Pancreaticopleural Fistula Successfully Treated by Thoracoscopic Drainage and Endoscopic Pancreatic Stenting: Report of a Case

Abstract

Pancreaticopleural fistula is a rare complication of chronic pancreatitis. In the past, it was treated by either conservative treatment or surgical intervention. Few cases have been treated with endoscopic stenting successfully in the literature. We report a case of 31 year-old man who suffered from right chest pain and progressive dyspnea for 1 week. He was an alcoholic and has been admitted due to chronic pancreatitis with acute exacerbation several times. The chest X-ray showed right massive pleural effusion. The amylase level of pleural fluid was very high (24800U/L). Endoscopic retrograde pancreatography revealed a pancreaticopleural fistula, a small pseudocyst and stricture of main pancreatic duct in the head of pancreas. A pancreatic stent bridging the stricture, not the orifice of the fistula was inserted at the same time. Unfortunately, fever and pleural empyema occurred 3 days after the procedure. The culture of pleural effusion yielded alfa-streptococcus initially, Escherichia coli, Klebsiella pneumoniae and Pseudomonus aeruginosa later. The possible reasons may be ascending infection related to contrast media injection or the reflux of duodenal juice through the pancreatic stent and the fistula. It was later successfully treated by antibiotics, thoracoscopic decortication and drainage, and another longer pancreatic stent bridging the orifice of a fistula. Although endoscopic pancreatic stenting is an alternative treatment for pancreaticopleural fistula, an appropriate stent is one of the important factors to success.