Optimizing management of pancreaticopleural fistulas

Pleural effusion in a patient with previous alcohol excess

Pleural amylase and/or lipase should be analysed in cases of pleural effusion in patients with pancreatic disease or a history of excess alcohol consumption. https://bit.ly/3Rk5UfO.

Pancreaticopleural fistula as the inaugural presentation of chronic pancreatitis: A case report

INTRODUCTION

Pancreaticopleural fistula is a rare complication most associated with alcohol-induced chronic pancreatitis. This usually presents with chest symptoms instead of abdominal ones. Diagnosis requires a high index of suspicion in patients with pancreatitis and persistent pleural effusions.

PRESENTATION OF CASE

We present a case of an 81-years-old man admitted in the emergency department with a one week complaints of productive cough, fever, dyspnea and left-side chest pain. The chest X-ray revealed a moderated-volume left-side pleural effusion. The pleural fluid analysis was consistent with an exsudative pleural effusion with high levels of amylase. The thoracoabdominal CT raised the suspicion of a pancreaticopleural fistula, confirmed by ERCP. A pancreatic main duct stenting was performed with good results. The patient was discharged asymptomatic after 18 days of hospitalization.

DISCUSSION

Because of PPF insidious presentation it poses a great number of differential diagnosis, so pleural fluid analysis is of paramount importance with high levels of amylase confirming the diagnosis. MRCP and ERCP may establish the fistulous tract between the pancreatic duct and the pleural cavity, with the latter being also therapeutic.

CONCLUSION

The rarity of this complication related to pancreatitis and the seldomly presence of abdominal pain in contrast with chest symptoms poses a diagnostic challenge.

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature

BACKGROUND

Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion.

CASE PRESENTATION

A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy.

CONCLUSION

The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Case Report: Pancreaticopleural fistula with an atypical tract in a child with bulging chest

Pancreaticopleural fistula (PPF) is a rare but serious complication caused by pancreatic lesions that presents primarily with respiratory tract symptoms and pleural effusion. We report a paediatric case of PPF without any respiratory symptoms throughout the course of the disease, including cough or shortness of breath, with only a bulging chest as the first symptom. Imaging revealed a large left pleural effusion and Magnetic Resonance Cholangiopancreatography (MRCP) revealed a fistula formed between the pancreatic tail and the pleural cavity, which penetrated the diaphragm and opened in the central tendon of the diaphragm. The patient eventually underwent resection of the pancreatic tail lesion and repair of the diaphragmatic fistula and recovered soon thereafter.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

Recurrent Pleural Effusions Secondary to Pancreaticopleural Fistula: A Case Presentation

Pleural effusion can be a complication of pancreatic diseases. Pancreaticopleural fistula (PPF) is a rare complication arising as a result of chronic pancreatitis that causes recurrent pleural effusions often resistant to thoracentesis. Diagnosis of PPF can be delayed, and presentation with respiratory symptoms related to pleural effusion is common. Elevated pleural fluid amylase and lipase levels are always helpful, but final diagnosis mostly requires demonstration of fistula on imaging modalities, such as computed tomography (CT) scan or magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde cholangiopancreatography (ERCP) serves as a diagnostic and therapeutic tool. Here, we present a case of PPF leading to recurrent pleural effusions, treated with stent placement.

Short- and Long-Term Outcomes After Multimodal Treatment of Pancreatic Duct Leakage in Patients With Chronic Pancreatitis

OBJECTIVES

In patients with chronic pancreatitis, pancreatic duct leakage is associated with a prolonged disease course and serious complications. We aimed to assess the efficacy of this multimodal treatment of pancreatic duct leakage.

METHODS

In a retrospective design, patients with chronic pancreatitis, an amylase content greater than 200 U/L in either ascites or pleural fluid and treated between 2011 and 2020, were evaluated. The primary end point was treatment success.

