A prospective study of post-traumatic biliary and pancreatic fistuli. The role of expectant management.

Abstract

Biliary or pancreatic fistulae occur frequently after operative repair of liver or pancreatic injuries. The existing literature is based on a few retrospective series. The objective of this prospective study is to evaluate the clinical course and efficacy of non-operative treatment of biliary fistuli (BF) and pancreatic fistuli (PF) post-traumatic fistulae. Patients who following a trauma Laparotomy, developed BF or PF were prospectively followed during a 38-month period (June 1999-August 2001). Demographics, injury type and severity, fistula characteristics and daily output, complications, interventions and cost were recorded. Optimal nutrition, wound management, and control of infection were priorities in fistula management. A fistula was considered completely healed if the patient was on regular diet and the output was zero for at least 48 h. Of 160 patients (injury severity score: 21 + 10) with trauma laparotomy for a liver or pancreatic injury, nineteen patients (12%) developed a fistula (11 BF, 8 PF). No patient died. Infections occurred in 45% (5/11) of BF patients and 50% (4/8) of PF patients. Only two patients required an operation, one for biliopericardium and one more for a pancreatic pseudo-cyst. Fistula management was responsible for more than half of the hospital stay and cost. Patients with PF had longer hospital stays (44 + 28 days) and charges (US dollars 345,000 + 218,000) than patients with BF (22 + 12 days and US dollars 103,000 + 61,000, respectively). Most post-traumatic BF and PF can be managed non-operatively. BF resolves earlier than PF. Both entities are responsible for substantial increases in hospital length of stay and charges.