Download PDF
CC BY 4.0 · Journal of Digestive Endoscopy 2024; 15(01): 35-41
DOI: 10.1055/s-0044-1782227
Research Article

Natural History and Endoscopic Management of Pancreaticopleural Fistula: A Tertiary Care Center Experience

Pritam Das
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Rakesh S. Kumar
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Swapnil Mujawdiya
2   Department of Gastroenterology, RML Institute of Medical Sciences, Gomtinagar, Lucknow, Uttar Pradesh, India
,
Dhruv Thakur
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Nagnath Wodeyar
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Kartik Balankhe
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Vivek Anand Saraswat
3   Department of Hepatology, MG Hospital, Sitapura, Jaipur, Rajasthan, India
,
Gaurav Pande
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
,
Samir Mohindra
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
› Author Affiliations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University (Sanjay Gandhi Post-Graduate Institute of Medical Sciences Lucknow) The study was approved by the institutional committee and was conducted in accordance with the Declaration of Helsinki.
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Pancreaticopleural fistula (PPF) is a rare complication associated with pancreatitis, caused by disruption of the pancreatic duct, either directly or through rupture of a peripancreatic fluid collection, resulting in leakage of pancreatic juice into the pleural space. It commonly presents as massive, relapsing pleural effusions, often on the left side with high amylase content. Nonspecific chest symptoms often predominate, making it a diagnostic challenge. There is a lack of clarity regarding the management of this rare entity.

Objectives This study aimed to review the typical presentations, pathophysiology, and current role of endoscopic therapy in patients with PPF.

Materials and Methods A retrospective analysis of the results of endoscopic treatment of patients with symptomatic PPF due to pancreatitis was done.

Results Ten patients with pancreatitis (6 males; mean age 33.6 ± 15.4 years: 6 chronic, 4 acute) with symptomatic PPF were analyzed. Endoscopic retrograde cholangiopancreatography was performed in all, with pancreatic sphincterotomy and stenting of the main pancreatic duct (passive transpapillary drainage). Technical and clinical success was achieved in 7/10(70%) and 10/10(100%) patients, respectively. Though the leak was bridged in three patients, pancreatic sphincterotomy and downstream stenting (when bridging was not possible) were successful in closing PPF. One (10%) patient needed surgery for gastric outlet obstruction. The mean duration of endotherapy was 12.1 ± 9.4 months and the time taken for leak closure was 15.3 ± 10.4 weeks. Long-term success of endoscopic treatment (median follow-up period of 48.9 ± 28.7 months) was achieved in all patients.

Conclusions Endoscopic treatment (passive trans-papillary drainage) is a safe and effective procedure for managing postinflammatory PPFs, and should be attempted in cases of failure of medical treatment.

Keywords

pancreaticopleural fistula - pancreatitis - pleural effusion - endoscopic retrograde cholangiopancreatography

Authors' Contributions

S.M. and V.A.S were involved in conceptualization, methodology, investigation, validation, resources, writing (original draft, review and editing), visualization, and supervision. P.D. and S.R.K. contributed to methodology, validation, writing (review and editing), and visualization. S.M. helped in methodology, investigation, data collection, validation, resources, and writing (original draft, review, and editing). D.T. and N.K. contributed to resources, visualization, and writing (reviewing and editing). K.B. helped in format analysis, reviewing, and editing. G.P. contributed to resources, visualization, and supervision.


Informed Consent

Informed consent was obtained from all individual participants included in the study.