RESULTS

Twenty-seven patients (22 males, median age 60, median American Society of Anesthesiologists score 3) were included.Endoscopic retrograde pancreatography was performed in 23 patients (85%) with transpapillary stenting of the main pancreatic duct in 22 patients (96%). Pancreatic sphincterotomy and dilation of the main pancreatic duct were done in 14 patients (61%) and 17 patients (74%), respectively. Twelve patients (44%) were treated with somatostatin analogs, parenteral nutrition, and were "nil by mouth" for a median of 11 days (range, 4-34 days). Six patients (22%) had extracorporeal shock wave lithotripsy due to pancreatic duct stones. One patient (4%) was referred for surgery. All 23 patients (100%) were treated with success after a median of 21 days (range, 5-80 days).

CONCLUSIONS

Multimodal treatment of pancreatic duct leakage is effective, with minimal need for surgery.

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.

Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy

Inflammatory diseases of the pancreas or pancreatic trauma result in ductal cell disruption, which in turn may lead to leakage of pancreatic fluid, mostly in the retroperitoneal space. Pancreatopleural fistulas are uncommonly encountered following pancreatic injury; however, they often prove a difficult problem to manage.

Herein, we present a rare case of a 68-year-old male suffering from a pancreaticopleural fistula (PF) between the pancreatic tail and the left pleural space one year following splenectomy for trauma. About three months after percutaneous drainage of a left pleural effusion and left upper quadrant abdominal collection and endoscopic pancreatic duct stent placement, surgical management was decided. Distal pancreatectomy and Roux-en-Y drainage of the pancreatic remnant were successfully performed.

Pancreaticopleural fistula in children: Report of 2 cases

Pancreaticopleural fistula is an extremely rare complication of pancreatic duct injury. The reported treatments include conservative approaches, such as pleural drainage, and interventional approaches, such as sphincter stenting via endoscopic retrograde cholangiopancreatography and surgery. However, no specific consensus treatment has been defined. We present 2 cases of pediatric patients with pancreaticopleural fistulas due to pancreatic trauma and pancreatitis that were successfully treated surgically. The most prominent symptom in both cases was dyspnea caused by pleural effusion. Thoracoabdominal computed tomography scans showed large pleural effusions and visible fistulas from the pancreatic duct to the thoracic cavity through the esophageal hiatus and aortic hiatus. Following unsuccessful conservative treatment using pleural drainage, the 2 patients underwent surgical fistulo-jejunostomy and cystojejunostomy. Both patients were stable and were discharged on postoperative days 10 and 12. Conservative treatment for pancreaticopleural fistula often fails, and a surgical approach, such as fistulo-jejunostomy and cystojejunostomy, can serve as an efficacious management strategy when conservative treatment fails.

A 58-Year-Old Woman with Gallstones, Chronic Pancreatitis, and Pancreatic Pseudocyst Presenting with Pleural Effusion Due to a Pancreaticopleural Fistula

BACKGROUND Pancreaticopleural fistula (PPF) is a rare complication of acute and chronic pancreatitis. PPF results from the release of pancreatic enzymes, either from a damaged pancreatic duct or pancreatic pseudocyst. This report is of a 58-year-old woman with a history of chronic pancreatitis associated with gallstones who had a known pancreatic pseudocyst that was being managed conservatively and who presented to the Emergency Department with pleural effusion due to a PPF. CASE REPORT A 58-year-old woman with past medical history of gallstone pancreatitis with subsequent development of pancreatic pseudocyst (being managed conservatively) presented with a 2-week history of progressive exertional shortness of breath. Physical examination indicated decreased breath sounds on the right lower lung fields. A chest X-ray revealed possible subphrenic free air. Laboratory test results were unremarkable except for elevated D-dimer levels. Computed tomography angiography revealed a large right-sided pleural effusion, which led to thoracentesis and the results illustrated elevated amylase levels. Magnetic resonance cholangiopancreatography was done, which showed pancreatic pseudocyst and possibly a fistula. Pancreatic enzymes were not checked in pleural fluid, as diagnosis was established with the presence of amylase and imaging findings. The patient felt better clinically after thoracentesis with volume removal and was discharged. She later underwent endoscopic ultrasound, which revealed a pancreatic duct leak requiring stent placement. CONCLUSIONS Pleural effusions rarely occur secondary to PPF. Physicians must be wary of the presentation, especially in patients with a history of a conservatively managed pancreatitis pseudocyst. Early diagnosis and management can lead to prevention of long-term morbidity and mortality.

