title: Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging.
abstract: OBJECTIVE
  Diagnosis of internal pancreatic fistulae (IPF) resulting in ascites or pleural effusions may be facilitated by multislice helical CT-scan and MR-pancreatography [MRP]). Conservative treatment with parenteral nutrition and somatostatin analogues (+/- pancreatic stenting) yields varying results. We aimed to evaluate the usefulness of helical CT and MRP in the diagnosis of IPF. The outcome of patients when the following stepwise treatment algorithm is applied is also descried: i) conservative (enteral nutrition and somatostatin analogues); ii) endoscopic stenting; iii) surgery.
  
  
  METHODS
  Sixteen consecutive patients (13 M; median age 42 (14-54) yrs) with chronic pancreatitis (alcoholic 15, hereditary 1) and an IPF were prospectively included between March-01 to December-03. All serous effusions (ascites, N=10; pleural effusion, N=6) contained high lipase [median: 7800 (506-59000) U/mL]. Patients with fistulae communicating with pancreatic pseudocysts were not included.
  
  
  RESULTS
  The diagnosis of IPF and its site were determined in 12/16 patients by CT and 14/15 patients by MRP (site of rupture: head: N=5; isthmus: N=5; body-tail: N=6) and confirmed by ERCP or surgery in 9. Localized atrophy of pancreatic parenchyma adjacent to pancreatic duct rupture was observed in 12 patients (75%). The median follow-up was 30 months (18-51). Early surgery was required in 3 patients (2 with infection of serous fluid at initial aspiration analysis). Thirteen entered the treatment algorithm: - seven patients responded favorably (54%) to conservative treatment (enteral nutrition and somatostatin analogues); - pancreatic stenting, possible in 4 of 6 patients, was successful in closing the IPF in 2; - surgery was required in the 4 remaining patients. Preoperative localization of the rupture site was possible in all patients using non-invasive imaging thus guiding elective intervention in all patients requiring surgery.
  
  
  CONCLUSIONS
  Helical CT scan and MRP are useful in localizing MPD rupture sites and fistulae and may obviate the need for pancreatic opacification. A systematic treatment algorithm can be safely used starting with medical strategies (enteral nutrition safely replacing the parenteral route) progressing to endoscopy and finally surgery. Overall about 44% of patients require surgery initially or at follow-up.
authors.affiliation: Pôle des maladies de l'appareil digestif, Hôpital Beaujon. deotoole@chu-angers.fr
authors.forename: Dermot
authors.initials: D
authors.lastname: O'Toole
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Vullierme
authors.forename: Philippe
authors.initials: P
authors.lastname: Ponsot
authors.forename: Frédéric
authors.initials: F
authors.lastname: Maire
authors.forename: Valérie
authors.initials: V
authors.lastname: Calmels
authors.forename: Olivia
authors.initials: O
authors.lastname: Hentic
authors.forename: Pascal
authors.initials: P
authors.lastname: Hammel
authors.forename: Alain
authors.initials: A
authors.lastname: Sauvanet
authors.forename: Jacques
authors.initials: J
authors.lastname: Belghiti
authors.forename: Valérie
authors.initials: V
authors.lastname: Vilgrain
authors.forename: Philippe
authors.initials: P
authors.lastname: Ruszniewski
authors.forename: Philippe
authors.initials: P
authors.lastname: Lévy
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D001201:Ascites / Q000209:etiology; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000209:etiology; D010185:Pancreatic Fistula / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D010996:Pleural Effusion / Q000209:etiology; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed