomb DC, Bleau BL, Ulrich CD 2nd, Martin SP (1999) Endoscopic pancreatic duct stenting to treat pancreatic ascites. Gastrointest Endosc 49(6):710–715. https://doi.org/10.1016/s0016-5107(99)70287-7

    Article  CAS  PubMed  Google Scholar 

  9. Brelvi ZS, Jonas ME, Trotman BW, Dodda G, DaCosta JA, Cho KC, Sundaram NK, Kim KH (1996) Nasopancreatic drainage: a novel approach for treating internal pancreatic fistulas and pseudocysts. J Assoc Acad Minor Phys 7(2):41–46

    CAS  PubMed  Google Scholar 

  10. Brennan PM, Stefaniak T, Palmer KR, Parks RW (2006) Endoscopic transpapillary stenting of pancreatic duct disruption. Dig Surg 23(4):250–254. https://doi.org/10.1159/000095398

    Article  CAS  PubMed  Google Scholar 

  11. Carr-Locke DL, Gregg JA (1981) Endoscopic manometry of pancreatic and biliary sphincter zones in man. Basal results in healthy volunteers. Dig Dis Sci 26(1):7–15. https://doi.org/10.1007/BF01307970

    Article  CAS  PubMed  Google Scholar 

  12. Chebli JM, Gaburri PD, de Souza AF, Ornellas AT, Martins Junior EV, Chebli LA, Felga GE, Pinto JR (2004) Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol 38(9):795–800. https://doi.org/10.1097/01.mcg.0000139051.74801.43

    Article  PubMed  Google Scholar 

  13. Cicek B, Parlak E, Oguz D, Disibeyaz S, Koksal AS, Sahin B (2006) Endoscopic treatment of pancreatic fistulas. Surg Endosc 20(11):1706–1712. https://doi.org/10.1007/s00464-005-0764-7

    Article  CAS  PubMed  Google Scholar 

  14. Costamagna G, Mutignani M, Ingrosso M, Vamvakousis V, Alevras P, Manta R, Perri V (2001) Endoscopic treatment of postsurgical external pancreatic fistulas. Endoscopy 33(4):317–322. https://doi.org/10.1055/s-2001-13695

    Article  CAS  PubMed  Google Scholar 

  15. Das R, Papachristou GI, Slivka A, Easler JJ, Chennat J, Malin J, Herman JB, Laique SN, Hayat U, Ooi YS, Rabinovitz M, Yadav D, Siddiqui AA (2016) Endotherapy is effective for pancreatic ductal disruption: a dual center experience. Pancreatology 16(2):278–283. https://doi.org/10.1016/j.pan.2015.12.176

    Article  PubMed  Google Scholar 

  16. Dhebri AR, Ferran N (2005) Nonsurgical management of pancreaticopleural fistula. JOP 6(2):152–161

    PubMed  Google Scholar 

  17. Drake LM, Anis M, Lawrence C (2012) Accuracy of magnetic resonance cholangiopancreatography in identifying pancreatic duct disruption. J Clin Gastroenterol 46(8):696–699. https://doi.org/10.1097/MCG.0b013e31825003b3

    Article  PubMed  Google Scholar 

  18. Eckhauser F, Raper SE, Knol JA, Mulholland MW (1991) Surgical management of pancreatic pseudocysts, pancreatic ascites, and pancreaticopleural fistulas. Pancreas 6(Suppl 1):S66–S75. https://doi.org/10.1097/00006676-199101001-00011

    Article  PubMed  Google Scholar 

  19. Enestvedt CK, Diggs BS, Cassera MA, Hammill C, Hansen PD, Wolf RF (2012) Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg 204(3):332–338. https://doi.org/10.1016/j.amjsurg.2011.10.019

    Article  PubMed  Google Scholar 

  20. Fielding GA, McLatchie GR, Wilson C, Imrie CW, Carter DC (1989) Acute pancreatitis and pancreatic fistula formation. Br J Surg 76(11):1126–1128. https://doi.org/10.1002/bjs.1800761106