Rapidly Accumulating Pleural Effusion: A Sequela of Chronic Pancreatitis

Chronic pancreatitis presents with epigastric abdominal pain, nausea, vomiting, and weight loss. Acute pancreatitis can also present with a pleural effusion which is typically left-sided, mild in nature, and self-limiting. However, recurrent bouts of pancreatitis may lead to a pancreaticopleural fistula (PPF) with a large, rapidly recurring, unilateral pleural effusion. Among patients with PPF, the most common presenting complaint is dyspnea. We present the case of a 53-year-old man with recurrent bouts of pancreatitis in the setting of alcohol who presented with progressively worsening shortness of breath. A high-resolution computed topography scan of the thorax demonstrated a large right-sided pleural effusion. A thoracentesis was performed with pleural fluid studies showing an exudative effusion with amylase significantly elevated at 18 382 U/L. An endoscopic retrograde cholangiopancreatography was performed which showed a pancreatic duct leak in the tail of the pancreas. A pancreatic sphincterotomy was performed, and a stent was placed into the ventral pancreatic duct. The patient’s shortness of breath improved, and he was discharged home with outpatient follow-up. The aim of this report is to present the diagnosis of a rare complication of chronic pancreatitis and discuss the management and options for treatment.

[Mediastinal pancreatobiliary pseudocysts]

OBJECTIVE

To select the optimal treatment for uninfected and suppurative rare mediastinal pancreatobiliary pseudocysts.

MATERIAL AND METHODS

There were 10 patients with mediastinal pancreatogenic (n=9) and biliogenic (n=1) pseudocysts formed through esophageal (n=9) and aortic (n=1) hiatus of the diaphragm. All patients were divided into groups: group A - uninfected pancreatic pseudocysts (n=5) formed through esophageal hiatus; group B - 5 patients with suppurative pancreatogenic (n=4) and biliogenic (n=1) mediastinitis complicated by biliopleuroesophageal (n=1), pancreatoesophageal (n=1) and pancreatopleural (n=2) fistulas.

RESULTS

In the group A, simultaneous procedures (n=5) were performed depending on pancreatic parenchyma and pancreatic duct destruction. Distal ductal obstruction required Frey procedure (n=3). If distal duct was patent, we resected cyst-containing pancreatic tail (n=2). Early and long-term results were favorable. In the group B, mediastinitis persisted for a long time with normal temperature as a rule. In our opinion, mild course is associated with gradual introduction of purulent tissues into mediastinum and development of a tissue barrier. Two-stage surgeries were performed in patients with pancreatopleural empyema. Mediastinitis lasting 6-8 weeks caused perforation of the lower third of esophagus (n=2) and death of 1 patient. Risk factors of mediastinal pseudocysts: hypertension in pancreatic duct and pseudocysts, immobile cicatricial tissues of omental bursa, proximity of subdiaphragmatic structures to esophageal and aortic hiatus of the diaphragm. Pressure in aortic canal (mmHg) is 10 times higher than in esophageal canal that increases migration through the esophageal hiatus. It is advisable to distinguish pancreatoesophageal and biliopleuroesophageal fistulas.

CONCLUSION

Uninfected mediastinal pseudocysts require simultaneous procedures, pancreatopleural empyema - two-stage interventions. Therapy is recommended in patients with esophageal fistula and no severe symptoms and intoxication.

Pancreaticopleural fistula: An insidious cause of pleural effusion –case report

Pancreaticopleural fistulas (PPF) are a rare etiology of pleural effusions. We describe a case of a 61-year-old man, with left chest pain with six months of progression who presented with a large volume unilateral pleural effusion. A thoracentesis was performed, which showed a dark reddish fluid(exudate) and high content of pancreatic amylase. After that an abdominal computed tomography (CT)and magnetic resonance cholangiopancreatography (MRCP) was done, revealing fistulous pathways that originated in the pancreas. The patient was admitted for conservative and endoscopic treatment by Endoscopic Retrograde Cholangiopancreatography (ERCP) and a prosthesis was placed on a fistulous path. He was discharged without complications, with the resolution of the pleural effusion and fistula.The interest of this case lies in the rarity of the event and absence of symptoms of the probable primary event (acute pancreatitis). The possible iatrogenic association with several drugs of his usual medication makes it even more complex.

Endoscopic Treatment of an Idiopathic Pancreaticopleural Fistula

A 61-year-old man was diagnosed with an exudative pleural effusion with raised amylase and bilirubin levels. The patient had no previous history of acute pancreatitis or trauma and no clinical or radiological signs of chronic pancreatitis. On thoracoabdominal computed tomography, a pancreatic pseudocyst with a pancreaticopleural fistula was identified. Endoscopic retrograde cholangiopancreatography identified a ductal disruption site in the body of the pancreas. Pancreatic sphincterotomy and stent placement in the duct of Wirsung, combined with medical management, allowed fistula closure, pseudocyst reabsorption, and no relapse of the pleural effusion. The relevance of this case lies not only in its rarity but also as it highlights the importance of a multidisciplinary approach in such uncommon conditions. Optimal management of this condition is debatable due to the absence of prospective studies comparing medical, endoscopic, and surgical approaches.

Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis

Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.

Pleural effusion secondary to chronic pancreatitis in childhood

Pleural effusion secondary to a pancreatico-pleural fistula is a very rare presentation in children, with limited reports in the literature. We describe two differing presentations of pleural effusions resulting from chronic pancreatitis (CP) with successful resolution of the pleural effusion. These cases highlight the need for consideration of this rare paediatric diagnosis, and the variety of investigations, management strategies, and complications that can occur in the setting of CP in children.

Pancreaticopleural fistula in a child with chronic pancreatitis harboring compound SPINK1 variants

Background

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis (CP) that requires a high index of clinical suspicion in the patient who presents with a pleural effusion. Visualizing the fistula tract from the pancreatic duct to the pleural space by radiological imaging provides confirmation of this complication.

Case presentation

A 9-year-old boy who presented with massive right pleural effusion secondary to PPF, a complication of CP from a genetic mutation involving two mutations of SPINK1. We successfully managed the case with by endoscopic pancreatic duct stent placement after failure of conservative treatment approaches.

Conclusions

PPF is a rare but serious complication of CP in all ages. The diagnosis of PPF in children requires a high index of clinical suspicion and should be considered in the differential diagnosis of massive pleural effusion where pancreatic pathology is present. A high level of pleural fluid amylase and the results from radiological imaging when the patients have symptoms play essential roles in the diagnosis of PPF. Currently, Magnetic resonance cholangiopancreatigraphy (MRCP) is the imaging modality of choice. Endoscopic therapy and surgery are treatment options for patients who do not respond to conservative therapy.

Pancreaticopleural Fistula: A Cause of Recurrent Pleural Effusions in Chronic Pancreatitis

Pancreaticopleural fistula is a rare complication of chronic pancreatitis caused by disruption of the pancreatic duct and fistulous communication with the pleural cavity. It usually presents with respiratory symptoms from recurrent large volume pleural effusions. Paucity of abdominal symptoms makes it a diagnostic challenge, leading often to delayed diagnosis. Marked elevation of pleural fluid amylase, which is not a commonly performed test, is a sensitive marker in its detection. Imaging with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography can help delineate the fistula. In this report, we present the clinical features, imaging, and management of a 59-year-old male patient with pancreaticopleural fistula, wherein the diagnosis was suspected only after repeated pleural fluid drainages were performed for re-accumulating pleural effusions and it was eventually successfully treated with pancreatic duct stenting. We review the literature with regards to the incidence, presentation, diagnosis, and management of this rare entity.

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.

Endoscopic management of pleural effusion caused by a pancreatic pleural fistula

Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting.

