Successful treatment of pancreaticopleural fistula by nasopancreatic drainage and endoscopic removal of pancreatic duct calculi: a case report

Abstract

Pancreaticopleural fistula results from pancreatic duct disruption and/or pancreatic pseudocyst extension into the pleural cavity. Patients usually present with a large, recurrent, pleural effusion; dyspnea; and/or chest pain in the setting of chronic pancreatitis.1.Rockey D.C. Cello J.P. Pancreaticopleural fistula: report of 7 patients and review of the literature.Medicine. 1990; 69: 332-334Crossref PubMed Scopus (155) Google Scholar, 2.Uchiyama T. Suzuki T. Adachi A. Hiraki S. Iizuka N. Pancreatic pleural effusion: case reports and review of 113 cases in Japan.Am J Gastroenterol. 1992; 87: 387-391PubMed Google Scholar Pancreaticopleural fistula has been considered a surgical disease; if the fistula does not close in response to conservative measures (e.g., total parenteral nutrition and somatostatin therapy) within 2 to 4 weeks, surgery usually is performed.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The case of a patient with a pancreaticopleural fistula in whom the diagnosis was confirmed by ERCP is presented. The patient was treated successfully by endoscopic transpapillary procedures and extracorporeal shock wave lithotripsy (ESWL).1. Case reportA 49-year-old man with a history of alcohol-induced pancreatitis and diabetes mellitus was hospitalized with complaints of dry cough and dyspnea. Examination revealed decreased breath sounds over the lower three quarters of the right lung field. The serum amylase at admission was elevated. A chest radiograph disclosed a massive right pleural effusion (Fig. 1). Placement of a thoracostomy tube yielded bloody fluid with a markedly elevated amylase concentration (45,771 IU/L) (normal: <38 IU/L). Numerous calcifications and multiple pseudocysts were demonstrated around the pancreas and anterior to the abdominal aorta by CT (Fig. 2), US, and magnetic resonance imaging. Bloody fluid with an amylase concentration of 42,196 IU/L was aspirated from a large cyst adjacent to the left lobe of the liver.Figure 2A, CT showing pseudocysts (arrows) around pancreas tracking into mediastinum. B, CT demonstrating numerous pancreatic calculi.View Large Image Figure ViewerDownload (PPT)Figure 2A, CT showing pseudocysts (arrows) around pancreas tracking into mediastinum. B, CT demonstrating numerous pancreatic calculi.View Large Image Figure ViewerDownload (PPT)At ERCP, there was irregular dilatation of the main pancreatic duct, which contained multiple calculi and pseudocysts extending to the mediastinum. Contrast medium flowed into the mediastinum and drained through the thoracostomy tube via the right pleural cavity (Fig. 3), confirming the diagnosis of pancreaticopleural fistula.Figure 3A, Retrograde pancreatogram showing dilated pancreatic duct with filling defects and extravasation of contrast medium (arrowhead). B, Retrograde pancreatogram demonstrating contrast medium flowing into mediastinum and right pleural cavity (arrow).View Large Image Figure ViewerDownload (PPT)Figure 3A, Retrograde pancreatogram showing dilated pancreatic duct with filling defects and extravasation of contrast medium (arrowhead). B, Retrograde pancreatogram demonstrating contrast medium flowing into mediastinum and right pleural cavity (arrow).View Large Image Figure ViewerDownload (PPT)A nasopancreatic drainage tube was placed endoscopically (Fig. 4A). Thereafter, the outflow from the thoracostomy tube decreased, and the pleural effusion and pseudocysts disappeared. The chest thoracostomy tube was removed 2 weeks later. Endoscopic sphincterotomy (EST) was performed, and pancreatic calculi were extracted in a series of 3 procedures in conjunction with ESWL (28,000 hits), which fragmented the calculi located in the main pancreatic duct. Large pancreatic calculi in the main duct that had obstructed the flow of pancreatic juice disappeared (Fig. 4B), and the nasopancreatic drainage tube was removed. At 1-year follow-up, there has been no recurrence of the pleural effusion or pseudocysts.Figure 4A, Retrograde pancreatogram made via nasopancreatic drain, showing dilated pancreatic duct with filling defects (arrows) and