Pancreas Transplant Recipient With a Fistula?

Robert J. Stratta, MD

Disclosures

August 23, 2001

Question

I have a pancreas transplant recipient who has a fistula in the allograft. Should I stop feeding the patient orally in order to interrupt the hormonal stimulus to release enzymes from the allograft?

Marcio Müller, MD

Response from Robert J. Stratta, MD

Treatment of a pancreatic allograft fistula is analogous to treating a native pancreatic fistula. Management principles include imaging and anatomic delineation of the fistula, adequate drainage, treatment of the underlying cause (ie, ductal disruption, pancreatitis, infection, obstruction, rejection), antibiotics if there is evidence of infection, H-2 blockers or proton-pump inhibitors to decrease acid secretion in the proximal gastrointestinal tract, bowel rest, provision of distal drainage (ie, urethral catheter drainage if the pancreas is bladder-drained and bowel catharsis/cleansing if the pancreas is enteric-drained), and octreotide if indicated.

If the pancreas is bladder-drained, I would recommend prolonged urethral catheter drainage. If the pancreas is enteric-drained, I might consider nasogastric tube decompression depending on the volume of fistula output, the location of the enteric anastomosis (proximal vs distal small bowel), and the severity of ileus. If the fistula is associated with a moderate-to-severe allograft pancreatitis (based on clinical and imaging parameters), I would recommend bowel rest, nothing by mouth except medications and possibly sips, and total parenteral nutrition. If the associated pancreatitis is mild or minimal, I might consider a liquid or elemental diet. The decision to use the GI tract is also determined by the degree of reflex ileus. If the fistula is an anastomotic leak or originates from the transplanted duodenum, I would recommend early surgical intervention. If the fistula is from the pancreatic parenchyma or tail, I would recommend nonoperative management initially. The importance of adequate and complete drainage of any/all peripancreatic fluid collections must be emphasized.

Although the pancreatic graft is denervated, it still responds to autocrine, paracrine, and endocrine stimulation. Therefore, bowel rest, decreasing acid secretion, and the use of octreotide may play an important role in the management. My indications for the use of octreotide include fistulas associated with high output (> 300 cc/day), fistulas associated with moderate-to-severe allograft pancreatitis, or fistulas refractory to initial therapy. I would recommend monitoring the amylase content and bacteriology of the drainage, and have a low threshold for starting antibiotics. Repeat imaging studies and sinography are helpful to monitor the response to therapy. If the patient develops evidence for infection or sepsis (as opposed to colonization), then surgical drainage/repair is usually warranted. In selected cases, biopsy of the pancreas may play a role in establishing the diagnosis and guiding treatment of the fistula.

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