Abstract
Objective Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting
from pancreatic duct disruption with leakage of pancreatic secretions into the pleural
cavity. Fistulization occurs either through the esophageal hiatus or straight through
the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed
diagnosis is frequent. Initial conservative treatment fails in a significant number
of cases. Ascending infection via the fistulous tract results in empyema and life-threatening
sepsis.
Methods All patients who underwent surgery for pancreaticopleural fistula-induced empyema
thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective
case study.
Results Altogether six patients with pancreaticopleural fistula and associated pleural empyema
were identified. All patients suffered from pancreatitis and received initial medical
and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection
led to left-sided pleural empyema in four and bilateral empyema in two cases. The
contagious spread took place through the fistulous tract connecting the pancreatic
duct with the pleural cavity. The patients were referred for surgery with considerable
delay and already advanced pleural empyema. Minimally invasive thoracic surgery with
pleural debridement was performed in all cases. Furthermore, left pancreatic resection
was mandatory in five cases and cystostomy in one case. All patients recovered well
and upon follow-up there were no further complications.
Conclusion Surgical management combining minimally invasive thoracic surgery and removal of
the fistulous tract is highly effective. If initial medical treatment fails, surgery
should be considered early to prevent severe sepsis. Further improvement seems achievable
by reducing the time between fruitless conservative efforts and surgical intervention.
Keywords
pancreaticopleural fistula - pancreatitis - pleural empyema - sepsis