pseudocysts (arrowheads). B, Pancreatogram made via nasopancreatic drain, showing disappearance of large pancreatic calculi, a decrease in diameter of main pancreatic duct, and absence of extravasation of contrast medium.View Large Image Figure ViewerDownload (PPT)Figure 4A, Retrograde pancreatogram made via nasopancreatic drain, showing dilated pancreatic duct with filling defects (arrows) and pseudocysts (arrowheads). B, Pancreatogram made via nasopancreatic drain, showing disappearance of large pancreatic calculi, a decrease in diameter of main pancreatic duct, and absence of extravasation of contrast medium.View Large Image Figure ViewerDownload (PPT)2. DiscussionPancreaticopleural fistula is caused by pancreatic duct disruption accompanied by pancreatic stricture or pancreatic calculi.1.Rockey D.C. Cello J.P. Pancreaticopleural fistula: report of 7 patients and review of the literature.Medicine. 1990; 69: 332-334Crossref PubMed Scopus (155) Google Scholar, 2.Uchiyama T. Suzuki T. Adachi A. Hiraki S. Iizuka N. Pancreatic pleural effusion: case reports and review of 113 cases in Japan.Am J Gastroenterol. 1992; 87: 387-391PubMed Google Scholar Surgery has been used to treat pancreaticopleural fistula when conservative therapy fails.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, several studies have found endoscopic transpapillary approaches, instead of surgery, to be efficacious for treatment of this condition.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 6.Holst T. Grille W. Asbeck F. Endoscopic therapy of a pancreatic effusion caused by chronic pancreatitis.Z Gastroenterol. 1998; 36: 893-896PubMed Google Scholar, 7.Cameron J.L. Chronic pancreatic ascites and pancreatic pleural effusions.Gastroenterology. 1978; 74: 134-140PubMed Scopus (164) Google Scholar, 8.Iglesias J.I. Cobb J. Levey J. Rosiello R.A. Recurrent left pleural effusion in a 44-year-old woman with a history of alcohol abuse.Chest. 1996; 110: 547-549Crossref PubMed Scopus (15) Google Scholar, 9.Kozarek R.A. Ball T.J. Patterson D.J. Freeny P.C. Ryan J.A. Traverso W. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.Gastroenterology. 1991; 100: 1362-1370PubMed Google Scholar, 10.Huibregtse K. Schneider B. Vrij A.A. Tytgat G.N. Endoscopic pancreatic drainage in chronic pancreatitis.Gastrointest Endosc. 1988; 34: 9-15Abstract Full Text PDF PubMed Scopus (201) Google Scholar Transpapillary stent placement can re-establish the flow of pancreatic juice into the duodenum, decrease intraductal pressure, and lead to closure of the fistula. In studies of patients with pancreaticopleural fistula, this procedure was performed preferentially, and clinical symptoms improved dramatically. Thus, transpapillary stent placement may obviate the need for surgery in patients with pancreaticopleural fistula.In patients with chronic calcific pancreatitis, removal of the main pancreatic duct calculi may relieve obstruction, restore the flow of pancreatic juice, and reduce elevated intraductal pressure, and, thereby, contribute to the improvement of symptoms of chronic pancreatitis without stent placement.11.Huibregtse K. Smith M.E. Endoscopic management of diseases of the pancreas.Am J Gastroenterol. 1994; 89: S66-S77PubMed Google Scholar Pancreatic sphincterotomy facilitates access to the pancreatic duct before attempts at calculus removal.12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar If calculi are large and/or impacted, they can be fragmented by ESWL to facilitate endoscopic removal.13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar Although complications can occur with these procedures,12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar relapse of symptoms of chronic pancreatitis over the long term, because of interruption of the flow of pancreatic juice, may be less frequent than with transpapillary stent placement.After the diagnosis of pancreaticopleural fistula was made in the case presented, a nasopancreatic drainage tube was placed and low intermittent suction was applied to decrease intraductal pressure. The patient had to endure the discomfort caused by the nasal tube and remain in the hospital, but this also allowed pancreatograms to be obtained repeatedly without further invasive