Pancreatic fistula

　　First, the cause of the disease

　　1. Pancreatic surgery

　　(1) Pancreatic trauma: The incidence of fistula after pancreatic trauma is as high as 40%. Due to the fact that the pancreatic tissue is mostly normal and soft during trauma, the embedding or anastomosis is not satisfactory, and fistula is easy to occur; in addition, the edema or stenosis of the pancreatic duct and ampulla during trauma causes poor outflow of pancreatic juice, making fistula more likely to occur.

　　(2) Pancreatic cyst drainage: External drainage can cause pancreatic fistula, which is now mostly replaced by internal drainage, thus greatly reducing the incidence of fistula. The occurrence of fistula after internal drainage is mainly related to the surgeon's surgical skills and the choice of operation timing.

　　(3) Pancreatectomy: including pancreaticoduodenectomy, pancreatic tumor resection, distal pancreatectomy, resection of the body or head of the pancreas, which is an important cause of fistula. The risk factors for the occurrence of fistula include:

　　① Age > 65 years.

　　② Small diameter of the pancreatic duct.

　　③ Unable to place a stent in the pancreatic duct.

　　④ The pancreas is soft or normal in texture.

　　⑤ Excessive blood loss during surgery.

　　⑥ Jaundice before surgery.

　　⑦ Excessive operation time.

　　Furthermore, the technical level of the surgeon directly affects the incidence of pancreatic fistula after pancreatectomy. In addition, different methods of handling the distal end of the pancreas, preoperative chemotherapy, the use of somatostatin, and other factors can all affect the occurrence of fistula.

　　2. Non-pancreatic surgery

　　Pancreatic fistula caused by non-pancreatic surgery is actually due to the invasion of the pancreas by the lesion or accidental injury to the pancreas during surgery. The most common cause is fistula formation due to the injury to the tail of the pancreas during splenectomy, and fistula formation due to accidental injury or invasion of the pancreas during subtotal gastrectomy and radical gastrectomy for gastric cancer.

　　3, Severe acute pancreatitis (SAP)

　　Artz et al. reported that 20% of survivors after SAP drainage developed pancreatic fistula. Pancreatic tissue necrosis can occur at the onset of SAP, and its scope can expand and erode the pancreatic duct, causing pancreatic juice leakage, which is drained externally for a long time, forming a pancreatic fistula; if it accumulates around the pancreas, it can form a pseudopancreatic cyst or abscess. Pancreatic abscess can also erode the pancreatic duct, causing secondary rupture of the pancreatic duct and leading to pancreatic fistula.

　　4, Secondary rupture of the pancreatic duct

　　Pancreatic duct injury is the fundamental cause of the formation of pancreatic fistula, and secondary pancreatic duct rupture as a hidden pathogenic factor should be paid more attention to. Secondary pancreatic duct rupture can be caused by progressive pancreatic necrosis, pancreatitis, or abscess, and the two often cause each other. Pancreatic surgery, inflammation, and trauma can all cause continuous necrosis of pancreatic tissue and the formation of pancreatic abscesses, and long-term erosion of the pancreatic duct can lead to pancreatic fistula. In addition, infection of the pancreatic fistula can affect the repair of the damaged pancreatic duct, which is also one of the reasons that promote the formation of pancreatic fistula.

　　Pancreatic fistulas can be broadly divided into internal fistulas and external fistulas. In addition, according to the amount of pancreatic juice leakage, Sitges-Serra divides pancreatic external fistulas into high-flow fistulas (>200ml/d) and low-flow fistulas (

　　Second, Pathogenesis

　　The pathological basis of the formation of pancreatic fistula is the rupture or fracture of the main pancreatic duct or its branches. A partial pancreatic fistula is called when only a part of the main pancreatic duct or its branches is ruptured, with less pancreatic juice loss and a high chance of spontaneous healing; a complete pancreatic fistula is called when the main pancreatic duct or its branches are completely fractured, with more pancreatic juice loss and difficulty in spontaneous healing. Pancreatic fistulas can be divided into high-flow fistulas (>200ml/d) and low-flow fistulas (1000ml/d), medium-flow fistulas (100-1000ml/d), and small fistulas (

