Pancreaticopleural Fistula: A Review
Abstract
Pancreaticopleural fistula is a rare complication of chronic pancreatitis consequent to posterior disruption of the pancreatic duct. The fistulous track ascends into the pleural cavity and gives rise to large volumes of pleural fluid. Pancreaticopleural fistula thus poses a diagnostic problem since the source of pleural fluid is extrathoracic. To further complicate the matter, abdominal pain is seldom the presenting or significant feature. The pleural effusion is typically rapidly accumulating, recurrent and exudative in nature. Pleural fluid amylase in the correct clinical setting virtually clinches the diagnosis. Magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography and computed tomography may delineate the fistula and thus aid in diagnosis. Endoscopic retrograde cholangiopancreatography has emerged both as a diagnostic as well as therapeutic modality in select patients of pancreaticopleural fistula while magnetic resonance cholangiopancreatography is the radiological investigation of choice. Besides delineating the ductal anatomy, magnetic resonance cholangiopancreatography can help stratify patients for appropriate management. A near normal or mildly dilated pancreatic duct responds well to chest drainage with octreotide while endoscopic stent placement benefits patients with duct disruption located in head or body of pancreas. Failure of medical or endoscopic therapy calls in for surgical intervention. Besides, a primary surgical management may be tried in patients with complete ductal obstruction, ductal disruption in tail or ductal obstruction proximal to fistula site.
Image: Logo of Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital. Mumbai, Maharashtra, India.
Downloads
References
Sut M, Gray R, Ramachandran M, Diamond T. Pancreaticopleural fistula: a rare complication of ERCP-induced pancreatitis. Ulster Med J. 2009; 78(3): 185-6. [PMID: 19907687]
Vyas S, Gogoi D, Sinha SK, Singh P, Yadav TD, Khandelwal N. Pancreaticopleurafistula: an unusual complication of pancreatitis diagnosed with magnetic resonance cholangiopancreatography. JOP 2009; 10(6): 671-3. [PMID:19890191]
Materne R, Vranckx P, Pauls C, Coche EE, Deprez P, Van Beers BE. Pancreaticopleural fistula: diagnosis with magnetic resonance pancreatography. Chest 2000; 117(3): 912-4. [PMID: 10713030]
Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP 2005; 6(2): 152-61. [PMID: 15767731]
Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD. Internal pancreatic fistulas: pancreatic ascites and pleural effusions. Ann Surg 1976; 184(5): 587-93. [PMID: 984927]
Lipsett PA, Cameron JL. Internal pancreatic fistula. Am J Surg 1992; 163(2): 216-20. [PMID: 1739176]
King JC, Reber HA, Shiraga S, Hines OJ. Pancreatic-pleural fistula is best managed by early operative intervention. Surgery 2010; 147(1): 154-9. [PMID: 19744435]
Safadi BY, Marks JM. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment. Gastrointest Endosc. 2000; 51(2): 213-5. [PMID: 10650272]
Miller JA, Maldjian P, Seeff J. Pancreaticopleural fistula. An unusual cause of persistent unilateral pleural effusion. Clinical Imaging 1998; 22: 105-7. [PMID: 9543587]
Ali T, Srinivasan N, Le V, Chimpiri AR, Tierney WM. Pancreaticopleural fistula. Pancreas. 2009; 38(1): e26-31. [PMID: 19106743]
Kiewiet JJ, Moret M, Blok WL, Gerhards MF, de Wit LT. Two Patients with Chronic Pancreatitis Complicated by a Pancreaticopleural Fistula. Case Rep Gastroenterol 2009; 3: 36-42. [PMID: 20651963]
Wronski M, Slodkowski M, Cebulski W, Moronczyk D, Krasnodebski IW. Optimizing management of pancreaticopleural fistulas. World J Gastroenterol. 2011; 17(42): 4696-703. [PMID: 22180712]
W. J. Anderson, D. B. Skinner, G. D. Zuidema, J. L.Cameron. Chronic pancreatic pleural effusions. Surgery Gynecology and Obstetrics 1973; 137: 827–830.