procedures.5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The volume of drainage from the thoracostomy tube decreased immediately after placement of the nasopancreatic tube, and pseudocysts around the pancreas disappeared. Nasopancreatic drainage was thus sufficient to control the pancreaticopleural fistula. However, to avoid obstruction of the pancreatic duct by calculi and recurrence of the fistula, after removal of the nasopancreatic tube, EST and ESWL were performed, instead of transpapillary stent placement. Calculi were removed successfully, and transpapillary stent placement was not needed to maintain the flow of pancreatic juice. This report demonstrates that nasopancreatic drainage and removal of pancreatic duct calculi by EST and ESWL are worth considering in the treatment of patients with chronic pancreatitis, pseudocyst, and pancreaticopleural fistula. Pancreaticopleural fistula results from pancreatic duct disruption and/or pancreatic pseudocyst extension into the pleural cavity. Patients usually present with a large, recurrent, pleural effusion; dyspnea; and/or chest pain in the setting of chronic pancreatitis.1.Rockey D.C. Cello J.P. Pancreaticopleural fistula: report of 7 patients and review of the literature.Medicine. 1990; 69: 332-334Crossref PubMed Scopus (155) Google Scholar, 2.Uchiyama T. Suzuki T. Adachi A. Hiraki S. Iizuka N. Pancreatic pleural effusion: case reports and review of 113 cases in Japan.Am J Gastroenterol. 1992; 87: 387-391PubMed Google Scholar Pancreaticopleural fistula has been considered a surgical disease; if the fistula does not close in response to conservative measures (e.g., total parenteral nutrition and somatostatin therapy) within 2 to 4 weeks, surgery usually is performed.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The case of a patient with a pancreaticopleural fistula in whom the diagnosis was confirmed by ERCP is presented. The patient was treated successfully by endoscopic transpapillary procedures and extracorporeal shock wave lithotripsy (ESWL). 1. Case reportA 49-year-old man with a history of alcohol-induced pancreatitis and diabetes mellitus was hospitalized with complaints of dry cough and dyspnea. Examination revealed decreased breath sounds over the lower three quarters of the right lung field. The serum amylase at admission was elevated. A chest radiograph disclosed a massive right pleural effusion (Fig. 1). Placement of a thoracostomy tube yielded bloody fluid with a markedly elevated amylase concentration (45,771 IU/L) (normal: <38 IU/L). Numerous calcifications and multiple pseudocysts were demonstrated around the pancreas and anterior to the abdominal aorta by CT (Fig. 2), US, and magnetic resonance imaging. Bloody fluid with an amylase concentration of 42,196 IU/L was aspirated from a large cyst adjacent to the left lobe of the liver.Figure 2A, CT showing pseudocysts (arrows) around pancreas tracking into mediastinum. B, CT demonstrating numerous pancreatic calculi.View Large Image Figure ViewerDownload (PPT)At ERCP, there was irregular dilatation of the main pancreatic duct, which contained multiple calculi and pseudocysts extending to the mediastinum. Contrast medium flowed into the mediastinum and drained through the thoracostomy tube via the right pleural cavity (Fig. 3), confirming the diagnosis of pancreaticopleural fistula.Figure 3A, Retrograde pancreatogram showing dilated pancreatic duct with filling defects and extravasation of contrast medium (arrowhead). B, Retrograde pancreatogram demonstrating contrast medium flowing into mediastinum and right pleural cavity (arrow).View Large Image Figure ViewerDownload (PPT)Figure 3A, Retrograde pancreatogram showing dilated pancreatic duct with filling defects and extravasation of contrast medium (arrowhead). B, Retrograde pancreatogram demonstrating contrast medium flowing into mediastinum and right pleural cavity (arrow).View Large Image Figure ViewerDownload (PPT)A nasopancreatic drainage tube was placed endoscopically (Fig. 4A). Thereafter, the outflow from the thoracostomy tube decreased, and the pleural effusion and pseudocysts disappeared. The chest thoracostomy tube was removed 2 weeks later. Endoscopic sphincterotomy (EST) was performed, and