Acute pancreatitis and pancreatic fistula formation

Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas

Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.

Magnetic resonance imaging in the evaluation and management of acute pancreatitis: a review of current practices and future directions

Acute pancreatitis is a condition marked by inflammation of the pancreas and surrounding tissues. While the majority of cases of acute pancreatitis are mild, a minority of severe cases are the primary contributors to the morbidity and mortality attributed to this condition. Retroperitoneal morphologic changes can be detected by utilization of various imaging modalities, and their accurate evaluation is crucial for effective management. Acute pancreatitis is commonly diagnosed using computed tomography (CT). However, there are certain clinical scenarios where magnetic resonance imaging (MRI) may have superiority over CT. In particular, MRI is useful in cases where patients cannot receive iodinated CT contrast, or where there is a need to investigate the underlying cause of acute pancreatitis. Additionally, MRI can be utilized to evaluate ductal disconnection and guide interventions for necrotic collections. The unique features of MRI can be particularly useful, including its ability to provide superior contrast resolution and to offer greater functional information through techniques such as diffusion-weighted imaging. The aim of this review is to discuss the MRI assessment of individuals with acute pancreatitis. Additionally, the recent advances in MRI for evaluation of acute pancreatitis will also be introduced.

Imaging Diagnosis and Management of Fistulas in Pancreatitis

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Recurrent Pleural Effusions Secondary to Pancreaticopleural Fistula: A Case Presentation

Pleural effusion can be a complication of pancreatic diseases. Pancreaticopleural fistula (PPF) is a rare complication arising as a result of chronic pancreatitis that causes recurrent pleural effusions often resistant to thoracentesis. Diagnosis of PPF can be delayed, and presentation with respiratory symptoms related to pleural effusion is common. Elevated pleural fluid amylase and lipase levels are always helpful, but final diagnosis mostly requires demonstration of fistula on imaging modalities, such as computed tomography (CT) scan or magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde cholangiopancreatography (ERCP) serves as a diagnostic and therapeutic tool. Here, we present a case of PPF leading to recurrent pleural effusions, treated with stent placement.

Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis

Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.

Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis

BACKGROUND

External pancreatic fistulae (EPF) associated with complete pancreatic duct (PD) disruption leading on to disconnected pancreatic duct syndrome (DPDS) is a therapeutic nightmare usually requiring surgery. However, spontaneous closure also has been reported. There is paucity of data on the natural history of EPF associated with DPDS.

OBJECTIVE

To retrospectively study outcome of conservative treatment in patients with low output (<200 ml/day) EPF with DPDS following percutaneous or surgical intervention in acute necrotising pancreatitis (ANP).

METHODS

The data of patients of low output EPF with DPDS treated conservatively in our unit over last 5 years was retrospectively analysed. Their clinical course, complications as well as time taken for fistula closure was retrieved.

RESULTS

33 patients (27 males; mean age: 40.5 ± 9.3 years) of low output EPF and DPDS were studied. 31 patients developed EPF following percutaneous drainage (PCD) and 2 patients developed fistula following surgery. The drain fluid amylase ranged from 1600 to 32,000 IU/l and site of disruption was neck, proximal body and distal body in 4, 16 and 13 patients respectively. EPF closed spontaneously in all patients within 88.2 ± 63.46 days. PCD slipped out in 2 patients and led to formation of pseudocyst in 1 patient that was treated endoscopically. There has been no recurrence in any patient over follow up of 32.5 ± 21.9 months.

CONCLUSION

Low output EPF developing post PCD or surgery in patients with DPDS following ANP closely spontaneously in majority of patients within 3 months with good long term outcome.

