Isolated massive pleural effusion caused by pancreatico-pleural fistula

Endoscopic treatment of pancreaticopleural fistulas

Introduction

Pancreaticopleural fistula (PPF) is a serious complication of acute and chronic pancreatitis.

Objective

To evaluate the effectiveness of various endoscopic techniques for the treatment of patients with PPFs.

Methodology

Prospective analysis of the results of endoscopic treatment of 22 patients with PPF due to pancreatitis was conducted at the Department of General, Gastroenterological, and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, between 2018 and 2021.

Results

PPF was diagnosed in 22 patients (21 men and 1 woman; mean age 49.52 [30–67] years) with pancreatitis. In 19/22 (86.36%) patients, PPF communicated with the left pleural cavity and in 3/22 (13.64%) patients with the right pleural cavity. Chronic pancreatitis was diagnosed in 14/22 (63.64%) patients. Symptomatic pancreatic fluid collections were found in 15/22 (68.18%) patients with PPF (pancreatic pseudocyst in 11 and walled-off pancreatic necrosis in four patients). Endoscopic retrograde cholangiopancreatography was performed in 21/22 (95.45%) patients, confirming the diagnosis of PPF. All 21 patients underwent endoscopic sphincterotomy with prosthesis implantation in the main pancreatic duct (passive transpapillary drainage). In 1/22 (4.55%) patients, active transmural/transgastric drainage of the PPF was necessary due to inflammatory infiltration of the peripapillary region, precluding endoscopic pancreatography. Endoscopic transmural drainage was performed in all the 15 patients with pancreatic fluid collection. Clinical success was achieved in 21/22 (95.45%) patients. The mean total time of endotherapy was 191 (range 88–712) days. Long-term success of endoscopic treatment of PPFs during one year follow-up period was achieved in 19/22 (86.36%) patients.

Conclusions

Endoscopic treatment is effective for managing post-inflammatory PPFs. The preferred treatment method is passive transpapillary drainage (prosthesis of the main pancreatic duct). If transpapillary drainage is not feasible, transmural drainage of the PPF remains the preferred method. Endoscopic transmural drainage leads to closure of the fistula canal in patients with pancreatic fluid collection complicated by PPF.

Early Endoscopic Intervention in Pancreaticopleural Fistula: A Single-Center Experience

Background Pancreaticopleural fistulas are among the rarest complications of chronic pancreatitis. The main objective of the research, conducted on a total of seven patients, was to evaluate the effectiveness of early endoscopic management of pancreaticopleural fistula.

Methods The diagnosis of fistula was reached when fistulous tract was demonstrated on imaging studies and/or pleural fluid amylase level was greater than 2,000 U/L. The data were retrospectively analyzed from the records.

Results The prototype patient in our series was a chronic alcoholic male with median age of 45 years. Computed tomography scan was performed in all the seven patients but could diagnose leak only in four patients. Magnetic resonance cholangiopancreatography was better in the remaining three patients for diagnosing fistula. Endoscopic retrograde cholangiopancreatography was the most sensitive test that diagnosed fistula in all the seven patients. Pancreatic duct (PD) cannulation was successful and pancreatic sphincterotomy with PD stenting was performed in all the seven patients. We could avoid surgical intervention in our patients.

Conclusions We advise early endoscopic treatment within 7 days of symptom onset as opposed to 3 weeks, which was proposed previously. Medical therapies should be complimentary to PD stenting.

Staged Interventional and Surgical Treatment of Patient with Chronic Pancreatitis Complicated by Pancreaticopleural Fistula with Lung Abscesses

Patient: Male, 37-year-old

Final Diagnosis: Chronic alcoholic pancreatitis • pancreaticopleural fistula • left lung abscesses

Symptoms: Fever with a body temperature of 39.1°C • left thoracic pain • severe cough with purulent sputum • shortness of breath • upper abdominal pain

Medication: —

Clinical Procedure: Repeated thoracenteses • chest tube • drainage of lung abscesses • ultrasound-guided drainage of pancreatic pseudocyst • ultrasound-guided transparietal external-internal pancreatic duct stenting • Bern modification of Beger procedure

Specialty: Surgery

Pancreaticothoracic fistula presenting with hemoptysis and pneumothorax in a chronic alcoholic patient

Pancreaticothoracic fistula is a rare complication of acute or chronic alcoholic pancreatitis. It may present with various symptoms, like dyspnea, abdominal pain, cough, chest pain, fever, back pain, hemoptysis, fatigue, or orthopnea. Pancreaticothoracic fistula can be detected by magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), or computed tomography. MRCP has high sensitivity and fewer side effects, and thus it has recently been recommended as the first choice for the detection of pancreaticothoracic fistula. On the other hand, ERCP enables the detection and treatment of pancreaticothoracic fistula and allows for stent insertion; for this reason it is a commonly used modality in pancreaticothoracic fistula cases. Herein, the authors describe a case of pancreaticothoracic fistula detected by ERCP and MRCP that manifested only respiratory symptoms, namely hemoptysis and pneumothorax without abdominal pain, which commonly accompanies pancreatitis.