　　The pathological and physiological changes caused by pancreatic fistula are mainly abnormal exocrine secretion. The composition of pancreatic juice is similar to that of tissue fluid, with concentrations of Na, K, and Ca2+ similar to those in serum, and Cl- lower than the serum value. The concentration of HCO3- in pancreatic juice is high, with a pH of 8.0-8.6, making it alkaline. The normal daily secretion volume of the pancreas is 800-1500ml. The maximum amount of pancreatic juice that can be drained from a pancreatic fistula in one day is 1800ml. Due to the large loss of pancreatic juice caused by the fistula, it can cause varying degrees of water and electrolyte imbalance and acid-base metabolism imbalance, and in severe cases, it can even lead to hypoproteinemia. The skin around the external fistula of the pancreas can appear congestion, erosion, ulcers, and even bleeding. It can also form a pseudopancreatic cyst due to poor drainage or be complicated by infection. Secondary infection can lead to purulent peritonitis and severe systemic infection and localized abscess formation. Pancreatic juice contains a large amount of digestive enzymes, which, when activated, can corrode the surrounding tissue and organs of the pancreas, causing them to溃烂、坏死, and even erode blood vessels to cause massive hemorrhage in the abdominal cavity; corrode the stomach, duodenum, or colon to cause gastrointestinal perforation; the leaked pancreatic juice can also be encapsulated by surrounding fibrous tissue to form a pseudocyst; if the pancreatic juice extends to the retroperitoneum, it can digest retroperitoneal fat tissue, causing widespread retroperitoneal infection, and if it develops upwards, it can cause pleural cavity infection or mediastinal infection, leading to sepsis, bacteremia, and multiple organ failure, with extremely serious consequences.

　　The accumulation of pancreatic juice in the peritoneal cavity due to poor drainage can cause necrosis of surrounding tissues, easy secondary infection, and accelerated activation of the pancreatic enzyme activation process after infection, which strengthens the digestive and corrosive effects of pancreatic juice. Perforation of the gastrointestinal tract can cause bleeding and internal fistula in the stomach, small intestine, colon, and other parts. If a blood vessel is perforated, it can cause致命性fatal massive hemorrhage. Weak and low-resistance patients may develop multiple, uncontrollable abscesses in the abdominal and retroperitoneal areas, and quickly appear multiple organ dysfunction and even death.

　　According to the daily drainage volume of pancreatic juice, pancreatic fistula can be divided into high-flow and low-flow fistula, and can also be divided into mild fistula (〈100ml/d), moderate fistula (100～500ml/d), and severe fistula (〉500ml/d). Early mild fistula may only manifest as an increase in amylase in the drainage fluid without other symptoms. Early severe fistula often manifests as marked abdominal tenderness, tachycardia, tachypnea, or mild restlessness in patients. With infection, there may be signs of peritonitis, and the amylase in the drainage fluid is often significantly increased, but this is not an indispensable feature. The loss of a large amount of pancreatic juice containing water, electrolytes, and proteins, if not supplemented in time, can cause dehydration and disturbance of electrolyte balance, as well as malabsorption of nutrients, manifesting as weight loss and malnutrition. The loss of excessive alkaline pancreatic juice can cause metabolic acidosis. The skin around the fistula opening may become edematous and eroded, forming ulcers, which can even lead to bleeding. It can also occur due to poor drainage, causing the skin of the fistula tube to heal before the pancreatic fistula, forming a pseudopancreatic cyst.

　　1. Pancreatic internal fistula

　　After the formation of an internal fistula between the pancreas and the duodenum or upper jejunum, the leaked pancreatic juice directly enters the intestine, which can alleviate the symptoms and signs caused by the original pseudopancreatic cyst or infected pancreatic peripancreatic abscess, and even heal spontaneously. If there were no obvious clinical manifestations originally, and the formation of the internal fistula did not cause complications such as hemorrhage or infection, the patient also had no special manifestations. When a colonic fistula is formed, due to the loss of pancreatic juice, it can cause varying degrees of hyponatremia, hypokalemia, and hypocalcemia, as well as malabsorption, metabolic acidosis, malnutrition, and other symptoms.

