External biliary-pancreatic fistulas

Twenty-seven patients treated for pancreatic and/or biliary-cutaneous fistulas have been reviewed. Four patients died mainly because of cardiopulmonary and septic complications. Spontaneous sealing of the fistula occurred in 81% of the conservatively treated cases (48% of all cases). All the LO fistulas but only 68% of the HO fistulas treated conservatively sealed spontaneously. Eleven patients were treated surgically. There were three deaths and three failures (reappearance of fistula). All the patients who died had been operated on within three months after the appearance of HO fistulas. There was no mortality among the patients with LO fistulas or among patients operated on at a later stage. We have reached the following conclusions: 1. There is a significant difference in prognosis between low output and high output fistulas. 2. In LO fistulas, there is no need for a surgical intervention aimed to close the fistula unless it persists for at least one year. 3. In HO fistulas, if a corrective operation is necessary, it should be withheld for at least three months whenever possible. 4. Roux-en-Y fistulojejunostomy is considered to be the procedure of choice. 5. Infection and premature colsure of the external part of the fistulous tract should be avoided by insertion of drains and repeated surgical drainage, where necessary. 6. High caloric feeding, elemental diet and intravenous hyperalimentation are very important factors that enhance recovery in the surgically and conservatively treated patients.