Diagnosis and management of pancreaticopleural fistula

Pancreaticopleural fistula is a rare diagnosis requiring a high index of clinical suspicion due to the predominant manifestation of thoracic symptoms. The current literature suggests that confirmation of elevated pleural fluid amylase is the most important diagnostic test. Magnetic resonance cholangiopancreatography is the recommended imaging modality to visualise the fistula, as it is superior to both computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) in delineating the tract within the pancreatic region. It is also less invasive than ERCP. While a trial of medical regimen has traditionally been the first-line treatment, failure would result in higher rates of complications. Hence, it is suggested that management strategies be planned based on pancreatic ductal imaging, with patients having poor chances of spontaneous closure undergoing either endoscopic or surgical intervention. We also briefly describe a case of pancreaticopleural fistula in a patient who was treated using a modified Puestow procedure after failed endoscopic treatment.

Pancreaticopleural fistula

OBJECTIVES

Pancreaticopleural fistula (PPF) is an unusual complication of chronic pancreatitis. Its diagnosis is obscured by predominance of pulmonary symptoms. A review of clinical presentation, etiology, diagnostic, and treatment modalities is presented in context of 2 cases from our institution.

METHODS

Case reports and case series of PPFs in the English literature from 1960 to 2007 were identified in the PubMed, OVID, and EMBASE search engines.

RESULTS

Fifty-two cases of PPF were identified. Common presenting complaint was dyspnea (65%) followed by abdominal pain (29%), cough (27%) and chest pain (23%). Computed tomography scanning diagnosed PPF in 8 (47%) of 17 patients, endoscopic retrograde cholangiopancreatography diagnosed PPF in 25 (78%) of 32 patients, and magnetic resonance cholangiopancreatography diagnosed PPF in 8 (80%) of 10 patients. Twenty-one patients (65%) improved with conservative management alone. Interventional therapy (5 endoscopic and 6 surgical interventions) was eventually needed in 35% of the patients after failing conservative management.

CONCLUSIONS

Pancreaticopleural fistula is a rare finding and requires a high index of suspicion for patients presenting with chest symptoms or pleural effusion and with history of pancreatitis or alcoholism. Magnetic resonance cholangiopancreatography is the better initial choice for being a noninvasive procedure and for better demonstration of complete main pancreatic duct obstruction. Restoring anatomic continuity is important if conservative approach fails.

Evaluation and management of thoracopancreatic fistula

BACKGROUND

Thoracopancreatic fistula is a rare clinical entity but a serious complication of inflammatory pancreatic diseases, caused by a disruption of the pancreatic ductal system. Its diagnosis is frequently misleading, however, and thus is often delayed.

METHODS

Seven patients with thoracopancreatic fistula who presented at our department between March 2002 and July 2005 were investigated, focusing on the diagnostic work-up as well as the treatment strategies, the response to therapy, and the outcome.

RESULTS

Thoracopancreatic fistulas developed secondary to alcohol-related chronic pancreatitis in 6 patients and acute severe pancreatitis in 1. The disruption sites of the pancreatic ductal system were the head of the pancreas in 2 patients, the pancreatic body in 2 patients, and the pancreatic tail in 3 patients. All patients, except 1, were complicated with stricture of the main pancreatic duct, with ductal disruptions developing distal to the pancreatic strictures. The precise demonstration of the pancreatic ductal anatomy with ultrasonography, computed tomography (CT), conventional magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography was limited. In contrast, MR-cholangiopancreatography (MRCP) provided excellent mapping of the pancreatic ductal stricture, disruption, and fistula in 6 patients. Various medical therapies failed to close the fistula in all patients. Subsequent treatments, based on the assessment of pancreatic ductal anatomy with MRCP, included endoscopic transpapillary implantation of a pancreatic stent, a longitudinal pancreaticojejunostomy, distal pancreatectomy, and peritoneal drainage. All patient outcomes were favorable.

