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

Abstract

Patient: Male, 37-year-oldFinal Diagnosis: Chronic alcoholic pancreatitis • pancreaticopleural fistula • left lung abscessesSymptoms: Fever with a body temperature of 39.1°C • left thoracic pain • severe cough with purulent sputum • shortness of breath • upper abdominal painMedication: —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 procedureSpecialty: SurgeryObjective:Unusual clinical courseBackground:Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Its formation is associated with local disruption of the pancreatic duct or pseudocyst communicating with the ductal system. Rarely, other intrathoracic complications may develop such as mediastinitis, pericarditis, hemothorax, and pleural empyema. The combination of pancreaticopleural fistula with lung abscesses is extremely rare.Case Report:A 37-year-old male patient, a long-term alcohol abuser, was admitted with complaints on left thoracic and upper abdominal pain, fever with a body temperature of 39.1°C, and a severe cough with purulent sputum. Left-sided pneumonia with pleural effusion was diagnosed. Thoracentesis and then a pleural drainage were performed. However, the symptoms persisted. Pleural effusion amylase was very high – more than 60 000 IU/L. Computed tomography and magnetic resonance imaging revealed cystic changes in the pancreatic head, pseudo-cyst in the pancreatic body, dilation of the Wirsung duct, and pancreaticopleural fistula with several left lung abscesses. Step by step, the patient underwent drainage of lung abscesses, external drainage of the pancreatic pseudocyst, and external-internal stenting of the pancreatic duct under ultrasound guidance. After fistula resolution, the patient was readmitted and successfully underwent the Bern variant of the Beger procedure. Six months later, he had no complaints and returned to work. In a follow-up examination, there was no fistula, no ductal hypertension, and only small pulmonary residual changes.Conclusions:A very rare case of chronic pancreatitis complicated by pancreaticopleural fistula with lung abscesses is presented. The clinical outcome was good due to the staged character of treatment and participation of a multi-disciplinary specialist team.