Publication History

Article published online:
27 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Chebli JMF, Gaburri PD, de Souza AF. et al. Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol 2004; 38 (09) 795-800
    CrossrefPubMedGoogle Scholar
  • 2 Chang LH, Francoeur L, Schweiger F. Pancreaticoportal fistula in association with antiphospholipid syndrome presenting as ascites and portal system thrombosis. Can J Gastroenterol 2002; 16 (09) 601-605
    CrossrefPubMedGoogle Scholar
  • 3 Miller JA, Maldjian P, Seeff J. Pancreaticopleural fistula. An unusual cause of persistent unilateral pleural effusion. Clin Imaging 1998; 22 (02) 105-107
    CrossrefPubMedGoogle Scholar
  • 4 Uchiyama T, Suzuki T, Adachi A, Hiraki S, Iizuka N. Pancreatic pleural effusion: case report and review of 113 cases in Japan. Am J Gastroenterol 1992; 87 (03) 387-391
    PubMedGoogle Scholar
  • 5 Pai CG, Suvarna D, Bhat G. Endoscopic treatment as first-line therapy for pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 2009; 24 (07) 1198-1202
    CrossrefPubMedGoogle Scholar
  • 6 Gupta S, Gaikwad N, Samarth A, Sawalakhe N, Sankalecha T. Efficacy of pancreatic endotherapy in pancreatic ascites and pleural effusion. Med Sci (Basel) 2017; 5 (02) 6 DOI: 10.3390/medsci5020006.
    CrossrefPubMedGoogle Scholar
  • 7 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 (06) 527-529
    CrossrefPubMedGoogle Scholar
  • 8 Kutz Leoz M, Irisarri Garde R, Vila Costas JJ, Martínez Echeverría A, Elizalde Apestegui I, Basterra Ederra M, Gómez Alonso M, Zozaya Urmeneta JM. [Pleural effusion secondary to pancreaticopleural fistula following acute pancreatitis]. Gastroenterol Hepatol 2012; Feb; 35 (02) 70-73 . Spanish. doi: 10.1016/j.gastrohep.2011.10.008. Epub 2012 Jan 11. PMID: 22240268
    PubMedGoogle Scholar
  • 9 Kozarek RA, Ball TJ, Patterson DJ, Freeny PC, Ryan JA, Traverso LW. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 1991; 100 (5 Pt 1): 1362-1370
    CrossrefPubMedGoogle Scholar
  • 10 Larsen M, Kozarek R. Management of pancreatic ductal leaks and fistulae. J Gastroenterol Hepatol 2014; 29 (07) 1360-1370
    CrossrefPubMedGoogle Scholar
  • 11 Bhasin DK, Rana SS, Siyad I. et al. Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 2006; 21 (06) 1059-1064
    CrossrefPubMedGoogle Scholar
  • 12 Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005; 61 (04) 568-575
    CrossrefPubMedGoogle Scholar
  • 13 Kim S, Kim JW, Jung PY. et al. Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: single center experience for 34 years. Int J Surg 2017; 42: 152-157
    CrossrefPubMedGoogle Scholar
  • 14 Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP 2005; 6 (02) 152-161
    Google Scholar
  • 15 Ferris H, Buckley M. Pancreaticopleural fistula: an unusual complication of chronic pancreatitis. Ir Med J 2012; 105 (07) 246-247
    PubMedGoogle Scholar
  • 16 Gestic MA, Callejas-Neto F, Chaim EA. et al Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual. ABCD, [Surgical treatment of chronic pancreatitis with frey procedure: current situation] arq bras cir dig 2011; 24 (04) 305-311 DOI: 10.1590/ S0102-67202011000400011.
    CrossrefGoogle Scholar
  • 17 Meybeck A, Gouteux D, Bolard F, Salez F, Guillemot P, Barbieux H. [A rare complication of chronic pancreatitis: pancreatico-pleural fistula]. Rev Pneumol Clin 2003; 59 (04) 205-208
    PubMedGoogle Scholar
  • 18 Neumann S, Caca K, Mössner J. Pankreatikopleurale Fistel bei chronischer Pankreatitis mit Pankreasschwanznekrose [Pancreatico-pleural fistula in chronic pancreatitis with necrosis of the pancreatic tail]. Dtsch Med Wochenschr 2004; Aug 20; 129 (34–35): 1802-1805 . German. doi: 10.1055/s-2004-829032. PMID: 15314743
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Rushforth JA, Beck JM, McMahon M, Puntis JW. Resolution of pancreatic ascites with octreotide. Arch Dis Child 1993; 68 (01) 135-136
    CrossrefPubMedGoogle Scholar
  • 20 Kurumboor P, Varma D, Rajan M. et al. Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol. Indian J Gastroenterol 2009; 28 (03) 102-106
    CrossrefPubMedGoogle Scholar
  • 21 Bhasin DK, Dhavan S, Sriram PV. et al. Endoscopic management of pancreatic diseases. Indian J Gastroenterol 1997; 16 (04) 151-152
    PubMedGoogle Scholar
  • 22 Agarwal J, Nageshwar Reddy D, Talukdar R. et al. ERCP in the management of pancreatic diseases in children. Gastrointest Endosc 2014; 79 (02) 271-278
    CrossrefPubMedGoogle Scholar
  • 23 Felux J, Sturm E, Busch A. et al. Sa1178 ERCP in infants, children and adolescents is feasible and safe – results from a tertiary care center. Gastrointest Endosc 2016; 83 (05) AB243-AB244
    CrossrefGoogle Scholar
  • 24 Zubiaurre L, Oyarzabal I, Beguiristain A, Amato E, Zapata E, Salvador P. Fístula pancreaticopleural: pruebas diagnósticas y tratamiento [Pancreaticopleural fistula: diagnostic tests and treatment]. Cir Esp 2005; Jun; 77 (06) 359-361 . Spanish. doi: 10.1016/s0009-739x(05)70871-x. PMID: 16420951
    CrossrefPubMedGoogle Scholar
  • 25 Parekh D, Segal I. Pancreatic ascites and effusion. Risk factors for failure of conservative therapy and the role of octreotide. Arch Surg 1992; 127 (06) 707-712
    CrossrefPubMedGoogle Scholar
  • 26 Jagielski M, Piątkowski J, Jackowski M. Endoscopic treatment of pancreaticopleural fistulas. Front Cell Infect Microbiol 2022; 12: 939137
    CrossrefPubMedGoogle Scholar
  • 27 Ali T, Srinivasan N, Le V, Chimpiri AR, Tierney WM. Pancreaticopleural fistula. Pancreas 2009; 38 (01) e26-e31
    CrossrefPubMedGoogle Scholar