The Use of Interventional Radiology Techniques in the Treatment of Pancreatic Fistula

One of the complications of pancreatic disease is the formation of pancreatic fistulae. The presence of fistula leads to body wasting and cachexia. The standard treatment is intubation of the Wirsung duct and in cases where there are no improvements the next proposed form of treatment is surgery. The aim of the study was to evaluate the efficacy of pancreatic fistula closure using interventional radiology techniques. In 2009 to 2014, 46 patients diagnosed with pancreatic fistula were treated with interventional radiology techniques. Treatment consisted of vascular coil implanted at the entry of the fistula and then sealed with tissue glue adhesive during endoscopic procedure. Technical success of vascular coil implantation and the use of tissue glue adhesive were reported in all patients. Pancreatic fistula recurred in 7 patients (15.2%). The latter group of patients underwent statistical analysis to determine what the risk factors in recurring pancreatic fistulas were. The results indicate a significant relationship between etiology of the fistula and treatment effect.

IN CONCLUSION

(1) the use of interventional radiology methods in the closure of pancreatic fistula is an effective and safe procedure; and (2) the recurrence of fistula is dependent on the etiology and often occurs after surgery or trauma.

Endoscopic transpapillary stenting for pancreatic fistulas after necrosectomy with necrotizing pancreatitis

BACKGROUND

Data concerning the incidence and treatment of pancreatic fistula after necrosectomy in severe acute necrotizing pancreatitis (SAP) are scarce. Our aim was to assess the incidence of pancreatic fistula, and the feasibility and results of endoscopic transpapillary stenting (ETS) in patients with SAP after necrosectomy.

METHODS

From January 2009 to December 2012 twenty-nine consecutive patients with SAP and necrosectomy in Oulu University Hospital were enrolled into this study. Five patients died before ETS because of the rapid progress of the disease and were, therefore, excluded.

RESULTS

ERP was performed for the remaining 24 patients demonstrating fistula in 22/24 patients (92 %). ETS was successful in 23 patients and the fistula closed in all of them after a median of 82 (2-210) days with acceptable morbidity and no procedure-related mortality.

CONCLUSION

All patients after necrosectomy for SAP seem to have internal or external pancreatic fistula. EST aimed at internal drainage of the necrosectomy cavity is a feasible and effective therapy in these patients.

Endoscopic transpapillary pancreatic stenting for internal pancreatic fistula with the disruption of the pancreatic ductal system

BACKGROUND

Internal pancreatic fistula (IPF) is a well-recognized complication of pancreatic diseases. Although there have been many reports concerning IPF, the therapy for IPF still remains controversial. We herein report our experiences with endoscopic transpapillary pancreatic stent therapy for IPF and evaluate its validity.

METHOD

Six patients with IPF who presented at our department and received endoscopic transpapillary pancreatic stent therapy were investigated, focusing on the clinical and imaging features as well as treatment strategies, the response to therapy and the outcome.

RESULTS

All patients were complicated with stenosis or obstruction of the main pancreatic duct, and in these cases the pancreatic ductal disruption developed distal to the areas of pancreatic stricture. The sites of pancreatic ductal disruption were the pancreatic body in five patients and the pancreatic tail in one patient. All patients received endoscopic stent placement over the stenosis site of the pancreatic duct. Three patients improved completely and one patient improved temporarily. Finally, three patients underwent surgical treatment for IPF. All patients have maintained a good course without a recurrence of IPF.

CONCLUSION

Endoscopic transpapillary pancreatic stent therapy may be an appropriate first-line treatment to be considered before surgical treatment. The point of stenting for IPF is to place a stent over the stenosis site of the pancreatic duct to reduce the pancreatic ductal pressure and the pseudocyst's pressure.

Spontaneous pancreatic pseudocyst-portal vein fistula: a rare and potentially life-threatening complication of pancreatitis

Pseudocyst formation following acute and chronic pancreatitis is a well known complication. A pancreatic pseudocyst fistulating into the portal vein is a rare and potentially fatal complication. We report a case of pancreatic pseudocyst – portal vein fistula, which was managed with a conservative approach.

CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety

OBJECTIVE

The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis.

MATERIALS AND METHODS

From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates.

RESULTS

Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed.

CONCLUSION

Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Uncommon acquired fistulae involving the digestive system: summary of data

PURPOSE

Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment.

