Pancreaticoureteral Fistula Following

Joshua H Wolf
1
, George Miller
1
, Russell Ashinoff
1
, Jasmine Dave
1
,
Richard S Lefleur
2
, Spiros G Frangos
1
, Maurizio A Miglietta
1
Departments of
1
Surgery and
2
Interventional Radiology, Bellevue Hospital Center,
New York University School of Medicine. New York, NY, USA
ABSTRACT
Context The main pancreatic duct can form a
fistulous communication with another
epithelium in the setting of prolonged
inflammation, operative manipulation, or
direct trauma. We present a rare complication
of a pancreaticoureteral fistula following a
trauma nephrectomy.
Case report A 17-year-old male who
sustained a gunshot wound to the back arrived
to our Emergency Room hyopotensive,
tachycardic, and with free intraperitoneal
fluid on focused assessment sonography for
trauma (FAST) exam. He was taken to the
operating room for an exploratory laporatomy
where a left nephrectomy was performed to
control active bleeding from the left renal
hilum. Significant bleeding was also
encountered at the portal venous confluence.
After packing and damage control
laparotomy, the periportal/pancreatic bleeding
was controlled during a second procedure 6
hours later. After one month in the Intensive
Care Unit with an open abdomen, a computed
tomography (CT) scan revealed a fluid
collection in the splenic fossa which was
drained by catheter. Persistent drainage
revealed a high amylase concentration
(greater than 50,000 U/L). A fistulogram
revealed interruption of the main pancreatic
duct, and a fluid collection by the tail of the
pancreas that was in communication with the
left ureter. The patient’s urine amylase was
also elevated. The patient was treated non-
operatively given the healing open abdomen
and controlled fistula. He had an otherwise
uncomplicated recovery.
Conclusions This is the second report of a
pancreaticoureteral fistula in the literature.
Treatment of this communication should be
similar to that of other pancreatic fistulae.
INTRODUCTION
Pancreatic fistulae result when the main
pancreatic duct communicates with another
epithelialized surface. These fistulae may
evolve in the setting of inflammatory
pancreatic disease or as a result of injury
following surgical resection or trauma. While
a variety of pancreatic fistulae have been
described in the literature, including
communication with peritoneal, pleural,
epidermal, and pericardial epithelium, to our
knowledge, there is only one prior report of a
pancreaticoureteral fistula [1, 2, 3, 4, 5].
CASE REPORT
A 17-year-old man who had sustained a
gunshot wound to the back was
brought into the emergency room where he
was found to be hypotensive and tachycardic.
Secondary survey revealed a bullet wound at
the level of T3/T4 on the left back. A focused
assessment sonography for trauma (FAST)

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exam revealed intraperitoneal free fluid. The
patient was emergently intubated and taken to
the operating room for an exploratory
laparotomy.
Intra-operative findings included a large,
expanding,
left-sided
retroperitoneal
hematoma. Further investigation revealed
active arterial and venous bleeding from the
left renal hilum and a left nephrectomy was
performed as a damage control intervention.
The left ureter was oversewn using an
absorbable suture. No other injuries involving
the ureter were found. Gross hematuria had
been noted prior to the operation. Difficult
bleeding was also encountered at the portal
venous confluence behind the pancreas
without obvious parenchymal pancreatic
injury. Secondary blast effects were noted in
the wall of the duodenum and proximal
jejunum. The patient was acidotic (lactate 8
mmol/L; reference range: 1.0-2.5 mmol/L),
hypothermic (33.8°C) and coagulopathic
(INR 2.8) and therefore damage control
measures were initiated and a temporary
abdominal closure was performed. After six
hours of unsuccessful intensive care unit
resuscitation, the patient was returned to the
operating room for presumed ongoing
surgical bleeding. Bleeding from the portal
venous confluence was identified and
definitively controlled by suture ligation. The
proximal duodenum and jejunum were noted
to be of questionable viability and were
protected with stapled pyloric exclusion.
Closed suction drains were left along the head
and tail of the pancreas. The patient was
further resuscitated and re-explored on post-
operative day 4. His bowel appeared viable
and gastrointestinal continuity was restored
with a gastrojejunostomy. A feeding
jejunostomy was also placed. The abdominal
wall fascia could not be approximated and
temporary abdominal closure was performed.
One of the closed suction drains inadvertently
fell out. On post trauma day 11, the
abdominal fascia was approximated with
cadaveric dermis and vacuum suction. The
remaining drain was taken out 18 days post
trauma for minimal output.
The patient’s post-operative course was
complicated by fevers. A computed
tomography (CT) scan one month post-injury
showed fluid collections in the splenic fossa
adjacent to the pancreas. Interventional
radiology catheter drainage of the collection
yielded 500-700 mL/day of fluid with an
amylase concentration of 50,000 U/L. The
patient was maintained on bowel rest,
sandostatin, and parenteral nutrition. Over the
next few weeks, output from the
pancreaticocutaneous fistula fluctuated but at
times was greater than 500 mL/day and not
altered by sandostatin therapy. Endoscopic
retrograde cholangiopancreatography (ERCP)
was attempted by our most experienced
endoscopist in order to stent the pancreatic
duct. Despite multiple attempts the ampulla
could not be accessed as a result of the
surgically altered anatomy. MRCP was
considered but it was felt that management
would not be altered. A fistulogram was
performed which showed a discontinuity of
the main pancreatic duct in the head of the
pancreas, a fluid collection adjacent to the tail
of the pancreas, and a communication
between the left fluid collection and the left
ureter (Figure 1). The patient’s urine amylase
concentration (815 U/L) was elevated. The
decision was made not to explore the
abdomen via laparotomy given the frozen
Figure 1. Injection of non-ionic contrast through the
external Jackson-Pratt drain pacifies the pancreatic
duct with immediate filling of the left ureter.

