Chebli JMF et al. (2004) Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol 38: 795–800

Internal pancreatic fistulas (IPF) are a rare but serious complication of chronic pancreatitis, and there is little consensus on how they should be treated. In an attempt to devise an appropriate management strategy, Chebli et al. have carried out a retrospective review of IPF cases at their center in Brazil.

During an 8-year period, 11 (7.3%) of 150 patients with chronic pancreatitis were diagnosed with IPF following CT scanning and endoscopic retrograde cholangiopancreatography (ERCP). The patients were assigned to conservative treatment (n = 5) or interventional therapy (n = 6) based on their pancreatic ductal system anatomy. Conservative therapy consisted of administration of octreotide, aspiration of fluid from the peritoneal or pleural cavities, and total parenteral nutrition. Interventional therapy included surgery or endoscopic placement of a transpapillary pancreatic duct stent (TPDS). One patient (from the conservative therapy group) died of sepsis. IPF resolved in the remaining 10 patients, and this was achieved more quickly in those receiving interventional treatment.

Based on these cases, Chebli et al. have proposed an algorithm for IPF management. They suggest that patients with main pancreatic duct dilatation should be treated conservatively at first. Endoscopic placement of TPDS is appropriate for patients who fail conservative treatment, and for those with partial disruption or stricture of the main pancreatic duct. Should this approach fail, or if there is complete disruption or stricture of the main pancreatic duct, surgery is recommended. Finally, pseudocysts should be treated surgically if endoscopic drainage fails. The authors call for randomized controlled trials to validate these proposals.