Gastrointestinal and pancreatic complications associated with severe pancreatitis
H. S. Ho and C. F. Frey
Department of Surgery, University of California, Davis Medical Center, USA.
OBJECTIVE: To study the outcomes of gastrointestinal fistulas and
pancreatic ductal disruption in severe pancreatitis. SETTING: University
tertiary referral center. PATIENTS: One hundred thirty-six patients from
1982 to 1994. INTERVENTION: Diversion followed by resection and ostomy
closure for gastrointestinal fistulas, pancreaticojejunostomy for
pancreatic fistulas, and excision, external drainage, or internal drainage
for pseudocysts. RESULTS: The incidence of infection was 24% (8/33) for
peripancreatic fluid collections and 59% (61/103) for patients with
necrosis plus fluid collections or necrosis without fluid. Sixty-nine
patients developed 25 gastrointestinal fistulas and 51 complications caused
by pancreatic ductal disruption. Necrosis and infection but not the open
packing technique were associated with increased risk of gastrointestinal
fistulas. In patients with pancreatic ductal disruption, pancreatic
fistulas developed following necrosectomy and external drainage, while
pancreatic pseudocysts evolved from undrained peripancreatic fluid
collections. Gastrointestinal fistulas required prompt operative
intervention, whereas pancreatic ductal disruption was treated
nonoperatively initially. The mortality rate was 13% (3/23) in patients
with gastrointestinal fistulas, similar to the overall mortality rate of
10.3% (14/136). There was no mortality in patients with pancreatic fistulas
or pseudocysts. Length of hospital stay was prolonged by the presence of
necrosis and infection, not by gastrointestinal fistulas or ductal
disruption. Thirty-eight of the 69 patients with these complications
required readmission for operative management of their complications. To
date, only 18 (13.2%) of 136 patients with severe pancreatitis have not
required surgical intervention. CONCLUSIONS: Gastrointestinal fistulas and
pancreatic ductal disruption are common in severe pancreatitis. Although
these complications are not associated with increased mortality or
prolonged initial length of stay, readmission for elective surgical
correction is necessary in most patients. Severe pancreatitis is a surgical
disease, requiring both acute and long-term surgical care.
