Pancreaticopleural Fistula

Recently, a 78-year-old gastrectomized male presented with fever (38°C) and chest pain of 1-w duration. Twenty days before, he underwent resection of left colon, spleen, and pancreatic tail for a gastric cancer recurrence. At presentation, no murmur was heard on auscultation of the left lung and hemogram revealed marked leukocytosis (40,000/mm3). Chest radiograph showed massive left-sided pleural effusion. On thoracentesis, abundant purulent fluid was aspirated: Cultures yielded Candida albicans and Enterococcus faecium, and targeted fluconazole and targosid were instituted. Biochemical analysis of the pleural fluid disclosed elevated concentrations of amylase and lipase (8,600 U/L and 53,000 U/L respectively): Hence, a clinical diagnosis of pancreaticopleural fistula (PPF) was formulated. Thoracoabdominal CT scan revealed a left subphrenic collection of 6 cm in diameter strongly tethered to the pancreatic margin and not dissociable from the left hemidiaphragm which appeared thickened and dishomogeneous: Such features corroborated the presumptive diagnosis of PPF (Fig. 1, Fig. 2). A 3-w course of antimicrobial agents along with somatostatin analogs effected a complete closure of the fistula.

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FIG. 1.

Chest CT scan showing left-sided pleural effusion which was in part loculated (L.P.E.: loculated pleural effusion) (C.: pig-tail catheter is in situ).

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FIG. 2.

Thoracoabdominal CT scan disclosed not only the left pleural effusion, but also a left subphrenic collection of 6 cm in diameter (S.c.: Subphrenic collection) closely tethered to the pancreatic margin (P.: Pancreatic remnant; cl.: surgical clips) and not dissociable from the left diaphragm (D.: Diaphragm), which resulted to be thickened and dishomogeneous: such findings corroborated the clinical diagnosis of PPF. (C.: pig-tail catheter in situ).

Pancreaticopleural fistula (PPF) is an unusual pancreatic disease; as of 2015, only 74 cases have been described in the world literature [1]. Pancreaticopleural fistula is observed in 0.4% of acute pancreatitis cases and in 4.5% of patients with pancreatic pseudocysts: In 90% of cases, it occurs as a complication of chronic pancreatitis [2,3]. Whatever the cause, PPF occurs when the pancreatic juice flowing from a transected pancreatic duct or a ruptured pseudocyst erodes the pleura through the esophageal or aortic hiatus or diaphragm [3]. Commonly, patients with PPF have no abdominal symptoms having a delay in diagnosis [3]. A massive pleural effusion is the most frequent radiological finding: It can be left-, right-sided, or bilateral (76%, 19%, and 14% of cases respectively) [3]. Thoracentesis with detection of high amylase and lipase concentrations is pathognomonic [3]. Visualizing the fistulous track is not a simple task: Sensitivity of CT, ERCP, and MRCP is variable with values of 47%, 78%, and 80% respectively. Given the rarity of this condition, there are no defined guidelines about its management [1–4].

The occurrence of infection affecting PPF is a rare event: Out of the 74 cases previously reported, we found only one instance of chronic pancreatitis related-PPF in which the pleural tap revealed frank purulent aspirate [5]. Our case represents the first example of post-surgical PPF resulted to be infected with Candida albicans and Enterococcus faecium.