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open abdomen. Repeat ERCP was not
attempted. Over the next 1-2 weeks, the
patient’s fistula output dramatically decreased
to less than 20 mL/day. The patient’s urine
amylase measured 300 U/L and serum
amylase measured 250 U/L (reference range:
25-125 U/L). The patient’s drainage catheter
was removed, oral feeds were restored, and
the remainder of his post operative course was
unremarkable.
Subsequent follow-up four months after
injury revealed no voiding dysfunction. The
ureter was not re-evaluated. The urinary
amylase normalized. Urinanalysis revealed no
hematuria.
DISCUSSION
The
precise
etiology
of
the
pancreaticoureteral fistula in this case is
uncertain. The fistula most likely resulted
either from unrecognized trauma to the main
pancreatic duct or from an iatrogenic
intraoperative injury. The pancreatic fistula
and collection most likely had eroded into the
area of the left nephrectomy and recently
oversewn ureter. It is conceivable that the use
of non-absorbable suture in ligating the ureter
may reduce the risk of fistula development. In
addition, the presence of a long ureteral stump
possibly contributed to fistula formation.
However, in the context of an unstable trauma
patient, further distal dissection of the ureter
would have been ill-advised.
Only one prior report describes a patient with
a traumatic pancreaticoureteral fistula and in
this case, unlike in the present report, the
kidney and ureter were both intact [5]. The
fistula developed one week after distal
pancreatic transection and ureteral contusion
secondary to a gunshot wound. After
discovery of the fistula, the patient’s ureter
was endoscopically stented and he was
managed with TPN and a somatostatin
analogue. Follow-up ureterograms revealed
closure of the fistula at twelve weeks post-
injury [5].
Pancreatic fistulae may be successfully
managed conservatively, endoscopically, or
with operative repair. Conservative
management results in spontaneous resolution
in 50-90% of all pancreatic fistulae [6]. This
treatment typically entails catheter drainage,
fluid management, and nutritional support. A
recent retrospective study found that 85% of
patients with post-operative pancreatic
fistulae resolved with expectant management
[7]. In a prospective study, 90% of post-
traumatic pancreatic fistulae that were
managed conservatively closed spontaneously
within 24 days [8].
Intervention becomes necessary when a high
output fistula persists beyond several months
or when it becomes complicated with
infection or bleeding [9]. Endoscopic therapy
with sphincterotomy and pancreatic stent
placement may be attempted to redirect
pancreatic secretions away from a fistula
tract. In a retrospective study, endoscopic
therapy was successful in 82% of cases [10].
In another study, pancreaticocutaneous
fistulae treated with endoscopic stent
placement resolved in 100% of patients
(n=15) within a median time of 10 days [11].
In cases of failed endoscopic therapy, surgery
is indicated. Surgical interventions include
either distal pancreatic resection or Roux-en-
Y pancreaticojejunostomy.
Of additional concern in cases of
pancreaticoureteral fistula is the potential
pathologic effects of pancreatic secretions on
uroepithelium. Exocrine pancreatic secretions
are known to damage uroepithelial tissue in
patients with bladder-drained pancreatic
allografts. Activated proteolytic enzymes and
alkaline pH may impair local mucosal
defenses thereby predisposing patients to
urinary tract infections, urethritis, ulcerations,
and strictures [12]. Pancreatic secretions have
also been reported to cause metaplastic
changes, ranging from cystitis cystica to
transitional cell papilloma [13]. Duodenal
enterokinase is required to activate pancreatic
proteolytic enzymes and patients who receive
segmental pancreatic transplants without
duodenocystostomy have lower rates of
complications related to pancreatic secretions
[14]. Because our patient’s uroepithelium was
only transiently exposed to pancreatic
secretions, and these did not contain activated

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proteolytic enzymes, future adverse urological
sequelae are unlikely.
In summary, pancreaticoureteral fistulas are
extremely rare after penetrating trauma and
should be managed similarly to other types of
pancreatic fistulae. Conservative management
with catheter drainage, electrolyte repletion
and nutritional support can result in very high
closure rates. Endoscopic stenting is another
option in cases where gastrointestinal
continuity is preserved. Surgical treatment in
the form of distal pancreatic resection or
Roux-en-Y pancreaticojejunostomy should be
reserved for failed conservative and
endoscopic management.
Received July 10
th
, 2007 - Accepted July 23
rd
,
2007
Keywords
Pancreatic Fistula; Ureter;
Wounds, Gunshot; Wounds, Penetrating
Abbreviation FAST focused assessment
sonography for trauma
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Maurizio A Miglietta
Trauma and Emergency Surgery
NewYork-Presbyterian Hospital/Columbia
Irving Pavilion Room 8-808
161 Fort Washington Avenue
New York, NY, 10032
Phone: +1-212.342.1734
Fax: +1-212.342.5754
E-mail: mm3161@columbia.edu
Document URL: http://www.joplink.net/prev/200709/13.html
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