Endoscopic management of pancreaticopleural fistula in a pediatric patient: A case report and literature review

INTRODUCTION

Pancreaticopleural fistula (PPF) is a rare but serious complication of pancreatic disorders. As the clinical presentations of PPF are often deceptive, it can cause a delay in the timely diagnosis and proper treatment. PPF is extremely uncommon in pediatric patients, and diagnostic and management strategies for PPF among pediatric patients are scanty.

PATIENT CONCERNS

A 12-year-old girl presented with cough and dyspnea owing to massive right-side pleural effusion confirmed by Chest X-ray. Biochemical examination of pleural effusion revealed a significant elevation of amylase level. Imaging modalities showed dilated pancreatic duct and fistulous tract connecting pancreatic duct and right thorax.

DIAGNOSIS

Chronic pancreatitis with PPF was diagnosed.

INTERVENTIONS

Medical therapy was initially attempted for 2 weeks. Endoscopic therapy with naso-pancreatic drainage tube placement was then performed without any complications after failed medical therapy.

OUTCOMES

The patient has remained healthy and symptom-free during 2 years of follow-up.

CONCLUSION

When pediatric patients presented with recurrent pleural effusion with unknown etiology, PPF should be taken into consideration. Pleural effusion amylase level is the most important laboratory test and magnetic resonance cholangiopancreatography is recommended to visualize the fistula. Optimal management of PPF should be based on pancreatic duct morphology.

Pancreaticopleural fistula in children with chronic pancreatitis: a case report and literature review

BACKGROUND

Pancreaticopleural fistula (PPF) is a very rare and critical complication of pancreatitis in children. The majority of publications relevant to PPF are case reports. No pooled analyses of PPF cases are available. Little is known about the pathogenesis and optimal therapeutic schedule. The purpose of this study was to identify the pathogenesis and optimal therapeutic schedule of PPF in children.

CASE PRESENTATION

The patient was a 13-year-old girl who suffered from intermittent chest tightness and dyspnea for more than 3 months; she was found to have chronic pancreatitis complicated by PPF. The genetic screening revealed SPINK1 mutation. She was treated with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde pancreatic drainage (ERPD); her symptoms improved dramatically after the procedures.

CONCLUSIONS

PPF is a rare pancreatic complication in children and causes significant pulmonary symptoms that can be misdiagnosed frequently. PPF in children is mainly associated with chronic pancreatitis (CP); therefore, we highlight the importance of genetic testing. Endoscopic treatment is recommended when conservative treatment is ineffective.

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

Pancreaticopleural fistula: a rare cause of pleural empyema

Aim: Pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis. When the pancreatic duct disrupts, pancreatic fluid may leak into the retroperitoneum and fistulate into the pleural cavity. Patients usually present with thoracic complaints, making it hard to suspect an abdominal etiology. Although PPF is uncommon, one must consider this diagnosis in patients with thoracic complaints and a history of alcohol abuse or pancreatitis. Methods: We present an illustrative case and review of the literature on PPF. Results: A 47-year old man was presented with recurrent PPF due to pancreas divisum, pancreatic stones and chronic exudative pancreatitis, resulting in unilateral empyema. After initial conservative treatment, operative measures were needed. We report omentoplasty against the diaphragmatic hiatus in combination with VATS (video-assisted thoracoscopic surgery) thoracotomy with decortication and debridement as a feasible operative option for resolving PPF. Conclusion: PPF is a rare complication of pancreatitis. The diagnosis is difficult to make and can be confirmed by thoracocentesis and proper imaging, preferably MRCP. Treatment options include conservative, endoscopic (ERCP) or surgical measures. Omentoplasty positioned against the diaphragmatic hiatus is a feasible technique for closure of PPF.

Endoscopic Management of Pancreaticopleural Fistula in a Child with Hereditary Pancreatitis

Pancreaticopleural fistula (PPF) a fistulous connection between the pancreas and pleural space due to prolonged chronic pancreatitis (CP). PPF is a very rare complication which presents in 0.4% of chronic pancreatitis cases, especially among children. We report a case involving a 3-year-old boy who presented with pleural effusion caused by a PPF, a complication of hereditary pancreatitis, which was, for the first time in Korea, successfully managed with endoscopic treatment. Chest radiography and computed tomography showed massive pleural effusion. Percutaneous catheter drainage was performed. High amylase levels were observed in the pleural fluid and serum, suggesting PPF. The patient was managed with bowel rest and octreotide infusion. Endoscopic retrograde cholangiopancreatography revealed CP, and pleural effusion was successfully managed with stent placement. PRSS1 genetic screening revealed R122H mutation.

