Delayed Pancreatic Fistula

asuhiro Ito, Tomoyuki Irino, Tomohisa Egawa, Shinobu Hayashi, Atsushi Nagashima
Department of Surgery, Saiseikai Yokohamashi Tobu Hospital. Kanagawa, Japan
ABSTRACT
Context Pancreatic fistulas still occur despite refinements in both surgical technique and perioperative management after a
pancreaticoduodenectomy. However, the occurrence of delayed pancreatic fistulas is very rare. Case report A 62-year-old woman
diagnosed with a lower biliary carcinoma had undergone a pylorus-preserving pancreaticoduodenectomy. The postoperative course
was uneventful and the patient was discharged from the hospital after 16 days. One year after surgery, she was admitted to our
hospital with a fluid collection around the pancreaticojejunal anastomosis. A catheter was inserted percutaneously and the fluid
collection was drained. The amylase value of the discharge was significantly elevated (119,500 IU/L). One week later, a
fistulography showed no significant collection and the tube was clamped. The patient was discharged from the hospital without
symptoms. Conclusions It is important to consider the occurrence of a delayed pancreatic fistula if the patient suffers from any
symptoms. It is then necessary to proceed rapidly.
INTRODUCTION
Pancreaticoduodenectomy is performed in many
hospitals. The morbidity and mortality rates of a
pancreaticoduodenectomy have decreased in recent
years. A pancreatic fistula still occurs in 5 to 40% of
patients despite refinements in surgical technique and
perioperative management [1, 2, 3, 4]. Most fistulas
occur in the perioperative period. Delayed pancreatic
fistulas after a pancreaticoduodenectomy are very rare.
We report a case of a delayed pancreatic fistula after a
pancreaticoduodenectomy.
CASE REPORT
A 62-year-old woman with abdominal pain was found
to have a lower biliary carcinoma. A pylorus-
preserving pancreaticoduodenectomy (using the
Traverso technique) with a lymph node dissection was
performed. Pancreaticojejunal anastomosis was
performed in an end-to-side fashion. The pancreatic
duct and the jejunal mucosa were fixed. The stump of
the pancreas and the jejunal wall were approximated
with interrupted sutures, which were inserted through
the anterior wall of the pancreas through the pancreatic
parenchyma to the posterior wall. Sutures were then
passed through the seromuscular layer of the jejunum,
in the posterior-to-anterior direction, wide enough to
cover the cut surface of the pancreas. A catheter with
multiple side-holes was inserted into the pancreatic
duct and sutured into place as an external stent. The
stent tube was guided externally through the stump of
the jejunal loop and fixed to the abdominal wall.
Histological and immunohistochemical studies resulted
in the diagnosis of a biliary carcinoma with lymph
node metastases. The postoperative course was
uneventful and the patient was discharged from the
hospital 16 days postoperatively. The external stent of
the pancreatic duct was removed on the 28th
postoperative day. After removal, there was no output
of fluid from the drain. After discharge, the patient was
followed up with computed tomography (CT),
ultrasonography (US), and laboratory examinations
every 3 months in the outpatient ward. No notable
findings were obtained (Figure 1). One year after
Received May 7th, 2011 - Accepted May 17th, 2011
Key words Pancreatic Fistula; Postoperative Complications;
Pancreaticoduodenectomy
Correspondence Yasuhiro Ito
Department of Surgery; Saiseikai Yokohamashi Tobu Hospital;
3-61-1 shimosueyoshi, Tsurumi-ku; Yokohama-shi, Kanagawa
230-0012; Japan
hone: +81-45.576.3000; Fax: +81-45.576.3586
E-mail: yasuito@ca3.so-net.ne.jp
Document URL http://www.joplink.net/prev/201107/06.html
Figure 1. Abdominal CT scan showing no remarkable findings.

