Evaluation and management of thoracopancreatic fistula

Abstract

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. 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. 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. 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.