pancreatic calculi were extracted in a series of 3 procedures in conjunction with ESWL (28,000 hits), which fragmented the calculi located in the main pancreatic duct. Large pancreatic calculi in the main duct that had obstructed the flow of pancreatic juice disappeared (Fig. 4B), and the nasopancreatic drainage tube was removed. At 1-year follow-up, there has been no recurrence of the pleural effusion or pseudocysts.Figure 4A, Retrograde pancreatogram made via nasopancreatic drain, showing dilated pancreatic duct with filling defects (arrows) and pseudocysts (arrowheads). B, Pancreatogram made via nasopancreatic drain, showing disappearance of large pancreatic calculi, a decrease in diameter of main pancreatic duct, and absence of extravasation of contrast medium.View Large Image Figure ViewerDownload (PPT)Figure 4A, Retrograde pancreatogram made via nasopancreatic drain, showing dilated pancreatic duct with filling defects (arrows) and pseudocysts (arrowheads). B, Pancreatogram made via nasopancreatic drain, showing disappearance of large pancreatic calculi, a decrease in diameter of main pancreatic duct, and absence of extravasation of contrast medium.View Large Image Figure ViewerDownload (PPT) A 49-year-old man with a history of alcohol-induced pancreatitis and diabetes mellitus was hospitalized with complaints of dry cough and dyspnea. Examination revealed decreased breath sounds over the lower three quarters of the right lung field. The serum amylase at admission was elevated. A chest radiograph disclosed a massive right pleural effusion (Fig. 1). Placement of a thoracostomy tube yielded bloody fluid with a markedly elevated amylase concentration (45,771 IU/L) (normal: <38 IU/L). Numerous calcifications and multiple pseudocysts were demonstrated around the pancreas and anterior to the abdominal aorta by CT (Fig. 2), US, and magnetic resonance imaging. Bloody fluid with an amylase concentration of 42,196 IU/L was aspirated from a large cyst adjacent to the left lobe of the liver. At ERCP, there was irregular dilatation of the main pancreatic duct, which contained multiple calculi and pseudocysts extending to the mediastinum. Contrast medium flowed into the mediastinum and drained through the thoracostomy tube via the right pleural cavity (Fig. 3), confirming the diagnosis of pancreaticopleural fistula. A nasopancreatic drainage tube was placed endoscopically (Fig. 4A). Thereafter, the outflow from the thoracostomy tube decreased, and the pleural effusion and pseudocysts disappeared. The chest thoracostomy tube was removed 2 weeks later. Endoscopic sphincterotomy (EST) was performed, and pancreatic calculi were extracted in a series of 3 procedures in conjunction with ESWL (28,000 hits), which fragmented the calculi located in the main pancreatic duct. Large pancreatic calculi in the main duct that had obstructed the flow of pancreatic juice disappeared (Fig. 4B), and the nasopancreatic drainage tube was removed. At 1-year follow-up, there has been no recurrence of the pleural effusion or pseudocysts. 2. DiscussionPancreaticopleural fistula is caused by pancreatic duct disruption accompanied by pancreatic stricture or pancreatic calculi.1.Rockey D.C. Cello J.P. Pancreaticopleural fistula: report of 7 patients and review of the literature.Medicine. 1990; 69: 332-334Crossref PubMed Scopus (155) Google Scholar, 2.Uchiyama T. Suzuki T. Adachi A. Hiraki S. Iizuka N. Pancreatic pleural effusion: case reports and review of 113 cases in Japan.Am J Gastroenterol. 1992; 87: 387-391PubMed Google Scholar Surgery has been used to treat pancreaticopleural fistula when conservative therapy fails.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, several studies have found endoscopic transpapillary approaches, instead of surgery, to be efficacious for treatment of this condition.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 6.Holst T. Grille W. Asbeck F. Endoscopic therapy of a pancreatic effusion caused by chronic pancreatitis.Z Gastroenterol. 1998; 36: 893-896PubMed Google Scholar, 7.Cameron J.L. Chronic pancreatic ascites and pancreatic pleural effusions.Gastroenterology. 1978; 74: 134-140PubMed Scopus (164) Google Scholar, 8.Iglesias J.I. Cobb J. Levey J. Rosiello R.A. Recurrent left pleural effusion in a 44-year-old woman with a history of alcohol abuse.Chest. 