Pancreatic Fistulas and Tumors of the Pancreas

Overview

Disruption of the major pancreatic duct or its tributaries may result in extravasation of pancreatic juice from the portion of the pancreas proximal to the obstruction. This juice may be locally contained and after 4–5 weeks develop a wall sufficiently thick to be called a pseudocyst. Less frequently, the pancreatic juice may not be contained by surrounding viscera and enter the abdominal cavity forming pancreatic ascites [1, 2]. Sometimes the juice may fistulize retroperitoneally into the pleural space [3], bronchus [4, 5], pericardium [3], colon [6, 7], portal vein [8], common bile duct [9], etc. The disruption of the pancreatic duct may be partial or complete and present from the anterior or posterior surface of the pancreas. In the case of necrotizing pancreatitis, large segments of the major pancreatic duct may be destroyed along with the surrounding parenchyma. In some instances of partial disruption of the major or tributary duct, obstruction of the major pancreatic duct proximal to the obstruction may be present which impedes flow to the duodenum and contributes to the persistence of the fistula.

Pancreatic fistulas may result from blunt or penetrating trauma, acute pancreatitis, operative trauma, pseudocysts, pancreatic necrosis, chronic pancreatitis, or carcinoma. The fistulas may be external or internal.

Pancreatic fluid collections may occur following an injury to the pancreaticductal system as a result of an operation, trauma, necrotizing pancreatitis, or infected pancreatic necrosis. Drainage of the pancreatic fluid collection externally may create a fistula. External pancreatic fistulas are usually considered low output if less than 200 ml/day and high output if over that amount [10]. Internal fistulas and ascites most often arise in the setting of chronic pancreatitis, cancer of the pancreas, or processes eroding into the pancreas, such as peptic ulcers or cancer.