Pancreatic Fistulas

  • Stefanos M. DokasEmail author


Pancreatic fistula is defined as an abnormal communication between the pancreatic ductal system and adjacent or remote epithelial surfaces containing pancreas-derived, enzyme-rich fluid. The cause of this abnormal communication is pancreatic ductal leak (pancreatic leak). The leak may originate from the major pancreatic duct or from side branches. Pancreatic leaks develop in the course of acute or chronic disease or manifest as iatrogenic complications. Pancreatic fistula may complicate the course of acute or chronic pancreatitis, blunt or penetrating abdominal trauma, pancreatic injury caused during pancreatectomy, gastrectomy, splenectomy, or other surgical procedures performed at the vicinity.

Leaking pancreatic juice initially forms a peripancreatic fluid collection, which later evolves to either internal or external fistula. Internal fistulas include pancreatic ascites, pancreatic pseudocysts, and high amylase pleural effusion. Sometimes, the collection erodes into neighboring hollow viscera, leading to pancreatico-splanchnic (gastric, enteric, colonic, bladder) fistula. External fistulas develop after a tract to the skin is formed. This occurs either spontaneously or more frequently after a drain is placed, be it percutaneous or surgical. The present chapter will mainly focus on external, postoperative fistulas.

A small leak from a side branch will usually heal fast and uneventfully. On the other hand, a persistent main pancreatic duct disruption leads to significant consequences and prolonged morbidity. The traditional treatment algorithm encompasses conservative treatment, including drainage, antibiotics, bowel rest, nutritional, fluid, and electrolyte support. This approach is effective with most low-volume leaks. Traditionally, surgical treatment is considered as the treatment of choice for persistent or complicated leaks. However, in recent years there is a trend toward aggressive endoscopic treatment as a surgery sparing, minimally invasive approach.


