Internal pancreatic fistulas: pancreatic ascites and pleural effusions

Thirty four patients seen over a 10 year period with internal pancreatic fistulas are reported. In 22 patients the fistula was into the peritoneal cavity and they presented with pancreatic ascites. In 7 patients the fistula tracked up through the mediastinum into a pleural cavity, and they presented with pancreatic pleural effusions. Five patients presented with both pancreatic ascites and pancreatic pleural effusions. Diagnosis was made by finding a markedly elevated amylase and protein content in the ascitic and pleural fluids. Serum amylase was usually, but not always, elevated. Over one half of the patients had no history of inflammatory pancreatic disease. Initial treatment was nonoperative using nasogastric suction, diamox, atropine, and multiple paracenteses or thoracenteses. This was successful in 48% (12/25). If nonoperative therapy failed, surgery was performed to drain or resect the internal fistula. Surgery was successfully demonstrated in most instances by preoperative, operative, or postmortem pancreatography, or by gross observation at the time of surgery.