　　2. Pancreatic external fistula

　　Most cases occur after surgery, and it is generally believed that 1 to 2 weeks after surgery are the peak periods for the occurrence of pancreatic fistula. Low-flow pancreatic fistula or small fistula can cause changes in the skin around the external fistula opening, but generally has no other clinical manifestations. High-flow pancreatic fistula or medium to large fistula can present with clinical manifestations similar to those of colonic fistula. The leakage fluid of pure pancreatic external fistula without communication with the digestive tract is colorless and transparent clear liquid, with the content of pancreatic amylase more than 20,000 U/L (Sotin units, the same below); when mixed with lymphatic leakage fluid, the amylase content is 1000 to 5000 U/L; when the leakage fluid is turbid, with bile color, green or brown, it indicates that the pancreatic juice has mixed with intestinal juice, the pancreatic enzymes have been activated, and their corrosive properties may cause tissue damage, major bleeding and other complications. If complications such as hemorrhage, infection, or intestinal fistula occur, there will be corresponding clinical manifestations. When the pancreatic fistula drainage is not smooth, patients may present with symptoms such as abdominal pain, fever, muscle tension, and leukocytosis.

　　Eliminate the related etiological factors causing pancreatic fistula (such as trauma, surgery, and other mechanical causes, or the rupture of pancreatic duct due to acute and chronic pancreatitis), to prevent the occurrence of pancreatic fistula.

　　The key to preventing the occurrence of pancreatic fistula lies in good pancreaticojejunal anastomotic technique and methods during surgery, and the correct postoperative management is an important guarantee for reducing the incidence of pancreatic fistula. Firstly, efforts should be made to improve the pancreaticojejunal anastomotic technique; secondly, attention should be paid to the management of the pancreatic duct; third, postoperative drainage must be kept unobstructed and effective; fourth, the patient's overall condition should be improved to promote the healing of the anastomosis.

　　Pancreatic fistula is the most common complication after pancreaticoduodenectomy. The management of the pancreatic residual is the key to preventing the occurrence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic residual should be cut into a fish mouth shape and the margin sutured. When anastomosing the pancreatic residual with the jejunum, it should be avoided to tear or injure the pancreas, and the patency of the pancreatic duct should be maintained. It is routine to place a stent in the pancreatic duct to effectively introduce pancreatic juice into the intestinal lumen or drain it out of the body, reducing the stimulation of pancreatic juice on the anastomosis and avoiding accidental injury to the pancreatic duct during surgery. The anastomotic segment should be long enough and well-vascularized. Regardless of the anastomosis method, it is necessary to ensure a tight and reliable anastomosis without tension, and there should be no intestinal obstruction after the anastomosis is completed. The placement of the pancreatic stent should be noted: choose a stent that is suitable for the diameter of the pancreatic duct, avoid too thick or too thin; avoid twisting and blocking, prevent the leakage of pancreatic juice along the outer wall of the stent to the anastomosis site, which is not conducive to the healing of the anastomosis; the stent outside the pancreas should have a certain length, and there should be no side holes on the wall; the pancreatic stent should be properly fixed to avoid early tube shedding, and the external drainage stent should be removed 3 to 4 weeks after surgery.

　　The method of pancreaticojejunal anastomosis is also very important for the occurrence of pancreatic fistula. Theoretically, mucosal-to-mucosal end-to-side anastomosis can better drain pancreatic juice into the intestinal lumen, reducing the stimulation of pancreatic juice on the anastomosis. However, since end-to-side anastomosis and invagination anastomosis are performed under different conditions, it has not yet been determined in clinical practice which method is more conducive to preventing the occurrence of pancreatic fistula. Generally, end-to-side anastomosis is better when the diameter of the pancreatic duct is greater than 0.5cm, and end-to-side anastomosis should not be forced when the diameter is less than 0.5cm. Invagination anastomosis is better when a stent is placed in the pancreatic duct.

　　During distal pancreatectomy, fibrin glue can be used to seal the distal pancreatic断面 to prevent the formation of postoperative pancreatic fistula. After transecting the pancreas, tie the main pancreatic duct with atraumatic knots, and then suture the residual pancreatic断面 in a continuous overlapping manner. Finally, apply 2ml of fibrin glue at the suture site. There is also a method of segmentally occluding the pancreatic duct with alcohol-soluble gliadin glue to prevent the formation of post-distal pancreatectomy pancreatic fistula. The pancreas is bluntly transected, and the断面呈凹形鱼口状. Leave a 5mm margin of the main pancreatic duct at the断面, clamp the pancreas with atraumatic forceps 2cm from the distal margin, inject 0.2ml of alcohol-soluble gliadin glue into the main pancreatic duct, tie and purse-string suture, and suture the pancreatic断面 after the glue hardens. Both methods are effective, and no toxic reactions have been observed.

