A Single-Center Experience of Internal Pancreatic Fistulas

Abstract

BackgroundInternal pancreatic fistula (IPF) is a complex disease with different etiologies, varied clinical presentations, and multiple management options. Unlike postoperative pancreatic fistula, IPF lacks guidelines for classification and management. The rarity of the disease makes randomized control studies unlikely and difficult to formulate guidelines. This has resulted in different approaches to managing IPF. IPF associated with both acute and chronic pancreatitis is treated with a step-up approach. Chronic pancreatitis-associated IPF treated with the traditional step-up approach is associated with increased morbidity. Prolonged fasting, drainage of protein-rich pancreatic fluid, and extended hospital stay add to the morbidity. Early surgical intervention in patients with IPF associated with chronic pancreatitis can treat both the fistula and underlying disease processes simultaneously. This may contribute to reduced morbidity and hospital stay. MethodologyA retrospective observational study was conducted between June 2018 and May 2019. IPF patients with fluid amylase >1,000 IU/L and fluid albumin >3 g/dL were included in the study. ResultsIn total, 32 patients were included in the study. A total of 13 patients had acute pancreatitis and 19 were associated with chronic pancreatitis. Pseudocyst and walled-off pancreatic necrosis were present in 18 patients. The duration of treatment for the traditional group was 8-14 weeks, and for the early surgery group, it was 8-10 days. Patients were followed up for two years, and none of the patients in the early surgery group had a recurrence. ConclusionsThe overall mortality of IPF is low but it has high morbidity. The delay in treatment may contribute to high morbidity; hence, early surgical intervention may change the clinical course. The primary pathology of the pancreas can be addressed simultaneously as well. In our study, early surgical intervention was associated with lesser morbidity and decreased duration of hospital stay while recurrence rates and mortality were comparable to the traditional management protocol.

The detours of pancreatic ducts, internal pancreatic fistulas: a rare complication of chronic pancreatitis

“…Persisting fistulous disease is attributed to large duct disease prompting endoscopic transgastric drainage or surgical intervention. 8,9 The successful non-operative management, guided by precise diagnostic modalities and a multidisciplinary approach, reflects the evolving paradigm favouring less invasive interventions.…”