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Paper text:
the commonest cause of external pancreatic fistulae is pancreatic surgery with an incidence reported between 3 and 30% ; 90% of cases are initially treated conservatively although 20% may ultimately require surgery .
a 39-year - old type 2 diabetic ( fn ) presented with a 48-h history of central crampy abdominal pain , radiating into his back and lower abdomen .
he had not opened his bowels or passed flatus in 36 h , although his appetite remained normal .
he had generalized abdominal tenderness localizing to the right iliac fossa ( rif ) with guarding .
blood tests showed raised c - reactive protein ( crp ) 94 mg / l , white cell count 21.79  10/l and neutrophils 19.04  10/l with normal liver function tests .
his condition deteriorated later that day , he became anorexic with localized peritonism in the rif .
a clinical diagnosis of appendicitis was made , and the patient submitted to open appendicectomy . at operation , purulent fluid
was found in the rif along with evidence of inflammatory changes in retroperitoneal tissues and a mildly inflamed retrocaecal appendix .
iv antibiotics were commenced prior to and following surgery . at this stage , it was unclear whether the appendix was responsible for the inflammatory process , the decision to operate was based on clinical findings ; however , subsequent histology showed no active inflammation . on the first post - operative day
a decision was made to proceed to laparotomy . at the surgery , copious blood - stained fluid
a consultant hepato - pancreato - biliary ( hpb ) surgeon was called for an opinion and found a severely swollen pancreas with areas of fat necrosis ; therefore , a diagnosis of acute haemorrhagic pancreatitis was made .
gallstones were neither seen nor found later by ultrasound scanning . excess alcohol intake was the suggested cause for the pancreatitis .
he remained unwell and 14 days later a computed tomography ( ct ) scan was performed , which confirmed the appearances of acute pancreatitis with poor perfusion and necrosis of most of the head area .
there was good perfusion of the body and tail , which were considerably swollen . on the 16th day ,
the amylase level of this fluid was 18 240 iu / l , suggesting the presence of a pancreatic fistula emerging via the appendicectomy wound ( see fig . 
serial ct scans continued to confirm that necrosis was limited to the head of the pancreas , the body and tail enhanced healthily .
fluid collections were seen especially in the right paracolic area compatible with a fistulous track and drains inserted into this area on several occasions . however , this never significantly affected the persistent fistulous output through the appendicectomy wound which remained between 150 and 250 ml per day .
after 8 weeks , the patient improved enough to be managed with regular home leave ; however , he did remain significantly nauseated and had a low mood throughout this period . 
 figure  1:a coronal ct image 12 weeks following his initial presentation with necrotizing pancreatitis ; there is atrophy of the pancreatic head and a fluid collection tracks caudally to the right iliac fossa wound .
the pancreatic duct is visible and of normal calibre . a coronal ct image 12 weeks following his initial presentation with necrotizing pancreatitis ; there is atrophy of the pancreatic head and a fluid collection tracks caudally to the right iliac fossa wound .
his case was discussed with several hpb surgeons and a decision was made that further conservative management was futile . on day 113 after his first laparotomy
there was extensive fibrosis around the right colon , where the fistulous track was found .
it ran close in front of the duodenum but was not possible to track safely into the pancreatic head itself .
a 50 cm roux loop procured from the proximal jejunum was anastomosed widely to the track just below the pancreatic head in front of the third part of the duodenum .
post - operatively , lanreotide injections were maintained , also parenteral nutrition for the first 2 weeks .
the fistulous output continued for 4 weeks , then declined to cease after 5 weeks .
a ct scan confirmed no further collections and healthy looking body and tail of pancreas .
he did not become diabetic and was well at 6- and 24-month follow - up .
we are not aware that a pancreatic fistula has previously been described through an appendicectomy incision .
it seems likely that , in this case , the original diagnosis of acute pancreatitis was missed because of clinical suspicion of appendicitis and laboratory difficulty measuring serum amylase because of lipaemia .
this might have been a clue to the diagnosis , which could have been confirmed by a ct scan and obviated the need for an unnecessary appendectomy .
this can not have been the first patient to undergo appendectomy at first presentation of pancreatitis .
first , pancreatitis can present in unusual ways and it is worthwhile sending peritoneal fluid for amylase if the appendix appears grossly normal . secondly
, this case confirms the fact that pancreatic fistulae are difficult to manage and may require prolonged conservative management .
it is interesting to note that the conservative approach to management of this case seemed ineffective .
pancreatic fistulae are not uncommon , and their development is due , in part , to proteolytic secretions , which can make them refractory to conservative management . in this case ,
a surgical approach to provide internal drainage was successful and proved an important and useful technique .
we report an unusual case of a pancreatic fistula communicating with an appendicectomy wound . 
 this occurred following an episode of acute haemorrhagic pancreatitis . 
 the patient was initially admitted with signs and symptoms indicating appendicitis and went to theatre for an open appendicectomy . 
 however , this did not resolve his symptoms and a laparotomy was performed the next day revealing haemorrhagic pancreatitis . 
 he endured a stormy post - operative course , the cause of which was found to be an external pancreatic fistula with discharge of amylase - rich fluid from the lanz incision . 
 a trial of conservative management failed despite multiple percutaneous drainage procedures and treatment with broad - spectrum antibiotics . 
 after a second opinion was sought , it was decided to fit a roux loop anastomosis between the head of the pancreas and the duodenum to divert the fistulous fluid . 
 this procedure was a success and the patient remains well 2 years later .