Generally defined as an abnormal connection formed between the pancreas and any adjacently located body structures, organs, or spaces, a pancreatic fistula (PF) is characterized by the pancreatic fluid leakage post-disruption of pancreatic ducts. After pancreatic resection or acute/chronic pancreatitis, pancreatic ducts may disrupt and the fluid may leak out. If the leakage is excess and not addressed in time, the result may be infection or excoriation, or morbidity owing to malnutrition in worst cases.
Often a burden for surgeons, pancreatic fistulae tend to complicate the pancreatic resections in case of acute as well as chronic tumors. Whether the fistula is internal or external, worse complications may also arise in case of necrosectomy after severe pancreatitis, and penetrating and blunt trauma.
According to the location, PFs are of two key types – internal and external. The former one involves communication of pancreatic duct with pleural or peritoneal cavity. It may also communicate with a hollow viscus. However, the latter one communicates with the skin. The type of PF can vary according to the instant predisposing cause and disease process.
A PF that is post-operative is often external and drains out a considerable amount of fluid after a surgical procedure. A post-operative fistula is typically formed as a complication of pancreatitis, partial pancreatectomy, blunt abdominal trauma, or pancreatic duct trauma that results from an upper abdominal surgery or pancreatic biopsy. Once a patient acquires pancreatic fistula, is usually leads to extended hospitalization and high risk of mortality. Studies indicate that out of the total number of patients who undergo pancreatic resection, around 10-30% develop pancreatic fistula.
Treatment for PF has been undergoing a lot of research and development since the past decade. For internal and external fistulae, a range of therapeutic options are considered, including medical, surgical, percutaneous, and endoscopic. Due to elevated levels of serum amylase and enzyme diffusion throughout the pleural or peritoneal surface, the diagnosis of pancreatic fistula involves endoscopic retrograde cholangiopancreatography (ERCP) and contrast-enhanced computed tomography (CECT). ERCP is however considered a critically essential component during the treatment.
The primary treatment involves suppression of the pancreatic enzyme production. When patients are subjected to long-acting somatostatin analogues, their oral intake is reduced to a considerable extent. The treatment with parenteral nutrition is continued for a few weeks and if no improvement is observed, endoscopic or surgical treatment is advised in most of the cases. In case of a surgery, ERCP is used for spotting the leakage site. The involved part of fistula is then removed by fistulectomy.
Medical therapeutic options are typically used for treating external fistulae. It is observed in a number of patients that non-invasive or less invasive procedures do not effectively cure, which is why there are higher chances of reoccurrence. Medical therapy is sometimes recommended to such patients so as to expect a positive outcome. However, there are records that medical therapies notably result in higher mortality rates. The field of pancreatic fistula treatment thus needs a set of solid treatments that represents higher efficacy and promisingly reduces mortality risks.
Innovations are hitting the field of PF treatment, offering better, more efficient, and visibly effective treatment options. The market for pancreatic fistula treatment foresees flourishing prospects in the near future.
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