PANCREATICODUODENAL FISTULA IN WALLEDOFF NECROSIS: COMPARATIVE OUTCOMES OF CONSERVATIVE AND SURGICAL STRATEGIES

Abstract

Background: Pancreaticoduodenal fistula (PDF) is an uncommon sequel of walled-off pancreatic necrosis (WON). Contemporary multicenter series of necrotizing pancreatitis report GI fistulas in ~16% of cases, with the duodenum accounting for ~35% and most gastroduodenal fistulas managed conservatively in ~68%; only ~11% of upper-GI fistulas need surgery under step-up protocols. However, PDFs complicating established WON may behave differently. 

Methods: Prospective cohort of 25 consecutive patients with PDF secondary to WON. Initial strategy was conservative (infection control, nutritional optimization, and close imaging). Failure criteria included persistent high-output drainage, ongoing sepsis, or no radiologic/endoscopic regression—then proceeding to surgery. Anatomic site of the fistula (first vs third duodenal part) guided operative reconstruction.

Results: Spontaneous closure occurred in 3/25 (12%), but 1/3 later deteriorated septic and required surgery; thus, definitive conservative success was 2/25 (8%). The remaining 22/25 (88%) showed no meaningful regression on side-view endoscopy and contrast-enhanced CT and underwent surgery.
• First-part fistulas: segmental duodenal resection + gastrojejunostomy (GJ) + jejunojejunostomy (JJ) + duodenal stump closure.

• Third-part fistulas: duodenojejunostomy with concurrent GJ and JJ.

Definitive closure was achieved in 100% of operated cases, with no operative mortality. Compared with recent NP series where most gastroduodenal fistulas close with non-operative step-up care, PDFs in WON in our cohort exhibited markedly lower spontaneous resolution and high surgical requirement. 

Conclusion: In WON-associated PDFs, spontaneous closure is uncommon and fragile. Early recognition of non-responders—high-output fistulas, persistent sepsis, or absent radiologic regression—should prompt timely surgical reconstruction tailored to fistula location, yielding reliable, definitive resolution and avoiding delayed septic morbidity. These findings contrast with broader NP data, where many gastroduodenal fistulas are conservatively managed, highlighting the distinct natural history of PDFs once WON is established.