　　1. After 7 days or more post-surgery, the drainage fluid contains pancreatic juice, and the amylase content is greater than 1000U/L. In cases of pancreaticoduodenectomy, the amylase level in the drainage fluid increases, even exceeding three times the normal serum amylase level, which is a very valuable criterion for the diagnosis of pancreatic fistula.

　　2. The amylase content in the peritoneal fluid and ascites drained after 7 days or more post-surgery is greater than 5000U/L, even greater than 10,000U/L.

　　3. CT: First, CT examination should be used to determine whether it is an external pancreatic fistula or a pancreatic pseudocyst, observe whether there is abscess formation and necrotic tissue around the fistula, and roughly understand whether the wall of the pseudocyst is thickened. CT is very important for determining the timing of surgery and can reveal rare pancreatic and external fistulas, such as pancreatic bronchial fistula and pancreatic pleural fistula. In addition, further understanding of the lesions of the pancreas and the course and changes of the pancreatic duct can be obtained through thin-section CT scanning of the pancreas and contrast enhancement.

　　4. ERCP: For pancreatic fistula, it is necessary to understand the relationship between the fistula and the pancreatic duct and surrounding organs, whether the fistula has branches, whether the fistula drainage is unobstructed, and to differentiate between end fistula and lateral fistula. Fistula angiography can be performed for observation. For patients with unsatisfactory fistula angiography and pseudocysts, ERCP examination is necessary.

　　During ERCP examination, if there is stenosis in the proximal pancreatic duct, endoscopic stent placement can also be performed, which can promote the spontaneous healing of pancreatic fistula in most cases. When performing ERCP or fistula angiography, attention should be paid to avoid triggering pancreatitis. There are reports that somatostatin and its analogs are used for prevention and treatment of concurrent pancreatitis before and after examination.

　　The last foods to be eaten in the diet for pancreatic fistula should be less:

　　1. Meat:There is no fiber-rich fiber. If meat is not properly chewed, it is not easy to digest, increasing the pancreas's workload.

　　2. Saturated fats:Saturated fats refer to animal fats and artificial fat cream.

　　3. Gluten:Gluten can form a paste-like sticky substance that adheres to the inner wall of the pancreas. It delays the passage of food, easily causes pancreatic putrefaction, and interferes with the absorption of the vitamin B group.

　　1. Treatment

　　The treatment principle of pancreatic fistula is first to inhibit pancreatic secretion, including extracorporeal nutritional support, inhibition of pancreatic enzyme activity, and the use of somatostatin analogs; secondly, fistula drainage, including various percutaneous catheter drainage, surgical drainage, and endoscopic drainage.

　　1. General treatment:Fasting and gastrointestinal decompression can reduce the stimulation of gastrointestinal juice to the pancreas and has a good effect in the early stage of pancreatic fistula. For patients with high-flow pancreatic fistula, attention should be paid to correct water and electrolyte imbalance and maintain homeostasis in the body.

　　2. Nutritional supportHigh-flow pancreatic fistula patients often suffer from excessive pancreatic juice leakage, affecting the patient's digestion and absorption function, leading to malnutrition. Active supplementation of calories, vitamins, and proteins should be provided to improve the overall condition and promote fistula healing. Practice has proven that tumor necrosis factor can inhibit pancreatic exocrine secretion, reduce the amount of fistula drainage, and shorten the time for fistula closure. In addition, enteral nutrition is also gaining more attention, as enteral nutrition can promote the recovery of intestinal function, protect the intestinal mucosal barrier function, prevent bacterial translocation, and is conducive to preventing the occurrence of systemic inflammatory response syndrome and multiple organ failure.

　　3. Prevention and treatment of infection:Pancreatic fistula complicated with infection often leads to severe consequences and has a relatively high mortality rate. The drainage fluid should be routinely cultured for bacteria and drug sensitivity tests, and antibiotics should be selected rationally. In the absence of culture results, empirical use of antibiotics can be used first, usually starting with Gram-negative bacteria and anaerobic bacteria, and the first choice of antibiotics is third-generation cephalosporins or aminoglycosides combined with metronidazole or quinolones for treatment.