[Mediastinal pancreatic cysts: review and own clinical observations]

OBJECTIVE

To present the results of surgical treatment of patients with mediastinalpancreatogeniccysts (MPC).

MATERIAL AND METHODS

There were 5 patients with MPC.

RESULTS

Laboratory tests revealed increased blood amylase level by 1.5-2 times in 3 cases, urine diastase by 4-5 times - in 2 cases. Pleural effusion with amylase concentration in the fluid from 5680 to 48 640 units was diagnosed in 4 cases. CT data of preudocysts of pancreatic body and tail were obtained in 3 cases, head and body - in 2 patients. These cysts extended to posterior mediastinum through the hiatal orifice for about 3.5-40 cm. Three patients underwent VATS removal of pleural fragments, one - thoracotomy, lung decortication and MPC drainage through pleural cavity. Three patients underwent pancreatic drainage procedures (cystogastrostomy, pancreaticojejunostomy and external drainage of the cyst). A small pseudocyst has been successfully treated by conservative treatment with octreotide.

CONCLUSION

MPC is a rare complication of pancreatitis and often associated with pleural effusion. CT and fluid amylase analysis are the main diagnostic measures. Surgical treatment includes VATS, destruction of pleural fragments and pleural drainage, cystogastrostomy, pancreaticojejunostomy or external drainage of pancreatic pseudocyst.

Pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, with dysphagia as initial symptom: A case report

RATIONALE

Pancreaticopleural and pancreaticomediastinal fistulas are rare complications of pancreatitis. They are often misdiagnosed and there are no strict guidelines of treatment. In this study, we present a brief report of a combined pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, causing dysphagia and cervical swelling as initial symptoms.

PATIENT CONCERNS

A 36-year-old female with history of alcohol abuse and pancreatitis presented progressing dysphagia and mild dyspnea on admission.

DIAGNOSIS

Chest X-ray and chest and abdominal computed tomography scan (CT) indicated pancreaticopleural fistula combined with pancreaticomediastinal fistula, a diagnosis confirmed by high amylase levels in pleural fluid.

INTERVENTIONS

Conservative treatment was administered and ERCP was performed but pancreatic duct stenting was impossible. The patient presented rapid anterior cervical swelling with progressing dysphagia and dyspnea. CT showed fistula penetration to the cervical region. The patient underwent urgent surgery and pancreaticojejunal anastomosis was performed.

OUTCOMES

The surgery led to recovery. Six months later, the patient reported good health and weight gain.

LESSONS

Coexistence of pancreaticopleural and pancreaticomediastinal fistula with cervical penetration is an extremely rare pancreatitis complication. It presents with dysphagia and anterior cervical swelling as initial symptoms. It is important to consider this complication in all patients with history of pancreatitis, presenting with dysphagia.

Pancreaticopleural Fistula: A Review of Imaging Diagnosis and Early Endoscopic Intervention

A 49-year-old male with history of chronic alcohol-induced pancreatitis presented with one month of worsening left pleuritic chest pain and shortness of breath. Chest radiograph demonstrated bilateral pleural effusions. Thoracentesis revealed increased amylase in the pleural fluid. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed a fistula tract between the left pleural cavity and pancreas which was confirmed on endoscopic retrograde cholangiopancreatography (ERCP). Patient was treated with placement of a pancreatic stent with complete resolution of the fistula tract approximately in 9 weeks. A systematic literature search was performed on reported cases with pancreaticopleural fistula (PPF) who underwent early therapeutic endoscopy within the last 10 years. Imaging modalities, particularly CT and MRCP, play essential role in prompt preprocedural diagnosis of PPF. Early therapeutic ERCP is an effective and relatively safe treatment option for PPF, so invasive surgery may be avoided.