1996; 110: 547-549Crossref PubMed Scopus (15) Google Scholar, 9.Kozarek R.A. Ball T.J. Patterson D.J. Freeny P.C. Ryan J.A. Traverso W. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.Gastroenterology. 1991; 100: 1362-1370PubMed Google Scholar, 10.Huibregtse K. Schneider B. Vrij A.A. Tytgat G.N. Endoscopic pancreatic drainage in chronic pancreatitis.Gastrointest Endosc. 1988; 34: 9-15Abstract Full Text PDF PubMed Scopus (201) Google Scholar Transpapillary stent placement can re-establish the flow of pancreatic juice into the duodenum, decrease intraductal pressure, and lead to closure of the fistula. In studies of patients with pancreaticopleural fistula, this procedure was performed preferentially, and clinical symptoms improved dramatically. Thus, transpapillary stent placement may obviate the need for surgery in patients with pancreaticopleural fistula.In patients with chronic calcific pancreatitis, removal of the main pancreatic duct calculi may relieve obstruction, restore the flow of pancreatic juice, and reduce elevated intraductal pressure, and, thereby, contribute to the improvement of symptoms of chronic pancreatitis without stent placement.11.Huibregtse K. Smith M.E. Endoscopic management of diseases of the pancreas.Am J Gastroenterol. 1994; 89: S66-S77PubMed Google Scholar Pancreatic sphincterotomy facilitates access to the pancreatic duct before attempts at calculus removal.12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar If calculi are large and/or impacted, they can be fragmented by ESWL to facilitate endoscopic removal.13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar Although complications can occur with these procedures,12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar relapse of symptoms of chronic pancreatitis over the long term, because of interruption of the flow of pancreatic juice, may be less frequent than with transpapillary stent placement.After the diagnosis of pancreaticopleural fistula was made in the case presented, a nasopancreatic drainage tube was placed and low intermittent suction was applied to decrease intraductal pressure. The patient had to endure the discomfort caused by the nasal tube and remain in the hospital, but this also allowed pancreatograms to be obtained repeatedly without further invasive procedures.5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The volume of drainage from the thoracostomy tube decreased immediately after placement of the nasopancreatic tube, and pseudocysts around the pancreas disappeared. Nasopancreatic drainage was thus sufficient to control the pancreaticopleural fistula. However, to avoid obstruction of the pancreatic duct by calculi and recurrence of the fistula, after removal of the nasopancreatic tube, EST and ESWL were performed, instead of transpapillary stent placement. Calculi were removed successfully, and transpapillary stent placement was not needed to maintain the flow of pancreatic juice. This report demonstrates that nasopancreatic drainage and removal of pancreatic duct calculi by EST and ESWL are worth considering in the treatment of patients with chronic pancreatitis, pseudocyst, and pancreaticopleural fistula. Pancreaticopleural fistula is caused by pancreatic duct disruption accompanied by pancreatic stricture or pancreatic calculi.1.Rockey D.C. Cello J.P. Pancreaticopleural fistula: report of 7 patients and review of the literature.Medicine. 1990; 69: 332-334Crossref PubMed Scopus (155) Google Scholar, 2.Uchiyama T. Suzuki T. Adachi A. Hiraki S. Iizuka N. Pancreatic pleural effusion: case reports and review of 113 cases in Japan.Am J Gastroenterol. 1992; 87: 387-391PubMed Google Scholar Surgery has been used to treat pancreaticopleural fistula when conservative therapy fails.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, several studies have found endoscopic transpapillary approaches, instead of surgery, to be efficacious for treatment of this condition.3.Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent replacement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar, 4.Safadi B.Y. Marks J.M. Pancreatic-pleural fistula: the role of ERCP in diagnosis and treatment.Gastrointest Endosc. 