Pancreatic Fistula: Treatment, Cost and Side Effects

A pancreatic fistula is a situation wherein the pancreatic ducts get damaged and thus there is a leakage of pancreatic fluids into other parts of the body or organs. In case of external pancreatic fistula the fluids are communicated to the skin but on the other hand the internal pancreatic fistula the fluids are leaked on to the organs or the abdominal spaces. An exocrine gland fistula is characterized by escape of exocrine gland fluid as a result of disruption of exocrine gland ducts. Disruption of exocrine gland ducts also known as the pancreatic ducts occurs due to pancreatic disease, exocrine gland surgical operation or trauma. Escape of exocrine gland secretions will cause important morbidity due to deficiency disease, skin excoriation, and infection. A duct gland fistula is outlined as the abnormal association between the exocrine gland and adjacent or distant organs, structures, or spaces. Internal pancreatic fistulas are mostly caused by the disruption of pancreatic duct due to chronic pancreatitis. The chronic pancreatitis is sometimes alcoholic in origin in adults, and traumatic in origin in youngsters. They can also be caused by the leakage from a pancreatic pseudocyst. The main symptoms associated with the pancreatic fistula are: abdominal pain, vomiting or nausea, diabetes, jaundice, organomegaly, hemepositive stools, back pain etc. A fistula is termed a high output fistula once the output is greater than two hundred milliliter in twenty four hours and low output once the output is a smaller amount than two hundred milliliter in twenty four hours. A fistula that drains solely digestive fluid is termed a pure fistula, whereas a fistula that drains digestive fluid mixed with enteric contents could be a mixed fistula. The output of a pure POPF contains inactive exocrine gland enzymes and isrelatively inert. The output of a mixed POPF contains activated proteases, which might cause further complications like death and hemorrhage. Patients with the symptoms are asked for a test for the diagnosis. Pleural or ascitic fluid is sent for the analysis and the outcome of the result shall direct the course of further treatment.

The treatment of Pancreatic Fistula begins with the patient reporting the symptoms to the doctor. The doctor asks for the test of the Pleural or ascitic fluid analysis. If the levels of the amylase is high and the protein levels are high then the doctor may ask for the patient to undergo the treatment. In some cases the specialist may make use of the Contrast-enhanced computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) so as to get the correct view of the patient situation. The treatment for Pancreatic Fistula is as follows:

1. Control Sepsis: The early treatment is started with the objective of supressing the pancreatic enzymes. This restriction is done by asking the patient to take oral food along with the support of somatostatin which is a growth hormone- inhibiting hormone and is capable of regulating the endocrine system. Thus the patient is asked to undergo nutrition strictly for two to three weeks. Abdominal imaging is needed to sight intra-abdominal collections needing drain. Maintenance of Fluid and electrolyte balance and Nutrition Maintenance of nutrition and metabolic function is vital. The explanation behind nutritionary therapies is twofold. First, nutritionary medical care aims to catch up on the impaired nutrition resulting from reduced delivery of duct gland secretions to the gut. Second, by limiting the amount of fistula output, it might increase the probability of spontaneous closure. There is evidence that total duct nutrition (TPN) reduces pancreatic secretion by 500th to 70th compared with enteral nutrition. Enteral feeding beyond the ligament of Treitz is perhaps equally effective at reducing pancreatic exocrine secretion and has several benefits. Commercially offered feeds could also be given through a properly placed nasojejunal feeding tube for two to three weeks, however if longer nutritionary support is anticipated, a percutaneous feeding operation is sometimes needed.
2. Skin Protection: Pancreatic secretions are activated on contact with enteric secretions and additionally undergo auto activation on exposure to air. Thus, even pure fistulas have the potential to cause severe skin necrosis if the effluent is left in touch with skin. External fistulas are optimally managed with a pouching system exploitation skin protection like karaya. If a drain is not in place, the fistula gap ought to be catheterized.
3. Surgery: If the condition of the patient does not improves even after the nutrition treatment and hormonal supplements, then the patient undergoes surgical operation. Most external exocrine gland fistulae are often effectively managed by non-surgical means. Surgery will be required for those in whom nonclosure has been predicted and who are not suitable for stenting. An ERCP is needed to identify the site of the leak. This group largely consists of patients with an end fistula. The choice of acceptable procedure depends on the ductal anatomy, site of the leak and the duration of the fistula.

Patients who experience the presence of symptoms like abdominal pain, fever, chills, jaundice or early satiety are eligible to receive treatment for pancreatic fistula. Pleural or Ascitic fluid is sent for analysis, an elevated amylase level, usually > 1000 IU/L , with protein levels over 3.0g/dL is diagnostic. ERCP (endoscopic retrograde cholangiopancreatography) may also assist in diagnosis.

Patients who are not having any symptoms related to the diseases or the conditions needed for the treatment are therefore not eligible for the disease. But the best advice can be given by the specialist doctor and therefore it is advised that the patient consults the doctor before the treatment.

There are various short term side effects related to the treatment of pancreatic fistula. Some of the major one’s are :

• Pain and discomfort after surgery
• Feeling sick
• Problems with digestion
• Hard / No bowel movements
• Tiredness/ Low energy levels
• Removing part of your pancreas may lead to Diabetes
• Surgical leaks

Postoperative pancreatic fistula (POPF) remains the main source of major morbidity and mortality after pancreatic resection, affecting between 13% and 41% of patients. Male sex is seen to be associated with increased risk of POPF, although no specific reason has been found for this phenomenon. Similarly age greater than 70 years is associated with increased risk for POPF. Other risk factors for POPF that have been already evaluated include duration of jaundice, creatinine, clearance and intraoperative blood loss.

The duration of pancreatic fistula ranges from few days to a few weeks depending upon the situation. In case the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may require intravenous feeding for 3-6 weeks while the pancreas slowly heals. This process is called total parenteral nutrition. However incase of mild disease, total parenteral nutrition provides no advantage.

The treatment cost for pancreatic fistula varies from hospital to hospital in India. For example, a hospital like Seven Hills will charge around INR 5 lakhs for the surgery whereas a government hospital like AIIMS will charge you way lesser. The cost also depends upon the treatment type.

A study was evaluated wherein 35 patients (30%) developed PF. Amongst these, 20 were managed conservatively and 14 were reoprated. These 2 group of patients were compared with patients without PF for analysis. The conservative treatment included the maintenance of the drain placed at the time of operation in 14 patients (70%) and percutaneous drainage in the other 6 (30%). There was no significant difference in the surgical time and blood replacement between the two groups. Also up to half of patients develop serious complications and 2 to 4 percent do not survive the procedure — one of the highest mortality rates for any operation. A common complication is the leakage of fluid from the pancreas after the surgery, generally in huge amounts that may cause an abscess and may cause infection and sepsis.

Treatment of pancreatic fistula by continuous irrigation and drainage of the preserved pancreatic remnant is a simple and feasible alternative to total pancreatectomy. This technique maintains a sufficient endocrine function and is associated with low mortality and reasonable quality of life.