Successful Conservative Management of Pancreatico-Colonic Fistula Following Videoscopic Assisted Retroperitoneal Debridement of Infected Pancreatic Necrosis. Case Report.

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Successful Conservative Management of Pancreatico-Colonic Fistula Following Videoscopic Assisted Retroperitoneal Debridement of Infected Pancreatic Necrosis. Case Report CONFERENCE PAPER · AUGUST 2015

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Available from: Mohammed M. H. Hajhamad Retrieved on: 03 October 2015

Successful Conservative Management of Pancreatico-Colonic Fistula Following Videoscopic Assisted Retroperitoneal Debridement of Infected Pancreatic Necrosis. Case Report. Hajhamad M1, Affendi R2, Reynu R, Kosai NR, Mustafa MT, Othman H1 1 Department of Surgery, 2Gastroenterology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Malaysia.

Colonic involvement is a dreaded rare complication of acute severe pancreatitis. Seen in 3% of cases, it varies from torrential gastrointestinal hemorrhage, intestinal obstruction, septic shock, colonic perforation and pancreatico-colonic fistula formation. Pancreatico-colonic fistula is seen in 30% of cases and is associated with a high mortality risk. We highlight a rare case of pancreaticocolonic fistula following a minimally invasive debridement of infected pancreatic necrosis.

A 40-year-old man presented to the emergency department and was diagnosed with acute severe pancreatitis. CT scan revealed grade E pancreatitis. Percutaneous drainage followed by VARD was performed. Post procedure, feculent material was noted in the drainage catheter. A diagnosis of pancreatico-colonic fistula was made and confirmed by fistulogram.

Figure 1. CT scan of abdomen shows presence of peripancreatic collection

Figure 2. Fistulogram of the lesser sac via percutaneous drain, note the opacification of the peripancreatic region with immediate opacification of the splenic flexure which indicate an enteropancreatic fistula.

Figure 3. Abdominal CT image showing no evidence of contrast at splenic flexure, suggesting resolution of the enteropancreatic fistula.

Conservative management with TPN and octreotide was adopted for 6 weeks. CT scan with oral, rectal and intravenous contrast done at the end of 6 weeks confirmed closure of the fistulous tract. The drain was removed and patient discharged home. A repeat CT 6 months later was unremarkable. Patient has been well since.

Pancreatico-colonic firstula has been attributed to splenic vein thrombosis, external pressure by pancreatic pseudocyst, enzymatic digestion of the colonic wall and post necrosectomy. CT with rectal enema, fistulogram, and ERCP can be used to confirm diagnosis. ERCP is superior and doubles as a diagnostic and therapeutic tool. Lower incidence of pancreatico-colonic fistula is seen with minimally invasive procedures compared to open necrosectomy. Only few successful cases of conservative management of pancreatico-colonic fistula have been reported, making our case an important learning point to those who are just embarking on their surgical career

1. Michael GT, Saxon C, David N. Criddle RS, and Neoptolemos JP. Acute pancreatitis and organ failure: pathophysiology, natural history, and management strategies. Current gastroenterology reports. 2004; 6:(2) 99-103. 2. Whitcomb DC, Yadav D, Adam S, Hawes RH, Brand RE et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008; 8:(4-5):520-31. 3. Yadav D, and Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006; 33,323–30.