METHODS

A literature review was carried out. Searches were conducted in Pubmed and related references reviewed.

RESULTS

Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery.

CONCLUSIONS

The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.

Pancreaticopleural fistula

OBJECTIVES

Pancreaticopleural fistula (PPF) is an unusual complication of chronic pancreatitis. Its diagnosis is obscured by predominance of pulmonary symptoms. A review of clinical presentation, etiology, diagnostic, and treatment modalities is presented in context of 2 cases from our institution.

METHODS

Case reports and case series of PPFs in the English literature from 1960 to 2007 were identified in the PubMed, OVID, and EMBASE search engines.

RESULTS

Fifty-two cases of PPF were identified. Common presenting complaint was dyspnea (65%) followed by abdominal pain (29%), cough (27%) and chest pain (23%). Computed tomography scanning diagnosed PPF in 8 (47%) of 17 patients, endoscopic retrograde cholangiopancreatography diagnosed PPF in 25 (78%) of 32 patients, and magnetic resonance cholangiopancreatography diagnosed PPF in 8 (80%) of 10 patients. Twenty-one patients (65%) improved with conservative management alone. Interventional therapy (5 endoscopic and 6 surgical interventions) was eventually needed in 35% of the patients after failing conservative management.

CONCLUSIONS

Pancreaticopleural fistula is a rare finding and requires a high index of suspicion for patients presenting with chest symptoms or pleural effusion and with history of pancreatitis or alcoholism. Magnetic resonance cholangiopancreatography is the better initial choice for being a noninvasive procedure and for better demonstration of complete main pancreatic duct obstruction. Restoring anatomic continuity is important if conservative approach fails.

Fistulojejunostomy for the management of refractory pancreatic fistula

BACKGROUND

Pancreatic fistula (PF) formation is a known complication of pancreatic surgery, pancreatitis, and pancreatic injury. When medical or endoscopic interventions fail to resolve PF, operation remains the only viable treatment option. Unfortunately, operation for the correction of PF is often difficult and associated with significant morbidity.

METHODS

Herein, we report on our experience with a previously described technique for the management of PF that is performed easily and is associated with reduced morbidity. During the period of 2003-2006, 8 patients (males = 6, female = 2) with PF were treated with prolonged percutaneous drainage. Once a mature scar tract formed around the percutaneous drain, patients underwent a fistulojejunostomy.

RESULTS

The age of these patients ranged from 43 to 61 years. Of the 8 patients, 5 had fistulas secondary to necrotizing pancreatitis. The remaining 3 patients had fistulas resulting from previous pancreatic surgery. The average interval between drain placement and fistulojejunostomy was 6 months (range, 4-7 months). The average duration of operation was 2.5 h (range, 1-4.5 h). The average blood loss was 280 mL (range, 50-600 mL). Average duration of stay was 9 days (average, 4-14 days). At a mean follow-up of 17 months (range, 2-58 months), 6 of 8 patients had resolution of their pancreatic fistulas, could resume regular diet, and were free of narcotic use. One patient developed a recurrent pseudocyst and required a distal pancreatectomy, and the final patient was lost to follow-up.

CONCLUSIONS

Fistulojejunostomy is an effective therapy for the definitive treatment of pancreatic fistulas.

Pathophysiology of pulmonary complications of acute pancreatitis

Acute pancreatitis in its severe form is complicated by multiple organ system dysfunction, most importantly by pulmonary complications which include hypoxia, acute respiratory distress syndrome, atelectasis, and pleural effusion. The pathogenesis of some of the above complications is attributed to the production of noxious cytokines. Clinically significant is the early onset of pleural effusion, which heralds a poor outcome of acute pancreatitis. The role of circulating trypsin, phospholipase A2, platelet activating factor, release of free fatty acids, chemoattractants such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, IL-6, IL-8, fMet-leu-phe (a bacterial wall product), nitric oxide, substance P, and macrophage inhibitor factor is currently studied. The hope is that future management of acute pancreatitis with a better understanding of the pathogenesis of lung injury will be directed against the production of noxious cytokines.

