Pancreatic Fistula

External and internal pancreatic fistulas have a different etiology and natural history. Approximately 50% of internal and 70% to 90% of external pancreatic fistulas can be expected to heal with nonoperative management. Nonclosure is predicted by anatomic factors, which may be defined at endoscopic retrograde cholangiopancreatography or by CT if disconnected pancreatic segments are seen. Enteral nutrition beyond the ligament of Treitz is probably as effective as total parenteral nutrition in reducing fistula output. Octreotide reduces output and, possibly, time to closure. It does not increase the incidence of closure, and there is no convincing evidence that it prevents significant postoperative leaks. Endoscopic stenting has been reported to be effective treatment for side leaks, particularly when associated with stenoses or calculi. However, it is not widely available and has a significant complication rate related to pancreatic sphincterotomy and stent blockage. Surgical treatment is indicated for end leaks with a disconnected pancreatic segment. The choice of appropriate procedure is important. Percutaneous interventional therapies are emerging as options for treatment of end leaks but are still investigational.