    Article  CAS  PubMed  Google Scholar 

  21. Gans SL, van Westreenen HL, Kiewiet JJ, Rauws EA, Gouma DJ, Boermeester MA (2012) Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula. Br J Surg 99(6):754–760. https://doi.org/10.1002/bjs.8709

    Article  CAS  PubMed  Google Scholar 

  22. Goasguen N, Bourrier A, Ponsot P, Bastien L, Lesurtel M, Prat F, Dousset B, Sauvanet A (2009) Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation. Am J Surg 197(6):715–720. https://doi.org/10.1016/j.amjsurg.2008.03.005

    Article  PubMed  Google Scholar 

  23. Gomez-Cerezo J, Barbado Cano A, Suarez I, Soto A, Rios JJ, Vazquez JJ (2003) Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000. Am J Gastroenterol 98(3):568–577. https://doi.org/10.1111/j.1572-0241.2003.07310.x

    Article  CAS  PubMed  Google Scholar 

  24. Halttunen J, Weckman L, Kemppainen E, Kylanpaa ML (2005) The endoscopic management of pancreatic fistulas. Surg Endosc 19(4):559–562. https://doi.org/10.1007/s00464-004-9140-2

    Article  CAS  PubMed  Google Scholar 

  25. Howard TJ, Stonerock CE, Sarkar J, Lehman GA, Sherman S, Wiebke EA, Madura JA, Broadie TA (1998) Contemporary treatment strategies for external pancreatic fistulas. Surgery 124(4):627–632. discussion 632–623. https://doi.org/10.1067/msy.1998.91267

    Article  CAS  PubMed  Google Scholar 

  26. Huibregtse K, Schneider B, Vrij AA, Tytgat GN (1988) Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 34(1):9–15. https://doi.org/10.1016/s0016-5107(88)71221-3

    Article  CAS  PubMed  Google Scholar 

  27. Kim WS, Choi DW, Choi SH, Heo JS, Kim MJ, Song SC, Lee HG, You DD (2011) Clinical validation of the ISGPF classification and the risk factors of pancreatic fistula formation following duct-to-mucosa pancreaticojejunostomy by one surgeon at a single center. J Gastrointest Surg 15(12):2187–2192. https://doi.org/10.1007/s11605-011-1726-0

    Article  PubMed  Google Scholar 

  28. Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J (2011) Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology 141(1):157–163, 163 e151. https://doi.org/10.1053/j.gastro.2011.03.040

    Article  PubMed  Google Scholar 

  29. Koshitani T, Uehara Y, Yasu T, Yamashita Y, Kirishima T, Yoshinami N, Takaaki J, Shintani H, Kashima K, Ogasawara H, Katsuma Y, Okanoue T (2006) Endoscopic management of pancreaticopleural fistulas: a report of three patients. Endoscopy 38(7):749–751. https://doi.org/10.1055/s-2006-925062

    Article  CAS  PubMed  Google Scholar 

  30. Kozarek RA (1990) Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 36(2):93–95. https://doi.org/10.1016/s0016-5107(90)70958-3

    Article  CAS  PubMed  Google Scholar 

  31. Kozarek RA, Ball TJ, Patterson DJ, Freeny PC, Ryan JA, Traverso LW (1991) Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 100(5 Pt 1):1362–1370

    Article  CAS  Google Scholar 

  32. Kozarek RA, Ball TJ, Patterson DJ, Raltz SL, Traverso LW, Ryan JA, Thirlby RC (1997) Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg 1(4):357–361. https://doi.org/10.1016/s1091-255x(97)80057-1

    Article  CAS  PubMed  Google Scholar 

  33. Kozarek RA, Jiranek GC, Traverso LW (1994) Endoscopic treatment of pancreatic ascites. Am J Surg 168(3):223–226. https://doi.org/10.1016/s0002-9610(05)80190-4

    Article  CAS  PubMed  Google Scholar 

  34. Kozarek RA, Patterson DJ, Ball TJ, Traverso LW (1989) Endoscopic placement of pancreatic stents and drains in the management of pancreatitis. Ann Surg 209(3):261–266. https://doi.org/10.1097/00000658-198903000-00002