Recurrent Pleural Effusion Secondary to a Pancreatic-Pleural Fistula Treated Endoscopically

Patient: Male, 44

Final Diagnosis: Pancreatic pleural fistula

Symptoms: Short of breath

Medication: —

Clinical Procedure: ERCP

Specialty: Gastroenterology and Hepatology

[Endoscopic pancreatic stenting in pancreatic fistulas management]

AIM

To present 18-year experience of endoscopic transpapillary stenting in patients with pancreatic fistula.

MATERIAL AND METHODS

The study included 48 patients with pancreatic fistula resistant to conservative management. Pancreatic stenting was successful in 32 (66.7%) patients. In 30 (93.8%) of them stenting appeared as the final stage of pancreatic fistula treatment.

RESULTS

Inclidence of complications after endoscopic treatment was 4.2%. We evaluated long-term results in 23 cases within 8-184 months. There were good results in 21 (91.3%) cases and satisfactory - in 2 (8.7%) cases. We had not unsatisfactory results in our experience.

Pancreaticopleural Fistula Causing Massive Right Hydrothorax and Respiratory Failure

Hydrothorax secondary to a pancreaticopleural fistula (PPF) is a rare complication of acute pancreatitis. In patients with a history of pancreatitis, diagnosis is made by detection of amylase in the pleural exudate. Imaging, particularly magnetic resonance cholangiopancreatography, aids in the detection of pancreatic ductal disruption. Management includes thoracocentesis and pancreatic duct drainage or pancreatic resection procedures. We present a case of massive right hydrothorax secondary to a PPF due to recurrent acute pancreatitis. Due to respiratory failure, urgent thoracocentesis was done. Distal pancreatectomy with splenectomy and cholecystectomy was performed. The patient remains well at one-year follow-up.

Mediastinal Pancreatic Pseudocysts

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Echinococcal Cyst of the Pancreas with Cystopancreatic Duct Fistula Successfully Treated by Partial Cystectomy and Cystogastrostomy

The primary pancreatic hydatid (echinococcal) cyst is extremely rare with a reported incidence of <1%. Owing to its rareness and a considerable overlap of imaging features, a preoperative diagnosis is usually difficult. The dilemma in confirming this benign diagnosis has often questioned the extent of radical pancreatic resection. The involvement of pancreatic duct (cystopancreatic duct fistula) further complicates the management of such cystic lesions. In this report, we present a case of isolated hydatid cyst of the pancreatic body and tail communicating with the pancreatic duct. Cystogastrostomy preceded by partial cystectomy in the same setting has never been reported to date. The patient had an uneventful postoperative course and follow-up showed no evidence of cyst recurrence or dissemination. We consider this a safe surgical option in longstanding large cysts, especially if a cystopancreatic fistula is detected beforehand. The success of such a procedure however may rely on the size and thickness of the cyst wall to support this anastomosis.

Pancreatic Pseudocyst Pleural Fistula in Gallstone Pancreatitis

Extra-abdominal complications of pancreatitis such as pancreaticopleural fistulae are rare. A pancreaticopleural fistula occurs when inflammation of the pancreas and pancreatic ductal disruption lead to leakage of secretions through a fistulous tract into the thorax. The underlying aetiology in the majority of cases is alcohol-induced chronic pancreatitis. The diagnosis is often delayed given that the majority of patients present with pulmonary symptoms and frequently have large, persistent pleural effusions. The diagnosis is confirmed through imaging and the detection of significantly elevated amylase levels in the pleural exudate. Treatment options include somatostatin analogues, thoracocentesis, endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting, and surgery. The authors present a case of pancreatic pseudocyst pleural fistula in a woman with gallstone pancreatitis presenting with recurrent pneumonias and bilateral pleural effusions.

Pancreaticopleural fistula: an unusual complication of pancreatitis

Pancreaticopleural fistula is an uncommon complication of pancreatitis. The authors describe a case of a man in his mid-40s with a history of alcohol abuse, who presented with dyspnoea and whose chest X-ray revealed a massive left pleural effusion. Further diagnostic work up revealed a pancreaticopleural fistula. There was no improvement with a conservative approach and endoscopic treatment was not feasible, leading to the need for a surgical intervention.

