Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Pancreatic fistulas: Management

Santhi Swaroop Vege, MD
Michael L Kendrick, MD
Section Editors
David C Whitcomb, MD, PhD
Stanley W Ashley, MD
Deputy Editor
Shilpa Grover, MD, MPH, AGAF


A pancreatic fistula is characterized by leakage of pancreatic fluid as a result of disruption of pancreatic ducts. Disruption of pancreatic ducts can occur following acute or chronic pancreatitis, pancreatic resection, or trauma. Leakage of pancreatic secretions can cause significant morbidity due to malnutrition, skin excoriation, and infection. Successful management of pancreatic fistulas requires a multidisciplinary approach [1].

This topic will review the management of pancreatic fistulas. The clinical features, diagnosis, and prevention of pancreatic fistulas and the management of walled-off pancreatic fluid collections, infected pancreatic necrosis, and pancreatic trauma are discussed separately. (See "Pancreatic fistulas: Clinical manifestations and diagnosis" and "Management of pancreatic pseudocysts and walled-off pancreatic necrosis" and "Endoscopic management of walled-off pancreatic fluid collections: Techniques" and "Endoscopic management of walled-off pancreatic fluid collections: Efficacy and complications" and "Pancreatic debridement" and "Management of duodenal and pancreatic trauma in adults".)


A pancreatic fistula (PF) is defined as an abnormal connection between the pancreas and adjacent or distant organs, structures, or spaces (image 1).

PFs are classified as internal if the pancreatic duct communicates with the peritoneal or pleural cavity or another hollow viscus and external if the pancreatic duct communicates with the skin (table 1). PFs can also be classified based upon the underlying disease process and the immediate predisposing cause. (See "Pancreatic fistulas: Clinical manifestations and diagnosis", section on 'Definition and classification'.)


The management of pancreatic fistulas (PFs) depends on the presence of symptoms (eg, abdominal pain, fever, chills, jaundice, or early satiety), the characteristics and location of the fluid collection on imaging (eg, presence of pancreatic necrosis, proximity to the bowel lumen), and the presence of associated complications (eg, infection of pancreatic fluid). (See "Pancreatic fistulas: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Feb 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Arvanitakis M, Delhaye M, Bali MA, et al. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007; 102:516.
  2. Klek S, Sierzega M, Turczynowski L, et al. Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology 2011; 141:157.
  3. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27:355.
  4. Gans SL, van Westreenen HL, Kiewiet JJ, et al. Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula. Br J Surg 2012; 99:754.
  5. Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Dig Surg 2004; 21:262.
  6. Bracher GA, Manocha AP, DeBanto JR, et al. Endoscopic pancreatic duct stenting to treat pancreatic ascites. Gastrointest Endosc 1999; 49:710.
  7. Telford JJ, Farrell JJ, Saltzman JR, et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc 2002; 56:18.
  8. Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 1991; 100:1362.
  9. Geenen JE, Rolny P. Endoscopic therapy of acute and chronic pancreatitis. Gastrointest Endosc 1991; 37:377.
  10. Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67:673.
  11. Pelaez-Luna M, Vege SS, Petersen BT, et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68:91.
  12. Pedrazzoli S, Liessi G, Pasquali C, et al. Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg 2009; 249:97.
  13. Cabay JE, Boverie JH, Dondelinger RF. Percutaneous catheter drainage of external fistulas of the pancreatic ducts. Eur Radiol 1998; 8:445.
  14. Hirota M, Kamekawa K, Tashima T, et al. Percutaneous embolization of the distal pancreatic duct to treat intractable pancreatic juice fistula. Pancreas 2001; 22:214.
  15. Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002; 235:751.
  16. Neff R. Pancreatic pseudocysts and fluid collections: percutaneous approaches. Surg Clin North Am 2001; 81:399.
  17. Voss M, Ali A, Eubanks WS, Pappas TN. Surgical management of pancreaticocutaneous fistula. J Gastrointest Surg 2003; 7:542.
  18. Smith CD, Sarr MG, vanHeerden JA. Completion pancreatectomy following pancreaticoduodenectomy: clinical experience. World J Surg 1992; 16:521.
  19. van Berge Henegouwen MI, De Wit LT, Van Gulik TM, et al. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg 1997; 185:18.
  20. Seewald S, Brand B, Groth S, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc 2004; 59:463.
  21. Labori KJ, Trondsen E, Buanes T, Hauge T. Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature. Scand J Gastroenterol 2009; 44:1491.