Pancreas: Pancreatic Leak/Fistula

Pancreatic Leak/Fistula

Definitions

  • Leak: Pancreatic Fluid Leak Due to Duct Disruption
  • Fistula: Abnormal Connection from Pancreas to Other Structures/Spaces
    • Internal: Duct Communicates with Peritoneal Cavity, Pleural Cavity or Hollow Viscus
    • External: Duct Communicates with Skin
  • Output:
    • Low Output: < 200 cc/Day
    • High Output: > 200 cc/Day

International Study Group of Pancreatic Fistula (ISGPF) Definition – 2016 Update

  • Postoperative Pancreatic Fistula: Drain Amylase 3x the Upper Limit of Normal Serum Amylase on POD#3 or Later
    • Similar Definition to Bile Leak
  • Grade:
    • Biochemical Leak: No Clinical Implications
      • Not Technically Considered a Fistula
      • *Previously Defined as Grade A Fistula – Now Considered as Part of the Natural Postoperative Course for Up to 3 Weeks After Surgery
    • Grade B Fistula: Clinical Implications
    • Grade C Fistula: Results in Reoperation, Organ Failure or Death
  • Clinical Implications:
    • Requires a Change in Postoperative Management
    • Persistent Drainage > 3 Weeks
    • Drain Requires Repositioning Through Endoscopic or Percutaneous Procedures
    • Requires Angiographic Procedure for Bleeding
    • Signs of Infection without Organ Failure

General

  • Fluid Collection with Rim Enhancement
  • Causes:
    • Pancreatic Surgery (Most Common)
    • Pancreatitis
    • Trauma
    • Splenectomy
  • CT: Walled-Off Fluid Collection

Treatment

  • Asymptomatic: Supportive (NPO, Nasojejunal Feeding & Octreotide)
    • Repeat Imaging at 4-8 Weeks
  • Symptomatic or Persistent on Repeat Imaging: ERCP & Stent
    • If Fails: Surgery (Enteric Drainage, Pancreaticojejunostomy or Resection)
  • Symptomatic Postoperative Fistula: Percutaneous Drain
  • Diet Management:
    • Low Output: Continue Oral Diet
    • High Output: NPO & TPN