Pancreatic fluid collections (PFC) are notorious for their extension beyond the normal confines of the pancreatic bed. This distribution is explained by dissection along the fascial planes in retroperitoneum due to the digestive enzymes within the PFC. In genitourinary track, PFCs have been described to involve the kidneys and the ureters. We report a case of severe acute necrotizing pancreatitis in a 28-year-old male, chronic alcoholic, who on readmission developed features of cystitis. The urine was turbid but did not show significant bacteriuria. Close location of the PFC near the urinary bladder (UB) prompted evaluation of urinary lipase and amylase. Elevated urinary enzyme levels suggested a Pancreatico-vesical fistula, conclusive demonstration of which was established by CT cystography. Percutaneous drainage of the necrosum and stenting of pancreatic duct led to spontaneous healing of the pancreatico-vesical fistula. Our case reiterates the remarkable property of pancreatic enzymes to dissect the fascial planes which is demonstrated by decompression of PFC via UB causing spontaneous Pancreatico-vesical fistula. Further, presence of main pancreatic duct fistulization should prompt endoscopic-guided stenting to obliterate the communication with the fistula and accelerate healing.

• Acute necrotizing pancreatitis
• pancreatic fistula
• urinary bladder fistula

The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.

• Graft survival
• Patient survival
• Anastomotic leak
• Morbidity
• Infection
• Surgery

• Abdominal Pain/etiology
• Anastomosis, Surgical
• Ascitic Fluid/cytology
• Cystostomy
• Duodenostomy
• Duodenum/transplantation
• Extravasation of Diagnostic and Therapeutic Materials
• Graft Rejection/complications
• Humans
• Kidney Failure, Chronic/etiology
• Kidney Failure, Chronic/therapy
• Kidney Transplantation
• Leukocyte Count
• Methylene Blue
• Pancreas/surgery
• Pancreas Transplantation/methods
• Peritoneal Dialysis, Continuous Ambulatory
• Peritonitis/etiology
• Postoperative Complications/diagnosis
• Postoperative Complications/etiology
• Recurrence
• Reoperation