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 4 - July 2011. [ISSN 1590-8577]
411
surgery, she was admitted to our hospital for abdominal
pain. All laboratory parameters, including the serum
levels of tumor markers, were normal. Abdominal CT
and US revealed a fluid collection around the
pancreaticojejunal anastomosis (Figure 2). The size of
the fluid collection was 45x33x20 mm. US-guided
drainage of the fluid collection was performed. A
catheter was inserted percutaneously and the fluid
collection was drained. Discharge showed a
gram-negative rod in the culture, and the amylase value
of the discharge was significantly elevated (119,500
IU/L). Contrast radiography of the drainage tube
showed no significant collection (Figure 3) and the
tube was clamped. The patient was discharged from the
hospital without symptoms. We evaluated the
pancreatic fistula by CT and US. There was no fluid
collection around the pancreaticojejunostomy.
DISCUSSION
The rates of morbidity and mortality associated with
pancreaticoduodenectomy procedures have decreased,
especially in high volume centers [5, 6, 7]. Pancreatic
anastomotic leakage is the most important complication
after pancreaticoduodenectomy. Leakage sometimes
causes the development of other abdominal
complications, such as intra-abdominal bleeding,
intra-abdominal abscess, sepsis and organ failure [8, 9],
and is among the common causes of perioperative
morbidity and mortality. Despite refinements in
surgical technique and improved perioperative
management of the safety and efficacy of pancreatic
surgery, pancreatic fistulas remain an unsolved
dilemma. Many reviews of the management of
pancreatic fistulas evaluate preventive approaches,
such as surgeon volume [10], stenting [2, 11, 12, 13,
14], and the period of drain insertion [15]. It remains
controversial. Hence, considerable time has been
devoted to preventing pancreatic fistulas.
Pancreatic fistulas generally occur during the
perioperative period. There are case reports of a
delayed pancreatic fistula after splenectomy [16, 17],
but the occurrence of a delayed pancreatic fistula after
a pancreaticoduodenectomy is very rare [18].
A pancreatic fistula is attributed to pancreatic juice
leakage a a result of disruption of the pancreatic duct
and the rupture of a pancreatic cyst which causes
elevation of pancreatic pressure. After surgery,
pancreatic leakage leads to an accumulation of
pancreatic juice around the pancreaticojejunal
anastomosis. In some cases, it can develop posteriorly
because the pancreas covered the retroperitoneum.
Pancreatic juice sometimes flows into the pleural
cavity through the pancreaticopleural fistula, causing
chronic pancreatitis, pancreatic injury and pancreatic
cancer [19]. In the perioperative period, pancreatic
leakage can easily spread into the abdominal cavity.
But, it has rarely been reported that pancreaticopleural
fistulas occur after pancreatic resection. This is likely
because a pancreatic resection will form adhesions
which prevent the pancreatic juice from leaking
through the pancreaticojejunal anastomosis.
In our case, postoperative examinations in the
follow-up period showed no recurrence and no
metastasis after the pancreaticoduodenectomy. One
year later, the patient suffered from abdominal pain and
fluid collection in front of the pancreaticojejunal
anastomosis, as detected by CT and US. Fortunately,
the fluid collection flowed from the surface of the
anastomosis. Percutaneous US-guided drainage was
performed easily. One week later, a fistulography
showed the disappearance of the fluid collection
around the pancreaticojejunal anastomosis, and we
confirmed the internal fistula into the intestine. Most
pancreatic fistulas are managed non-operatively by
conservative treatment. However, surgical treatment is
sometimes required [20]. The exact reason for a
delayed pancreatic fistula is unclear. But, it appears
that a small initial amount of leakage is aggravated by
infection. Barreto et al. [21] discussed the gray zone
between a pancreatic fistula and post-operative
Figure 2. Abdominal CT scan showing a fluid collection in front of
the pancreaticojejunal anastomosis.
Figure 3. Fistulography showing the disappearance of the fluid
collection around the pancreaticojejunal anastomosis. We confirmed
the presence of an internal fistula into the intestine.

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JOP. J Pancreas (Online) 2011 Jul 8; 12(4):410-412.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 4 - July 2011. [ISSN 1590-8577]
412
collections. They suggested that the causes of a delayed
pancreatic fistula were drains failing to drain due to
blockage, displaced or misplaced drains, and vascular
factors.
A delayed pancreatic fistula after a pancreatico-
duodenectomy occurs rarely. Early detection and
management is therefore difficult. It is important to
consider the occurrence of a delayed pancreatic fistula
if the patient suffers from fever, abdominal pain and
elevation of serum amylase levels. In such a clinical
situation, prompt action is required.
Conflicts of interest The authors have no potential
conflicts of interest
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