Evaluation and management of thoracopancreatic fistula

BACKGROUND

Thoracopancreatic fistula is a rare clinical entity but a serious complication of inflammatory pancreatic diseases, caused by a disruption of the pancreatic ductal system. Its diagnosis is frequently misleading, however, and thus is often delayed.

METHODS

Seven patients with thoracopancreatic fistula who presented at our department between March 2002 and July 2005 were investigated, focusing on the diagnostic work-up as well as the treatment strategies, the response to therapy, and the outcome.

RESULTS

Thoracopancreatic fistulas developed secondary to alcohol-related chronic pancreatitis in 6 patients and acute severe pancreatitis in 1. The disruption sites of the pancreatic ductal system were the head of the pancreas in 2 patients, the pancreatic body in 2 patients, and the pancreatic tail in 3 patients. All patients, except 1, were complicated with stricture of the main pancreatic duct, with ductal disruptions developing distal to the pancreatic strictures. The precise demonstration of the pancreatic ductal anatomy with ultrasonography, computed tomography (CT), conventional magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography was limited. In contrast, MR-cholangiopancreatography (MRCP) provided excellent mapping of the pancreatic ductal stricture, disruption, and fistula in 6 patients. Various medical therapies failed to close the fistula in all patients. Subsequent treatments, based on the assessment of pancreatic ductal anatomy with MRCP, included endoscopic transpapillary implantation of a pancreatic stent, a longitudinal pancreaticojejunostomy, distal pancreatectomy, and peritoneal drainage. All patient outcomes were favorable.

CONCLUSIONS

MRCP is an essential diagnostic modality in all suspected cases of thoracopancreatic fistula. The goal of treatment should be directed toward a sufficient decompression of the obstructed pancreas. If severe pancreatic stricture is present, then surgical decompression may be required in accordance with the individual pancreatic ductal anatomy.

Early and late complications after pancreatic necrosectomy

BACKGROUND

Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients.

METHODS

The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed.

RESULTS

The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency.

CONCLUSIONS

Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients

PURPOSE

The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS.

METHODS

We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded.

RESULTS

A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months).

CONCLUSIONS

A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.

Complications of acute pancreatitis: clinical and CT evaluation

Mortality of acute pancreatitis is dependent on the development of potentially lethal complications that can coexist and occur at any time following an acute attack. The nature and clinical relevance of these complications differ, contingent on the time of occurrence following a severe episode of pancreatitis. They can be divided into (1), early complications that manifest at the onset or within the first 2 to 3 days, (2) intermediate complications that occur predominantly during the second to fifth week, and (3) late complications that usually manifest months or years following the resolution of an acute attack. Early complications are systemic in nature with diverse clinical manifestations of the cardiovascular, pulmonary, renal, and/or metabolic systems. Intermediate complications are abdominal, pancreatic, and retroperitoneal, and are mostly septic in nature, associated with pancreatic or peripancreatic fat necrosis and pseudocysts. Late, life-threatening complications are mainly vascular or hemorrhagic in nature or involve the development of chronic pancreatic ascites. The early detection and objective evaluation of these complications by clinical and imaging methods leads to specific treatment options in the continuous attempt to decrease mortality rates in acute pancreatitis.

Pancreatico-mediastinal fistula with a mediastinal mass lesion demonstrated by MR imaging

Internal pancreatic fistulas are uncommon but well-recognized complications of inflammatory pancreatic disease. A case of a pancreatico-mediastinal fistula with a mediastinal mass lesion in a patient with a documented history of chronic alcohol consumption and previous episodes of acute pancreatitis is described. Since the clinical symptomatology was dominated by pulmonary complaints, magnetic resonance (MR) imaging using a breathhold coronal T2-weighted sequence with spectral fat saturation was essential in clarifying this difficult and rare pathology. Furthermore, the depiction of a fistulous tract between a mediastinal mass lesion and the retroperitoneum posterior to the pancreas, i.e., a pancreatico-mediastinal fistula by MR imaging has not been previously reported, to the best of our knowledge.

Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis

BACKGROUND

Roux-en-Y (RNY) internal drainage has been our primary surgical strategy to definitively treat disconnected duct syndrome in patients after severe acute pancreatitis (SAP). This study compares the results of internal drainage with the results of distal pancreatectomy-splenectomy (DPS) performed in a contemporaneous group of patients.

METHODS

For 5 years (June 1995 to June 2000), 27 consecutive patients with disconnected duct syndrome after SAP were identified: 13 treated with internal drainage and 14 with DPS. Fistula characteristics, operative management, and clinical outcome were analyzed. Comparisons between groups were made with the Student t test and Fisher exact test, with statistical significance defined as P <.05.

RESULTS

Age, sex, etiology of pancreatitis, comorbid diseases, and prior operations were similar between groups. Internal drainage required less operative time (211 +/- 37 vs 269 +/- 88 minutes, P =.04), blood loss (735 +/- 706 vs 2757 +/- 3062 mL, P =.03), and transfusion requirements (0.69 +/- 1.7 vs 4.21 +/- 8.0 units, P =.05). Clinical outcomes--as measured by postoperative complication rate, reoperation rate, fistula recurrence rate, and death rate--were similar between groups.

CONCLUSIONS

RNY internal drainage, when technically feasible, is the best surgical option to treat disconnected duct syndrome after SAP.

Contemporary treatment strategies for external pancreatic fistulas

BACKGROUND

Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions.

METHODS

Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract.

RESULTS

Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups.

CONCLUSIONS

Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.

Pancreatic ascites: a rare complication of necrotizing pancreatitis. A case report and review of the literature

We describe a young patient with a family history of hereditary pancreatitis who developed extensive pancreatic necrosis complicated by pancreatic ascites. Because of failure of medical management, he was successfully treated with operative necrosectomy and primary wound closure over peripancreatic drains. A postoperative low-output pancreaticocutaneous fistula resolved with time. Pancreatic ascites, as a result of pancreatic duct disruption, is more common in chronic rather than acute pancreatitis and is exceedingly uncommon in the context of necrotizing pancreatitis. When it complicates the latter, treatment should be guided by the principles of management of necrotizing pancreatitis. However, when true pancreatic ascites persists, the pancreatic duct anatomy and site of leak should be defined with endoscopic retrograde pancreatography (ERP). Treatment options include endoscopic duct dilatation and stent placement (if a stricture exists proximal to the leak), onlay pancreaticojejunostomy, or distal pancreatectomy (especially if the leak is located in the distal pancreas or in an enterically isolated distal pancreas).

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.

Pancreaticopleural fistula: a rare complication of chronic pancreatitis

Pancreaticopleural fistula is an uncommon sequelae of pancreatitis. The condition is often elusive, as respiratory rather than abdominal symptoms usually predominate and the fistula can be difficult to demonstrate radiologically. Confirmation is by demonstrating a high amylase content in the pleural aspirate relative to the serum. About half the fistulae will close with conservative treatment but persistent or recurrent effusions, often associated with stenosis or disruption of the main pancreatic duct, are an indication for surgery. The long-term outcome is good in 80-95% of cases. We report five patients with pleural effusion of pancreatic origin due to pancreaticopleural fistula.

Complete disruption of the main pancreatic duct: endoscopic management

BACKGROUND

Complete disruption of the main pancreatic duct is an unusual event in the course of acute or chronic pancreatitis. Endoscopic management has already proven effective in the treatment of partial ruptures.

METHODS

Thirteen patients presented over a 7-year period with acute (9 patients) or chronic (4 patients) pancreatitis complicated by complete disruption of the main pancreatic duct and cyst formation. Endoscopic treatment was attempted in 12. Treatment varied depending on the site of the rupture and accessibility of the pseudocyst and consisted either of transpapillary drainage (3), cystogastrostomy (3), cystoduodenostomy (2), or combined procedures (4) when one of these procedures did not induce significant decrease in collection size. Long-term results were obtained by observing the patients with ultrasound, CT, ERCP, and clinical evaluation.