CONCLUSIONS

MRCP is an essential diagnostic modality in all suspected cases of thoracopancreatic fistula. The goal of treatment should be directed toward a sufficient decompression of the obstructed pancreas. If severe pancreatic stricture is present, then surgical decompression may be required in accordance with the individual pancreatic ductal anatomy.

Pancreaticothoracic fistulas: imaging findings in five patients

BACKGROUND

Pancreaticothoracic fistulas are a rare complication of chronic pancreatitis. This study evaluated the imaging findings in patients with pancreaticothoracic fistulas.

METHODS

We retrospectively reviewed the medical records and radiographic images in five patients with pancreaticothoracic fistulas diagnosed at our institution during the previous 6 years. Data from radiography, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), magnetic resonance cholangiopancreatography, and drainage catheter studies were evaluated.

RESULTS

Persistent pleural effusions were present on the radiographs of all patients. ERCP was performed in three patients. Contrast material was injected into drainage catheters placed in a pancreatic pseudocyst in one patient and a pancreatic abscess in another patient. Pancreaticothoracic fistulas were demonstrated on all of these studies. One patient had a CT study immediately after ERCP and another patient had a CT study immediately after contrast material was injected through a drainage catheter placed percutaneously in a pseudocyst. CT demonstrated the full extent of the pancreaticothoracic fistula in both patients.

CONCLUSION

Pancreaticothoracic fistulas are rare and may require multiple imaging modalities to establish a diagnosis.

Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate

BACKGROUND

The treatment of pancreatic fistula can be difficult. A novel endoscopic approach to sealing pancreatic fistulas by using N-butyl-2-cyanoacrylate is described.

METHODS

Twelve patients with pancreatic fistulas underwent endoscopic injection of N-butyl-2-cyanoacrylate into the fistulous tract, in addition to endoscopic drainage.

RESULTS

Fistulas were closed successfully in 8 of 12 patients. A single treatment session was successful in 7 patients; a second session was required in one patient. In two patients, closure was temporary, and, in one patient, the treatment failed. One patient died 24 hours after treatment. He developed a pulmonary thromboembolism from a left popliteal vein thrombosis and died from complications of surgical thromboembolectomy. At autopsy, a pulmonary embolus was found, but there was no evidence of N-butyl-2-cyanoacrylate in the lungs. No procedure-related complication occurred over a median follow-up of 20.7 months (range 9-51 months).

CONCLUSIONS

In this preliminary study, occlusion of pancreatic fistulas by using N-butyl-2-cyanoacrylate glue was safe and effective, and obviated the need for surgery in a substantial proportion of patients. Further studies of the use of N-butyl-2-cyanoacrylate for closure of pancreatic fistula are warranted.

Operative treatment of pancreatico-bronchial fistula

BACKGROUND

Pancreatico-bronchial fistulas are a rare complication of acute or chronic pancreatitis. Both conservative and surgical management have been described previously.

CASE OUTLINE

The management of a 68-year-old woman with acute pancreatitis complicated by a pancreatico-bronchial fistula was reviewed. CT scanning and magnetic resonance cholangio-pancreatography demonstrated a pancreatic pseudocyst with extension into the posterior mediastinum and right pleura. Despite conservative management as well as ERCP with pancreatic stent insertion, the fistula failed to resolve. Successful management of this difficult problem was achieved with distal pancreatectomy and intercostal drainage.

DISCUSSION

Pancreatico-bronchial fistulas may be managed conservatively, but there should be a low threshold for surgical intervention if endoscopic measures fail.

Pancreatico-mediastinal fistula with a mediastinal mass lesion demonstrated by MR imaging

Internal pancreatic fistulas are uncommon but well-recognized complications of inflammatory pancreatic disease. A case of a pancreatico-mediastinal fistula with a mediastinal mass lesion in a patient with a documented history of chronic alcohol consumption and previous episodes of acute pancreatitis is described. Since the clinical symptomatology was dominated by pulmonary complaints, magnetic resonance (MR) imaging using a breathhold coronal T2-weighted sequence with spectral fat saturation was essential in clarifying this difficult and rare pathology. Furthermore, the depiction of a fistulous tract between a mediastinal mass lesion and the retroperitoneum posterior to the pancreas, i.e., a pancreatico-mediastinal fistula by MR imaging has not been previously reported, to the best of our knowledge.