Hastier P, Rouquier P, Buckley M, Simler JM, Dumas R, Delmont JP. Endoscopic treatment of Wirsungo-cysto-pleural fistula. Eur J Gastroenterol Hepatol 1998; 10: 527-9. [PMID: 9855072]
Wypych K, Serafin Z, Gałązka P, Strześniewski P, Matuszczak W, Nierzwicka K,Lasek W, Prokurat AI, Bąk M. Pancreaticopleural fistulas of different origin:Report of two cases and a review of literature. Pol J Radiol. 2011; 76(2): 56-60. [PMID: 22802835]
Oh YS, Edmundowicz SA, Jonnalagadda SS, Azar RR. Pancreaticopleural fistula: report of two cases and review of the literature. Dig Dis Sci 2006; 51: 1-6. [PMID: 16416200]
Fulcher AS, Capps GW, Turner MA. Thoracopancreatic fistula: clinical and imaging findings. J Comput Assist Tomogr. 1999; 23(2): 181-7. [PMID: 10096323]
Sonoda S, Taniguchi M, Sato T, Yamasaki M, Enjoji M, Mae S, Irie T, Ina H,Sumi Y, Inase N, Kobayashi T. Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment. Intern Med 2012; 51(18): 2655-61. [PMID: 22989845]
Rockey DC, Cello JP. Pancreaticopleural fistula. Report of 7 patients and review of the literature. Medicine (Baltimore) 1990; 69: 332-44. [PMID: 2233231]
Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996; 76: 1159-73. [PMID: 8841370]
Kaman L, Behera A, Singh R, Katariya RN. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. ANZ J Surg 2001; 71(4): 221-5. [PMID: 1355730]
Branca P, Rodriguez RM, Rogers JT, Ayo DS, Moyers JP, Light RW. Routine measurement of pleural fluid amylase is not indicated. Arch Intern Med 2001 22; 161(2): 228-32. [PMID: 11176736]
Neher JR, Brady PG, Pinkas H, Ramos M. Pancreaticopleural fistula in chronic pancreatitis: Resolution with endoscopic therapy. Gastrointestinal Endoscopy 2000; 52: 416-8. [PMID: 10968864]
Ondrejka P, Faller J, Siket F, et al. Isolated massive pleural effusion caused by pancreatico-pleural fistula. Z Gastroenterol 2000; 38: 583-5. [PMID: 10965555]
Cocieru A, Saldinger PF. Frey procedure for pancreaticopleural fistula.J Gastrointest Surg 2010; 14: 929-30. [PMID: 19862581]
Akahane T, Kuriyama S, Matsumoto M, et al. Pancreatic pleural effusion with a pancreaticopleural fistula diagnosed by magnetic resonance cholangiopancreatography and cured by somatostatin analogue treatment. Abdom Imaging 2003; 28: 92–95. [PMID: 12483394]
R. Schoefl, M. Haefner, S. Pongratz et al. Endoscopic treatment of fistulas and abscesses in pancreatitis: three case reports. Endoscopy 1996; 28: 776–779. [PMID: 9007433]
H. Kin, K. I. Kiriya, S. Mori et al. Pancreatic pleural effusion successfully treated by endoscopic pancreatic duct drainage combined with extracorporeal shock-wave lithotripsy: report of a case. Digestive Endoscopy 2001; 13: 49–53.
E. W. Pottmeyer, C. F. Frey, and S. Matsuno. Pancreaticopleural Fistulas. Archives of Surgery 1987; 122: 648–654. [PMID: 3579578]
Machado NO. Pancreaticopleural fistula: revisited. Diagn Ther Endosc 2012; 2012: 815476. [PMID: 22454555]
Saeed ZA, Ramirez FC, Hepps KS. Endoscopic stent placement for internal and external pancreatic fistulas. Gastroenterology 1993; 105: 1213-7. [PMID: 8405869]
Shah HK, Shah SR, Maydeo AP, Pramesh CS. Pancreatico-pleural fistula.Endoscopy. 1998; 30(3): 314. [PMID: 9615885]
Will U, Meyer F, Manger T, Wanzar I. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis. Endoscopy 2005; 37: 171-3. [PMID: 15692934]
Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases. Gastrointest Endosc 2004; 59: 100-7. [PMID: 14722561]
Koshitani T, Uehara Y, Yasu T, et al. Endoscopic management of pancreaticopleural fistulas: a report of three patients. Endoscopy 2006; 38: 749-51. [PMID: 16586252]
Miyachi A, Kikuyama M, Matsubayashi Y, et al. Successful treatment of pancreaticopleural fistula by nasopancreatic drainage and endoscopic removal of pancreatic duct calculi: a case report. Gastrointest Endosc 2004; 59: 454-7. [PMID: 14997157]
B. Griesshammer and M. Strobel, “Pancreaticopleural fistula treated by transpapillary implantation of a plastic prosthesis. Endoscopy 30: 741, 1998. [PMID: 9865571]
Khan AZ, Ching R, Morris-Stiff G, England R, Sherridan MB, Smith AM. Pleuropancreatic fistulae: specialist center management. J Gastrointest Surg 2009; 13: 354-358. [PMID: 18972169]
Pai CG, Suvarna D, Bhat G. Endoscopic treatment as first- line therapy for pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 2009; 24: 1198-1202. [PMID: 19486258]
Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gas- trointest Endosc 2005; 61: 568-575. [PMID: 15812410]
O'Toole D, Vullierme MP, Ponsot P, Maire F, Calmels V, Hentic O, Hammel P, Sauvanet A, Belghiti J, Vilgrain V, Ruszniewski P, Lévy P. Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging. Gastroenterol Clin Biol 2007; 31: 686-693. [PMID: 17925768]
Burgess NA, Moore HE, Williams JO, Lewis MH. A review of pancreaticopleural fistula in pancreatitis and its management. HPB Surg 1992; 5:79-86. [PMID: 1610729]
O’Neil SJ, Aranha GV. Lateral pancreaticojejunostomy for chronic pancreatitis. World J Surg 2003; 27:1196-202.
Copyright (c) 2015 Yashant Aswani, Priya Hira
This work is licensed under a Creative Commons Attribution 4.0 International License.
As a member of Publisher International Linking Association, PILA, iMedPub Group’s JOP follows the Creative Commons Attribution License and Scholars Open Access publishing policies. Journal of the Pancreas is the Council Contributor Member of Council of Science Editors (CSE) and following the CSE slogan Education, Ethics, and Evidence for Editors.