2000; 51: 213-215Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 6.Holst T. Grille W. Asbeck F. Endoscopic therapy of a pancreatic effusion caused by chronic pancreatitis.Z Gastroenterol. 1998; 36: 893-896PubMed Google Scholar, 7.Cameron J.L. Chronic pancreatic ascites and pancreatic pleural effusions.Gastroenterology. 1978; 74: 134-140PubMed Scopus (164) Google Scholar, 8.Iglesias J.I. Cobb J. Levey J. Rosiello R.A. Recurrent left pleural effusion in a 44-year-old woman with a history of alcohol abuse.Chest. 1996; 110: 547-549Crossref PubMed Scopus (15) Google Scholar, 9.Kozarek R.A. Ball T.J. Patterson D.J. Freeny P.C. Ryan J.A. Traverso W. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.Gastroenterology. 1991; 100: 1362-1370PubMed Google Scholar, 10.Huibregtse K. Schneider B. Vrij A.A. Tytgat G.N. Endoscopic pancreatic drainage in chronic pancreatitis.Gastrointest Endosc. 1988; 34: 9-15Abstract Full Text PDF PubMed Scopus (201) Google Scholar Transpapillary stent placement can re-establish the flow of pancreatic juice into the duodenum, decrease intraductal pressure, and lead to closure of the fistula. In studies of patients with pancreaticopleural fistula, this procedure was performed preferentially, and clinical symptoms improved dramatically. Thus, transpapillary stent placement may obviate the need for surgery in patients with pancreaticopleural fistula. In patients with chronic calcific pancreatitis, removal of the main pancreatic duct calculi may relieve obstruction, restore the flow of pancreatic juice, and reduce elevated intraductal pressure, and, thereby, contribute to the improvement of symptoms of chronic pancreatitis without stent placement.11.Huibregtse K. Smith M.E. Endoscopic management of diseases of the pancreas.Am J Gastroenterol. 1994; 89: S66-S77PubMed Google Scholar Pancreatic sphincterotomy facilitates access to the pancreatic duct before attempts at calculus removal.12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar If calculi are large and/or impacted, they can be fragmented by ESWL to facilitate endoscopic removal.13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar Although complications can occur with these procedures,12.Smith M.E. Rauws E.A.J. Tytgat G.N.J. Huibregste K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.Gastrointest Endosc. 1996; 43: 556-560Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 13.Brand B. Kahl M. Sidhu S. Nam V.C. Sriram P.V.J. Jaeckle S. et al.Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis.Am J Gastroenterol. 2000; 95: 3428-3438Crossref PubMed Google Scholar relapse of symptoms of chronic pancreatitis over the long term, because of interruption of the flow of pancreatic juice, may be less frequent than with transpapillary stent placement. After the diagnosis of pancreaticopleural fistula was made in the case presented, a nasopancreatic drainage tube was placed and low intermittent suction was applied to decrease intraductal pressure. The patient had to endure the discomfort caused by the nasal tube and remain in the hospital, but this also allowed pancreatograms to be obtained repeatedly without further invasive procedures.5.Neher J.R. Brady P.G. Pinkas H. Ramos M. Pancreaticopleural fistula in chronic pancreatitis: resolution with endoscopic therapy.Gastrointest Endosc. 2000; 52: 416-418Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The volume of drainage from the thoracostomy tube decreased immediately after placement of the nasopancreatic tube, and pseudocysts around the pancreas disappeared. Nasopancreatic drainage was thus sufficient to control the pancreaticopleural fistula. However, to avoid obstruction of the pancreatic duct by calculi and recurrence of the fistula, after removal of the nasopancreatic tube, EST and ESWL were performed, instead of transpapillary stent placement. Calculi were removed successfully, and transpapillary stent placement was not needed to maintain the flow of pancreatic juice. This report demonstrates that nasopancreatic drainage and removal of pancreatic duct calculi by EST and ESWL are worth considering in the treatment of patients with chronic pancreatitis, pseudocyst, and pancreaticopleural fistula.