　　4. Somatostatin:The main effect of somatostatin analogs in the treatment of similar fistulas is to inhibit pancreatic secretion and relax the smooth muscle of the intestinal tract, which can significantly reduce the incidence of fistulas and accelerate the closure of fistula openings. A randomized, prospective clinical study found that the prophylactic use of somatostatin can reduce the incidence and mortality of pancreatic fistula after selective pancreatic resection.

　　Martineau et al. reported that somatostatin analogs as adjuvant therapy can reduce the incidence of postoperative pancreatic fistula and have the effect of accelerating fistula healing, but they have poor effects on recent fistulas with a course of less than 8 days.

　　5. Percutaneous catheter placement and surgical drainage of pancreatic fistula:The pancreatic juice can be drained through a percutaneous catheter to promote the closure of the fistula opening, but due to the digestive and corrosive effects of pancreatic juice on local tissues, there are problems such as long drainage time and slow fistula healing, especially for fistulas communicating with the main pancreatic duct.

　　(1) Surgical indications for pancreatic fistula: The vast majority of pancreatic fistulas can close spontaneously. Zinner reported that the average closure time for 35 cases of low-flow pancreatic fistulas (〈200ml/d) was 92 days. Zhao Ping reported that the average closure time for 61 cases of pancreatic fistulas was 83 days for low-flow fistulas; 100 days for high-flow fistulas; 90% of fistulas can close within 3-6 months. During this period, patients can recover from the effects of surgery, and time is given for fistula healing. Therefore, some people believe that observation should be made for 6-12 months; others advocate that high-flow fistulas should be operated on after 2 months of continuous existence. In the following situations, active consideration should be given to surgical treatment:

　　① The pancreatic fistula lasts for more than 3 months, and there is no trend of reduction in the amount of drainage.

　　② Poor drainage, recurrent infection, fever, especially when a large abscess cavity is found; ③ massive intra-abdominal hemorrhage; ④ obstructive pancreatitis and pain caused by scar formation at the distal end of the pancreatic duct.

　　(2) Surgical methods for pancreatic fistula:

　　① Pancreatic fistula sinus tract resection: Suitable for cases with small fistulae and unobstructed outflow of pancreatic juice. During the operation, the surrounding tissue of the fistula should be freed, and the fistula should be ligated and excised near the pancreas. Necrotic tissue should be thoroughly removed. Peking Union Medical College Hospital has performed 3 cases of pancreatic fistula sinus tract resection, 2 cases were successful, 1 case had postoperative recurrence of pancreatic fistula, which was spontaneously closed after conservative treatment. This operation is currently rarely used because the vast majority of chronic pancreatic fistulas with unobstructed outflow of pancreatic juice can be closed spontaneously. For individual cases that do not heal for a long time, the method of blocking the pancreatic fistula with an adhesive agent can be adopted, inserting a 2-4mm diameter polyvinyl chloride catheter into the sinus tract of the pancreatic fistula, first flushing with antibiotic solution and aspirating the contents of the sinus tract, then injecting 3-6ml of high-purity styrene butadiene emulsion into the sinus tract; followed by injecting 12.5% acetic acid 0.5-1.5ml, and finally removing the catheter, the pancreatic fistula will be sealed by the polymer. After blocking the pancreatic fistula, atropine, fluorouracil, and other drugs should be used to inhibit pancreatic secretion; causing the pancreatic tissue leading to the pancreatic fistula to atrophy. This method has been applied in 9 clinical cases, observed for 2-8 months, all were successful and there was no recurrence. This method is simple and effective, with ideal results. No adverse reactions were found in clinical application.

　　② Pancreatic fistula sinus transplantation: Long-standing pancreatic fistulas have formed sinus tracts with complete epithelial coverage. If the daily output of pancreatic juice is more than 100ml/d or there is obstruction in the outflow tract of pancreatic juice, sinus transplantation of the pancreatic fistula can be performed. The method is to first insert a catheter or inject methylene blue (methylene blue) after injection, make a diamond-shaped incision next to the fistula, and carefully suture the distal end of the sinus tract.