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Kurumboor P, Varma D, Rajan M, Kamlesh NP, Paulose R, Narayanan RG, Philip M (2009) Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol. Indian J Gastroenterol 28(3):102–106. https://doi.org/10.1007/s12664-009-0037-9

    Article  PubMed  Google Scholar 

  36. Larsen M, Kozarek R (2014) Management of pancreatic ductal leaks and fistulae. J Gastroenterol Hepatol 29(7):1360–1370. https://doi.org/10.1111/jgh.12574

    Article  PubMed  Google Scholar 

  37. Lipsett PA, Cameron JL (1992) Internal pancreatic fistula. Am J Surg 163(2):216–220. https://doi.org/10.1016/0002-9610(92)90104-y

    Article  CAS  PubMed  Google Scholar 

  38. Madiba TE, Haffejee AA, Singh B, Reddy R (1995) Nutritional support in the management of external pancreatic fistulas. S Afr J Surg 33(2):81–84

    CAS  PubMed  Google Scholar 

  39. Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C (2014) Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg 399(7):801–810. https://doi.org/10.1007/s00423-014-1242-2

    Article  PubMed  Google Scholar 

  40. Melloul E, Raptis DA, Clavien PA, Lesurtel M, European-African Hepato-Pancreato-Biliary A (2013) Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey. HPB (Oxford) 15(4):307–314. https://doi.org/10.1111/j.1477-2574.2012.00599.x

    Article  Google Scholar 

  41. Morgan KA, Adams DB (2007) Management of internal and external pancreatic fistulas. Surg Clin North Am 87(6):1503–1513. https://doi.org/10.1016/j.suc.2007.08.008

    Article  PubMed  Google Scholar 

  42. Neoptolemos JP, London NJ, Carr-Locke DL (1993) Assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. Br J Surg 80(1):94–99. https://doi.org/10.1002/bjs.1800800131

    Article  CAS  PubMed  Google Scholar 

  43. Pai CG, Suvarna D, Bhat G (2009) Endoscopic treatment as first-line therapy for pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 24(7):1198–1202. https://doi.org/10.1111/j.1440-1746.2009.05796.x

    Article  PubMed  Google Scholar 

  44. Parekh D, Segal I (1992) Pancreatic ascites and effusion. Risk factors for failure of conservative therapy and the role of octreotide. Arch Surg 127(6):707–712. https://doi.org/10.1001/archsurg.1992.01420060083012

    Article  CAS  PubMed  Google Scholar 

  45. Pelaez-Luna M, Vege SS, Petersen BT, Chari ST, Clain JE, Levy MJ, Pearson RK, Topazian MD, Farnell MB, Kendrick ML, Baron TH (2008) Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 68(1):91–97. https://doi.org/10.1016/j.gie.2007.11.041

    Article  PubMed  Google Scholar 

  46. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM Jr (2007) Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 245(3):443–451. https://doi.org/10.1097/01.sla.0000251708.70219.d2

    Article  PubMed  PubMed Central  Google Scholar 

  47. Rana SS, Bhasin DK, Nanda M, Siyad I, Gupta R, Kang M, Nagi B, Singh K (2010) Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions. J Gastroenterol Hepatol 25(6):1087–1092. https://doi.org/10.1111/j.1440-1746.2009.06172.x

    Article  PubMed  Google Scholar 

  48. Saeed ZA, Ramirez FC, Hepps KS (1993) Endoscopic stent placement for internal and external pancreatic fistulas. Gastroenterology 105(4):1213–1217. https://doi.org/10.1016/0016-5085(93)90970-n

    Article  CAS  PubMed  Google Scholar 

  49. Shrode CW, Macdonough P, Gaidhane M, Northup PG, Sauer B, Ku J, Ellen K, Shami VM, Kahaleh M (2013) Multimodality endoscopic treatment of pancreatic duct disruption with stenting and pseudocyst drainage: how efficacious is it? Dig Liver Dis 45(2):129–133. https://doi.org/10.1016/j.dld.2012.08.026

