The latent presentation of pancreatic fistulas

Pancreatic fistula is traditionally suspected on the basis of increased drain amylase activity. However, some patients have a low amylase level but later manifest clinical evidence of a fistula. This study investigated the prevalence and significance of these presentations.

Severity of fistula was determined according to the International Study Group on Pancreatic Fistula criteria for 405 consecutive pancreatic resections. Latent fistulas, initially lacking amylase-rich effluent but ultimately clinically relevant (grades B or C), were examined to determine their impact and significance.

Fistula of any extent occurred in 107 patients (26.4 per cent). Latent fistulas occurred in 20 patients (4.9 per cent of all resections, 18.7 per cent of all fistulas and 36 per cent of all clinically relevant fistulas). Initial amylase activity was consistently low (range 3-235 units/l), but these fistulas subsequently manifested clinical relevance (abdominal pain, radiographic evidence, fever, sinister effluent, wound infection). Latent presentations had twice the infection rate of evident fistulas, required more aggressive interventions, resulted in longer hospitalizations and incurred greater hospital costs.

A considerable proportion of patients with pancreatic fistula do not initially demonstrate an amylase-rich effluent. These patients have significantly worse outcomes. In fistula definition, the clinical course is important as well as biochemical parameters.