Management of Pancreaticopleural Fistulas

Pancreaticopleural fistulas are uncommon complications of acute or chronic pancreatitis in which pancreatic secretions track through disrupted ductal systems into the pleural cavity. Patients typically present with large, recurrent pleural effusions rich in amylase, accompanied by dyspnoea or chest discomfort rather than overt abdominal pain. The underlying mechanism involves disruption of the pancreatic duct or rupture of a pseudocyst, with enzymatic fluid dissecting through retroperitoneal planes or via diaphragmatic hiatuses.

Accurate diagnosis relies on a high index of suspicion in patients with pancreatitis and unexplained pleural effusions. Analysis of pleural fluid amylase levels exceeding serum values is pathognomonic. Cross-sectional imaging, particularly contrast-enhanced computed tomography, delineates pancreatic ductal anatomy, fluid collections and fistulous tracts. Magnetic resonance cholangiopancreatography offers non-invasive visualisation of ductal disruption and pseudocyst-to-pleural communications.

Management follows a stepwise approach. Initial conservative measures include pleural drainage, bowel rest and somatostatin analogues to reduce pancreatic exocrine secretion. When conservative therapy fails or fistula persists beyond several weeks, endoscopic interventions via endoscopic retrograde cholangiopancreatography (ERCP) permit pancreatic duct stenting or sphincterotomy to redirect flow and promote fistula closure. In cases with large pseudocysts or failure of endoscopic techniques, surgical options such as internal drainage procedures or resection may be indicated. Long-term outcomes hinge on resolution of underlying pancreatitis, optimisation of ductal flow and minimisation of complications such as infection or recurring effusions.

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Management of Pancreaticopleural Fistulas publication trend

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Technical terms

Pancreaticopleural fistula: An abnormal channel allowing pancreatic fluid to pass from the pancreas into the pleural cavity.

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure combining endoscopy and fluoroscopy to visualise and intervene upon the biliary and pancreatic ducts.

Magnetic resonance cholangiopancreatography (MRCP): A magnetic resonance imaging technique that non-invasively depicts the pancreaticobiliary ductal system.

Pancreatic pseudocyst: A walled-off collection of pancreatic fluid encapsulated by fibrous tissue, lacking an epithelial lining.

Transpapillary drainage: Endoscopic placement of a stent across the pancreatic ductal papilla to divert secretions and facilitate fistula closure.

References

1. MANAGEMENT OF PANCREATICOPLEURAL FISTULAS SECONDARY TO CHRONIC PANCREATITIS. ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) (2017).
2. Pancreaticopleural Fistula: A Review of Imaging Diagnosis and Early Endoscopic Intervention. Case Reports in Gastrointestinal Medicine (2018).
3. Pancreaticopleural fistula in children with chronic pancreatitis: a case report and literature review. BMC Pediatrics (2020).
4. Endoscopic treatment of pancreaticopleural fistulas. Frontiers in Cellular and Infection Microbiology (2022).