Pancreatic fistula Pancreatic leak ERCP Postoperative leak Pancreatic stent 


  1. 1.
    Malleo G, Crippa S, Butturini G, Salvia R, Partelli S, Rossini R, et al. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford). 2010;12(9):610–8. S1365-182X(15)30343–9 [pii].CrossRefGoogle Scholar
  2. 2.
    Giardino A, Spolverato G, Regi P, Frigerio I, Scopelliti F, Girelli R, et al. C-Reactive protein and procalcitonin as predictors of postoperative inflammatory complications after pancreatic surgery. J Gastrointest Surg. 2016;20(8):1482–92. 1007/s11605-016-3171-6 [pii].CrossRefPubMedGoogle Scholar
  3. 3.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13. S0039606005002291 [pii].CrossRefPubMedGoogle Scholar
  4. 4.
    Itoh S, Ikeda M, Ota T, Satake H, Takai K, Ishigaki T. Assessment of the pancreatic and intrapancreatic bile ducts using 0.5-mm collimation and multiplanar reformatted images in multislice CT. Eur Radiol. 2003;13(2):277–85. Scholar
  5. 5.
    Kakihara D, Yoshimitsu K, Irie H, Tajima T, Asayama Y, Hirakawa M, et al. Usefulness of the long-axis and short-axis reformatted images of multidetector-row CT in evaluating T-factor of the surgically resected pancreaticobiliary malignancies. Eur J Radiol. 2007;63(1):96–104. S0720-048X(07)00046-0 [pii].CrossRefPubMedGoogle Scholar
  6. 6.
    O’Toole D, Vullierme MP, Ponsot P, Maire F, Calmels V, Hentic O, et al. Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging. Gastroenterol Clin Biol. 2007;31(8-9 Pt 1):686–93. MDOI-GCB-09-2007-31-8-9-C1-0399-8320-101019-200520009 [pii].CrossRefGoogle Scholar
  7. 7.
    Raman SP, Horton KM, Cameron JL, Fishman EK. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol. 2013;201(1):2–13. Scholar
  8. 8.
    Gillams AR, Kurzawinski T, Lees WR. Diagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography. AJR Am J Roentgenol. 2006;186(2):499–506. 186/2/499 [pii].CrossRefPubMedGoogle Scholar
  9. 9.
    Drake LM, Anis M, Lawrence C. Accuracy of magnetic resonance cholangiopancreatography in identifying pancreatic duct disruption. J Clin Gastroenterol. 2012;46(8):696–9. Scholar
  10. 10.
    Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg. 2014;399(7):801–10. Scholar
  11. 11.
    Schorghuber M, Fruhwald S. Effects of enteral nutrition on gastrointestinal function in patients who are critically ill. Lancet Gastroenterol Hepatol. 2018;3(4):281–7. S2468-1253(18)30036-0 [pii].CrossRefPubMedGoogle Scholar
  12. 12.
    Buchman AL, Iyer K, Fryer J. Parenteral nutrition-associated liver disease and the role for isolated intestine and intestine/liver transplantation. Hepatology. 2006;43(1):9–19. Scholar
  13. 13.
    Jin K, Zhou H, Zhang J, Wang W, Sun Y, Ruan C, et al. Systematic review and meta-analysis of somatostatin analogues in the prevention of postoperative complication after pancreaticoduodenectomy. Dig Surg. 2015;32(3):196–207. 000381032 [pii].CrossRefPubMedGoogle Scholar
  14. 14.
    Gans SL, van Westreenen HL, Kiewiet JJ, Rauws EA, Gouma DJ, Boermeester MA. Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula. Br J Surg. 2012;99(6):754–60. Scholar
  15. 15.
    Lakhtakia S, Reddy DN. Pancreatic leaks: endo-therapy first? J Gastroenterol Hepatol. 2009;24(7):1158–60. Scholar
  16. 16.
    Forker EL. Two sites of bile formation as determined by mannitol and erythritol clearance in the Guinea pig. J Clin Invest. 1967;46(7):1189–95. Scholar
  17. 17.
    Esteller A. Physiology of bile secretion. World J Gastroenterol. 2008;14(37):5641–9.CrossRefGoogle Scholar
  18. 18.
    Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, et al. Pancreatic leaks and fistulae: an endoscopy-oriented classification. Dig Dis Sci. 2017;62(10):2648–57. 10.1007/s10620-017-4697-5 [pii].CrossRefPubMedGoogle Scholar
  19. 19.
    Kozarek RA, Ball TJ, Patterson DJ, Freeny PC, Ryan JA, Traverso LW. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology. 1991;100(5 Pt 1):1362–70. S0016508591001774 [pii].CrossRefGoogle Scholar
  20. 20.
    Kozarek RA, Ball TJ, Patterson DJ, Raltz SL, Traverso LW, Ryan JA, et al. Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg. 1997;1(4):357–61. S1091255X97800571 [pii].CrossRefGoogle Scholar
  21. 21.
    Cicek B, Parlak E, Oguz D, Disibeyaz S, Koksal AS, Sahin B. Endoscopic treatment of pancreatic fistulas. Surg Endosc. 2006;20(11):1706–12. Scholar
  22. 22.
    Engler S, Dorlars D, Riemann JF. Endoscopic fibrin gluing of a pancreatic duct fistula following acute pancreatitis. Dtsch Med Wochenschr. 1996;121(45):1396–400. Scholar
  23. 23.
    Fischer A, Benz S, Baier P, Hopt UT. Endoscopic management of pancreatic fistulas secondary to intraabdominal operation. Surg Endosc. 2004;18(4):706–8. Scholar
  24. 24.
    Seewald S, Brand B, Groth S, Omar S, Mendoza G, Seitz U, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc. 2004;59(4):463–70. S0016510703027081 [pii].CrossRefGoogle Scholar
  25. 25.
    Mutignani M, Tringali A, Khodadadian E, Petruzziello L, Spada C, Spera G, et al. External pancreatic fistulas resistant to conventional endoscopic therapy: endoscopic closure with N-butyl-2-cyanoacrylate (Glubran 2). Endoscopy. 2004;36(8):738–42. Scholar
  26. 26.
    Zuber-Jerger I, Herold T, Kullmann F. Transpapillary sealing of a pancreatic fistula with Onyx. Gastrointest Endosc. 2006;63(7):1068–9.; discussion 9. S0016-5107(05)03213-X [pii].CrossRefPubMedGoogle Scholar
  27. 27.
    Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc. 2005;61(4):568–75. S0016510704028329 [pii].CrossRefGoogle Scholar
  28. 28.
    Telford JJ, Farrell JJ, Saltzman JR, Shields SJ, Banks PA, Lichtenstein DR, et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc. 2002;56(1):18–24. S0016510702000020 [pii].CrossRefGoogle Scholar
  29. 29.
    Rana SS, Bhasin DK, Nanda M, Siyad I, Gupta R, Kang M, et al. Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions. J Gastroenterol Hepatol. 2010;25(6):1087–92. JGH6172 [pii].CrossRefPubMedGoogle Scholar
  30. 30.
    Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc. 2007;65(4):609–19. S0016-5107(06)02407-2 [pii].CrossRefPubMedGoogle Scholar
  31. 31.
    Arvanitakis M, Delhaye M, Bali MA, Matos C, Le Moine O, Deviere J. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol. 2007;102(3):516–24. AJG1014 [pii].CrossRefPubMedGoogle Scholar
  32. 32.
    Pelaez-Luna M, Vege SS, Petersen BT, Chari ST, Clain JE, Levy MJ, et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc. 2008;68(1):91–7. S0016-5107(07)03178-1 [pii].CrossRefPubMedGoogle Scholar
  33. 33.
    Varadarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg. 2011;15(11):2080–8. Scholar
  34. 34.
    Bang JY, Wilcox CM, Navaneethan U, Hasan MK, Peter S, Christein J, et al. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Ann Surg. 2016;267:561. Scholar
  35. 35.
    Francois E, Kahaleh M, Giovannini M, Matos C, Deviere J. EUS-guided pancreaticogastrostomy. Gastrointest Endosc. 2002;56(1):128–33. S001651070200024X [pii].CrossRefGoogle Scholar
  36. 36.
    Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest Endosc. 2007;65(2):224–30. S0016-5107(06)01953-5 [pii].CrossRefPubMedGoogle Scholar
  37. 37.
    Walter D, Will U, Sanchez-Yague A, Brenke D, Hampe J, Wollny H, et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy. 2015;47(1):63–7. Scholar
  38. 38.
    Siddiqui AA, Adler DG, Nieto J, Shah JN, Binmoeller KF, Kane S, et al. EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos). Gastrointest Endosc. 2016;83(4):699–707. S0016-5107(15)03036-9 [pii].CrossRefPubMedGoogle Scholar
  39. 39.
    Grobmyer SR, Hunt DL, Forsmark CE, Draganov PV, Behrns KE, Hochwald SN. Pancreatic stent placement is associated with resolution of refractory grade C pancreatic fistula after left-sided pancreatectomy. Am Surg. 2009;75(8):654–7; discussion 7–8.CrossRefGoogle Scholar
  40. 40.
    Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M. Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. Case Rep Gastroenterol. 2013;7(2):332–9. crg-0007-0332 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Onodera M, Kawakami H, Kuwatani M, Kudo T, Haba S, Abe Y, et al. Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc. 2011;26(6):1710–7. Scholar
  42. 42.
    Bartoli E, Rebibo L, Robert B, Fumery M, Delcenserie R, Regimbeau JM. Efficacy of the double-pigtail stent as a conservative treatment for grade B pancreatic fistula after pancreatoduodenectomy with pancreatogastric anastomosis. Surg Endosc. 2013;28(5):1528–34. Scholar
  43. 43.
    Fazel A, Quadri A, Catalano MF, Meyerson SM, Geenen JE. Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc. 2003;57(3):291–4. S0016-5107(02)00240-7 [pii].CrossRefPubMedGoogle Scholar
  44. 44.
    Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc. 1990;36(2):93–5. S0016-5107(90)70958-3 [pii].CrossRefGoogle Scholar
  45. 45.
    Kozarek R, Hovde O, Attia F, France R. Do pancreatic duct stents cause or prevent pancreatic sepsis? Gastrointest Endosc. 2003;58(4):505–9. S0016-5107(03)01891-1 [pii].CrossRefGoogle Scholar
  46. 46.
    Murage KP, Ball CG, Zyromski NJ, Nakeeb A, Ocampo C, Sandrasegaran K, et al. Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis. Surgery. 2010;148(4):847–56.; discussion 56–7. .S0039-6060(10)00407-1 [pii].CrossRefPubMedGoogle Scholar
  47. 47.
    Behrns KE, Howard TJ. Pancreatic necrosis: when to scope, poke, or cut? Gastrointest Endosc. 2010;72(6):1326–7.; author reply 7–8. S0016-5107(10)01371-4 [pii].CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Endoscopy DepartmentSt. Luke’s Private HospitalThessalonikiGreece

Personalised recommendations