Severe Acute Necrotising Pancreatitis Presenting as Pancreaticocutaneous Fistula: A Rare Complication

Dear Editor,

Pancreatic glandular necrosis is the most common contributor to severe acute pancreatitis. When necrosis is present, the mortality and morbidity that come with acute pancreatitis are significantly higher, with associated infection in the necrotic area. Pancreatic fistulas generated by a ruptured pancreatic duct can develop following the surgery. In 15-23% of instances, pancreatic fistulas aggravate necrotising pancreatitis (1).

Treatment can range from early surgical debridement (“necrosectomy”) to aggressive intensive medical care (2).

This letter is about a 36-year-old male, who came to the casualty with complains of pain in abdomen radiating to his back and associated with distension of abdomen, nausea and 8-10 episodes of vomiting since five days. The patient was a chronic alcoholic. There were no other co-morbidities. He was admitted to the Intensive Medical Care Unit.

On physical examination, the patient was afebrile, tachycardia was present, and abdomen was tender. Investigations revealed serum amylase to be 800 U/L, serum lipase 1400 U/L, total leucocyte count 12.2×109 /L, platelets 1.62 lac, and serum calcium 6mg/dl. Ultrasonography (abdomen and pelvis) was suggestive of acute pancreatitis, hepatomegaly with grade II fatty liver, and mild splenomegaly.

The patient was kept nil by mouth and was started on fluid resuscitation, injection Meropenum 1 gm i/v thrice a day, injectable metronidazole 100 ml thrice a day, injection tramadol 100 ml i.v. thrice a day, pancreatin minimicrospheres capsules 25000-10000-10000 IU thrice a day, multivitamin with L-Methionine, and selenium yeast tablets twice a day.

Contrast-enhanced CT abdomen revealed bulky pancreas throughout its course and peri-pancreatic fat stranding and fluid collection abutting lesser curvature of stomach suggestive of acute pancreatitis with necrotic collection, modified CT severity index score was 10.

Interventional Radiologist’s opinion was taken in view of necrotic collection. An USG-guided catheter was inserted, and 300 ml output was obtained in five days. The drain was removed when there was less than 20 mL output per day. The patient developed anterior abdominal wall swelling within three days after the drain was removed (Table/Fig 1).

Local examination revealed pus draining through the catheter insertion site along with anterior abdominal wall swelling (Table/Fig 2). As the abdominal distension increased CECT abdomen was repeated. It revealed acute pancreatitis with necrotic collection in subcutaneous and intramuscular plane of anterior abdominal wall, in the left hypochondriac and supra umbilical region communicating through a tract (Table/Fig 3).

The patient was planned for incision and drainage and 50 cc of necrotic material was drained (Table/Fig 4).

Describe patients condition before discharge and is awaiting followup after one month.

This case reports an uncommon complication that happened during the treatment of a reasonably frequent acute surgical illness. Enteroatmospheric fistulas are known to have a notably higher fatality rate than their analogue, enterocutaneous fistulas [3-5]. Pancreaticoatmospheric fistulas may present in similar pattern and is associated with high mortality (28.6%) (3). When compared to primary open necrosectomy, the Patients with Acute Necrotising Pancreatitis (PANTER) study found that the minimally invasive stepup method lowered the rate of complications and mortality. In this way, more than one-third of patients were effectively treated with percutaneous drainage only (6).

Management of severe acute necrotising pancreatitis necessitate multidisciplinary approaches, including resuscitative and supportive measures, as well as prompt management of fistula drainage for optimal wound management with eventual wound coverage and fistula closure.