Internal compared with external drainage of pancreatic duct during pancreaticoduodenectomy: a retrospective study

OBJECTIVE

To compare internal with external drainage of the pancreatic duct during pancreaticoduodenectomy with regard to the incidence of postoperative pancreatic fistula (POPF) and other complications.

METHODS

We retrospectively analyzed 316 patients who underwent pancreaticoduodenectomy with a placed drainage tube (external, n=128; internal, n=188) in the pancreatic duct from 1 January 1999 to 31 December 2011 in Tianjin Third Central Hospital of China. The incidence of POPF and some other complications were compared.

RESULTS

There was no difference in the incidence rates of POPF between those given an internal or external drainage tube (P=0.788), but POPF was more severe in the former (P=0.014). Intraperitoneal bleeding rate was also higher in the patients with internal drainage (P=0.040), but operative time and postoperative hospitalization were longer in those with external drainage (P=0.002 and P=0.007, respectively). There was no difference between the groups with regard to the incidence rates of gastrointestinal bleeding, delayed gastric emptying, pulmonary infection, or incision infection and in-hospital mortality.

CONCLUSIONS

External drainage of the pancreatic duct during pancreaticoduodenectomy can decrease the severity of POPF, but operative time and postoperative hospitalization will be extended.

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: an overlooked entity

Pleuropulmonary complications of pancreatitis are well known. Less commonly encountered is pancreaticopleural fistula. We describe the case of a 15-year-old boy with a presumed episode of pancreatitis, complicated by pseudocyst and development of a pancreaticopleural fistula. Successful medical management was achieved, and he made a full recovery. This case demonstrates that the rarity of such a condition leads to delay as well as challenges in diagnosis and management.

Length of Nonoperative Treatment and Risk of Pleural Empyema in the Management of Pancreatitis-induced Pancreaticopleural Fistula

Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Initial conservative treatment fails in a significant number of cases. Ascending infection through the fistulous tract results in pleural empyema. The aim of this study is to investigate the relation between lengths of nonoperative management and risk of pleural empyema. The retrospective study includes our own experience as well as all case reports identified by a systematic review of the English literature from 1954 to 2012. Inclusion criteria were acute or chronic pancreatitis, whereas tumorous fistulization or complications of pancreatic surgery were kept out. A total of 113 patients were identified. There were 86 men and 27 women. The mean age was 46.5 years and 78 patients had a history of alcoholism. The mortality rate was 1.8 per cent (two of 113). Non-operative management including interventional therapy and endoscopic stenting was successful in only 40 cases (36%), whereas 73 patients (64%) finally underwent surgery. The most common procedure was distal pancreatectomy (32 of 73). Pleural empyema occurred in 17 cases. Successful nonoperative management had a mean length of 5.5 weeks, whereas surgery was performed after an average of 10.9 weeks of failed conservative efforts. Initial nonoperative therapy was significantly longer in patients eventually sustaining empyema (17 weeks, P < 0.001) and all needed surgical intervention. Prolonged nonoperative treatment is associated with a noteworthy risk of septic complications such as pleural empyema. Further improvement seems achievable by reducing the time gap between fruitless conservative efforts and surgical intervention.

Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment

A 53-year-old man developed bilateral pleural effusion with respiratory failure. The amylase level in the pleural effusion was elevated. He had neither abdominal symptoms nor abdominal physical findings. Abdominal computed tomography (CT) also showed no abnormalities. Magnetic resonance cholangiopancreatography (MRCP) was non-diagnostic, but endoscopic retrograde cholangiopancreatography (ERCP) and subsequent CT showed a fistula connecting the pancreatic duct with the right pleural cavity. The pleural effusion was refractory to drug therapy, leading to the need for surgical intervention. The pathological findings revealed chronic pancreatitis without pseudocysts. The elevated pancreatic amylase in the pleural effusion offered an important clue to the correct diagnosis.