　　③ Excision of the distal part of the pancreas including the pancreatic fistula: Excision of the distal part of the pancreas including the pancreatic fistula is suitable for pancreatic fistulas in the body and tail of the pancreas where there is no obstruction in the proximal part of the pancreatic duct. Before surgery, it is necessary to perform fistulography or retrograde cholangiopancreatography (ERCP) to understand the location and origin of the fistula, and to judge its likelihood of spontaneous closure. If the fistula only involves the second or third-order pancreatic ducts and the main pancreatic duct is normal, such fistulas can generally close spontaneously without surgical treatment. If the main pancreatic duct is involved or there is stenosis in the proximal pancreatic duct, surgery is often required. Pancreatic fistula surgery is generally complex, although most surgeries are successful, there is still a small number of recurrences of pancreatic fistulas. Reconstruction of the pancreatic juice回流道 is an effective treatment method for patients with proximal obstruction of the main pancreatic duct or pancreatic fistulas involving the main pancreatic duct. Surgical methods include pancreaticojejunostomy, pancreaticojejunal anastomosis, and pancreatic duct choledochojejunal anastomosis. Oddi's sphincteroplasty is also one of the methods to relieve obstruction of the proximal part of the main pancreatic duct.

　　6. Endoscopic treatment of pancreatic fistula:Pancreatic fistula, also known as pancreatic pseudocyst. DellAbate performed endoscopic drainage on 15 pancreatic pseudocysts, with an average hospital stay of 4.8 days, zero mortality rate, and zero incidence of severe complications, indicating that endoscopic drainage is effective for pancreatic pseudocysts compressing the gastrointestinal tract. Sciume reported a success rate of 88% (7/8) for endoscopic drainage. Libera compared the results of endoscopic drainage through the papilla and through the gastric wall and found no significant difference between them, with high success rates and low incidence of complications. DePalma followed up on patients with pancreatic pseudocysts who underwent endoscopic drainage, comparing the effects of drainage through the gastric wall and through the papilla. Twelve patients experienced complications, including hemorrhage (2 cases), mild pancreatitis (2 cases), and cyst infection (8 cases), and 9 patients had recurrence of pseudocysts. After a follow-up of 25.9 months, 75.5% of the patients showed effective treatment.

　　7. Endoscopic treatment of pancreatic fistula outside the pancreas:For pancreatic fistulas that communicate with the main pancreatic duct, nasopancreatic negative pressure drainage can be performed endoscopically to drain pancreatic juice outside the body and promote the closure of the fistula, or endoscopic placement of pancreatic duct stent drainage can be performed to promote the closure of the fistula.

　　(1) Endoscopic nasopancreatic drainage: Sun Zhwei and others in China reported the use of nasopancreatic negative pressure drainage to treat 8 patients with pancreatic fistula, the fistula healed in 6-28 days, but the nasopancreatic tube is easy to fall off, and it cannot solve the root problem of pancreatic duct stenosis. Brelvi reported on 3 patients with long-term alcohol abuse and chronic pancreatitis, 2 had dyspnea and chest pain, imaging suggested pleural effusion, ERCP found the fistula from the pancreatic duct to the pleural cavity, and another patient had left upper quadrant pain, a small amount of pleural effusion, pseudocyst adjacent to the stomach. The first two were treated with nasopancreatic drainage and thoracic duct drainage, and the patient with pseudocyst underwent gastric nasocyst drainage. The fistula closed within 7 days, the pseudocyst absorbed within 14 days, and all three had no pain attacks, and there was no recurrence of pseudocyst and fistula after discharge.

　　(2) Pancreatic duct stent drainage: Endoscopic placement of pancreatic duct stent drainage can relieve pancreatic duct stenosis and obstruction, make pancreatic juice drainage smooth, rapidly reduce the amount of external drainage of pancreatic fistula, and quickly close the fistula.

　　Kozarek et al. treated a patient with pancreatic fistula that was ineffective after conservative treatment with pancreatic duct stents, and the fistula healed 10 days after the placement of the stent, with no recurrence or other complications.

　　(3) Closure of fistula with biological glue: Traditionally, due to the formation of pancreatic fistula caused by pancreatic necrosis, the treatment methods are long-term percutaneous catheter drainage or open drainage after surgery, but part of the pancreatic function is lost after surgery, and there is also the risk of concurrent infection and venous thrombosis. Findeiss used biological glue to close the fistula, and during the subsequent 1 year, the patient had no symptoms and no longer needed to place a drainage tube or other interventional operations.

　　II. Prognosis

　　Endoscopic treatment of pancreatic fistula: The mortality rate is 0, and the incidence rate of serious complications is also 0, with ideal efficacy. Endoscopic treatment of pancreatic fistula, feasible endoscopic placement of pancreatic duct stent drainage, promotes the closure of the fistula, and the efficacy is still good.