GASTROINTESTINAL AND PANCREATIC COMPLICATIONS ASSOCIATED WITH SEVERE PANCREATITIS

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.