    Article  PubMed  Google Scholar 

  50. Sikora SS, Khare R, Srikanth G, Kumar A, Saxena R, Kapoor VK (2005) External pancreatic fistula as a sequel to management of acute severe necrotizing pancreatitis. Dig Surg 22(6):446–451discussion 452. https://doi.org/10.1159/000091448

    Article  PubMed  Google Scholar 

  51. Smith MT, Sherman S, Ikenberry SO, Hawes RH, Lehman GA (1996) Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 44(3):268–275. https://doi.org/10.1016/s0016-5107(96)70163-3

    Article  CAS  PubMed  Google Scholar 

  52. Tanaka T, Kuroki T, Kitasato A, Adachi T, Ono S, Hirabaru M, Matsushima H, Takatsuki M, Eguchi S (2013) Endoscopic transpapillary pancreatic stenting for internal pancreatic fistula with the disruption of the pancreatic ductal system. Pancreatology 13(6):621–624. https://doi.org/10.1016/j.pan.2013.08.006

    Article  PubMed  Google Scholar 

  53. Telford JJ, Farrell JJ, Saltzman JR, Shields SJ, Banks PA, Lichtenstein DR, Johannes RS, Kelsey PB, Carr-Locke DL (2002) Pancreatic stent placement for duct disruption. Gastrointest Endosc 56(1):18–24. https://doi.org/10.1067/mge.2002.125107

    Article  PubMed  Google Scholar 

  54. Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB (2005) Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 61(4):568–575. https://doi.org/10.1016/s0016-5107(04)02832-9

    Article  PubMed  Google Scholar 

  55. Varadarajulu S, Rana SS, Bhasin DK (2013) Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 23(4):863–892. https://doi.org/10.1016/j.giec.2013.06.008

    Article  PubMed  Google Scholar 

  56. Vollmer CM Jr, Sanchez N, Gondek S, McAuliffe J, Kent TS, Christein JD, Callery MP, Pancreatic Surgery Mortality Study G (2012) A root-cause analysis of mortality following major pancreatectomy. J Gastrointest Surg 16(1):89–102.; discussion 102–103. https://doi.org/10.1007/s11605-011-1753-x

    Article  PubMed  Google Scholar 

  57. Voss M, Pappas T (2002) Pancreatic Fistula. Curr Treat Options Gastroenterol 5(5):345–353. https://doi.org/10.1007/s11938-002-0023-0

    Article  PubMed  Google Scholar 

  58. Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Traverso LW, Freeny PC (1992) Pancreaticoenteric fistula: no longer a surgical disease? J Clin Gastroenterol 14(2):117–121

    Article  CAS  Google Scholar 

Download references

Acknowledgment

The authors acknowledge Dr. Tolga Erim for contributing images for Figures 1 and 2.

Author information

Authors and Affiliations

  1. Department of Medicine, Harvard Medical School, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Corey S. Miller & Douglas Pleskow

Authors
  1. Corey S. Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Douglas Pleskow
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Douglas Pleskow .

Editor information

Editors and Affiliations

  1. Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, MILANO, Milano, Italy

    Pier Alberto Testoni

  2. Digestive Diseases Center, Showa University Hospital, Tokyo, Japan

    Haruhiro Inoue

  3. Div. of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA

    Michael B. Wallace

Section Editor information

  1. Gastrointestinal Endoscopy Unit, Vita‐Salute San Raffaele University, Milan, Italy

    Pier Alberto Testoni

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this entry

Check for updates. Verify currency and authenticity via CrossMark

Cite this entry

Miller, C.S., Pleskow, D. (2020). Treatment of Pancreatic Leaks and Fistulae. In: Testoni, P.A., Inoue, H., Wallace, M.B. (eds) Gastrointestinal and Pancreatico-Biliary Diseases: Advanced Diagnostic and Therapeutic Endoscopy. Springer, Cham. https://doi.org/10.1007/978-3-030-29964-4_93-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-29964-4_93-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-29964-4

  • Online ISBN: 978-3-030-29964-4

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation