Management of Pancreatic Fistula in Acute Pancreatitis

Severe acute necrotizing pancreatitis can cause destruction of the main pancreatic duct, smaller ducts or pancreatic parenchyma and can lead to leakage of pancreatic juice in terms of a pancreatic fistula formation. Internal fistulas to the gastrointestinal tract, bronchi, pleural, mediastinal space, pericardium, and other organs have to be differentiated from external cutaneous fistulas. As internal fistulas are often clinically asymptomatic, they are more difficult to diagnose and may not immediately be detected. In contrast, external fistulas are observed more often and can be easily be diagnosed by analyzing the pancreatic enzyme content of the respective fluid. To differentiate between simple and complex fistulas radiological imaging should be performed. Conventional fistulography, computed tomography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography (ERCP) can be used for this purpose. ERCP has the additional therapeutic value in terms of placement of a stent to bridge the leak site, which may contribute to the definitive resolution of partial pancreatic duct disruption. Simple internal and external fistulas tend to close spontaneously. Therefore, these fistulas are usually managed conservatively in the beginning using supportive regimens. If leaks do not resolve endoscopic stenting or percutaneous drainage is recommended in the majority of cases. Persistent fistulas require surgery as an alternative treatment option. Surgery usually requires a resection of the fistula-bearing pancreatic region and should be postponed as long as possible.