RESULTS

Short-term results were excellent with complete cyst resolution and clinical recovery in all but one patient treated by endoscopy. Two patients had pseudocyst infection successfully treated by drainage and antibiotics. Long-term follow-up was available for 11 patients (mean duration, 30.2 months; range, 12 to 72 months) without relapsing clinical symptoms or pseudocyst.

CONCLUSIONS

Endoscopic management is effective and safe for treating patients with complete main pancreatic duct disruption. A double drainage combining transpapillary drainage and cystoenterostomy must be done in selected instances, especially when rupture occurs in the setting of chronic pancreatitis with stricture or stone distal to the rupture.

Endoscopic stent placement for internal and external pancreatic fistulas

Stents have been effectively used for various pancreatic conditions. Pancreatic fistulas, however, have traditionally been considered a surgical disease, and if the fistula does not respond to conservative measures, an operation is usually performed. Stents were placed endoscopically in five consecutive patients who presented with pancreatic fistulas that did not respond to conservative management. Fistulas resolved in all patients after endoscopic stent placement, and after 14-30 months of follow-up, none has recurred. The cases comprise two patients with pancreaticocutaneous fistula and one each with pancreaticopleural, pancreaticoperitoneal, and pancreaticocholedochal fistula. The need for an operation can be obviated in many patients with internal and external pancreatic fistulas.

Short report: octreotide in the treatment of external pancreatic fistulas

The efficacy of the long-lasting somatostatin analogue, octreotide, in the treatment of high-output pancreatic fistulas was investigated in this prospective, open study. Sixteen patients with post-operative pancreatic fistulas were treated with subcutaneous injections of octreotide 0.1 mg b.d. The output of the fistulas before the somatostatin therapy ranged between 190 and 570 ml/day. The therapy was begun on average 17 days following the appearance of the fistula (range 4 to 35 days). The decrease in volume one day after initiation of therapy ranged from 26% to 69%. By the third day of treatment the fistula volume decreased to 0-45% of the initial output. The treatment resulted in the closure of 14 of the 16 fistulas; the time to closure ranging from 3 to 15 days. The results suggest that octreotide is a useful adjuvant agent in the treatment of an external pancreatic fistula.

[Severe acute pancreatitis: diagnostic approaches and therapeutic implications]

Diagnosis of acute pancreatitis (AP) can be obtained with a high level of accuracy by clinical assessment and determination of common laboratory parameters such as serum amylase and lipase concentrations. However, the key of an optimal management of patients with AP is based on an early discrimination between interstitial oedematous and necrotizing forms. The former resolves spontaneously whereas parenchymal necrosis acting as a focus for bacteria has a very high severity. In this respect, multifactor prognostic scoring systems and new biological assessments like C reactive protein are valuable methods for forecasting the prognosis of AP. However, these indicators of severity require a full 48 hour period of observation. In order to overcome these drawbacks, other prognostic criteria have been explored based mainly, on laboratory data. The most interesting ones are trypsinogen activation peptides and leucocyte elastase. Finally, the more useful tool is computed tomography (CT). Combined with high dose intravenous contrast agent, it allows an early identification of necrosis. Other goals of computed tomography are an accurate diagnosis of infection by guided needle aspirations and a preoperative recognition of devitalized and infected tissues, which require a careful surgical necrosectomy. A prolonged drainage is always recommended but relative merits of a conventional closed drainage and an open one are controversial. Another therapeutic challenge is gallstone associated to severe pancreatitis. An early stone removal is advocated by some authors but others prefer delayed surgery because of high mortality rates in case of emergency surgery. Delayed surgery until biological parameters of pancreatitis are normalized seems preferable. An early endoscopic sphincterotomy in an attractive alternative method.