(1142) Management Dilemma for Pancreaticopleural Fistula Post-Pseudocyst Drainage

Sunday, February 23, 2025

12:15pm – 1:15pm Eastern Time

Location: Connections Central - RST 15

First Author(s)

TARK ABOU-ELMAGD, MD, MSc, MBBCH

Cape Fear Valley Medical Center, USA

Co-Author(s)

AC

Alejandro Chapa-Rodriguez, MD, FACP

Department of Pulmonary and Critical care
Cape Fear Valley Medical Center
fayetteville, North Carolina, United States
rA

rana Al-Zear, MD

Internal medicine physician
Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville NC, United States
EA

Eric Acker, MD

Resident physician
Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville NC, United States
CO

Cody O'Rear, DO

Pulmonary Medicine fellow
Department of Pulmonary and Critical Care Medicine, Cape Fear Valley Medical Center, Fayetteville NC, United States
MD

Merina Dongol, MD

Department of Pulmonary and Critical Care
n/a
fayetteville, North Carolina, United States
IL

Irlene Locklear, MD

Pulmonology and Critical Medicine physician
2. Department of Pulmonary and Critical Care, Cape Fear Valley Medical Center, Fayetteville NC, United States

Introduction: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis occurring in approximately 0.4% of cases and accounts for less than 1% of pleural effusion cases.1,2 Though most commonly due to chronic pancreatitis; acute pancreatitis and post pancreatic pseudocyst drainage are well known and reported causes.

Description: A 60-year-old patient with a medical history of chronic pancreatitis who presented with complains of dyspnea and chest pain. She had underwent ERCP with stent placement and pseudocyst drainage 4 days prior to her admission. CT was evident for large loculated left pleural effusion. A thoracentesis was performed, removing over 1L of tan-colored fluid. Analysis revealed significantly elevated amylase level at 1041. A repeat CT of the chest and abdomen with contrast was done for PPF evaluation, showed a likely fistulous tract. A trial of medical therapy including NPO status, TPN, octreotide infusion and ERCP was initially pursued. However, ERCP failed to identify the tract with no evidence of duct obstruction and cystogastrostomy not feasible. Chest tube was eventually placed with continuous high fluid output, but showed decreasing amylase levels. Salvage surgery was done with thoracotomy and decortication, which showed thick inflammatory peel and large amount of necrotic tissue. Following this, the patient improved and was discharged safely.

Discussion: PPF is a rare complication of chronic pancreatitis, with the most common initial complain being dyspnea in 65-74% of patients.3 The diagnosis is established with elevated amylase in pleural fluid, with values over 1000 being highly suggestive of a fistula.4 Imaging modalities show comparable sensitivity, with CT being able to identify the fistula in 47-63% of patients, ERCP identified 70% and MRCP 80% of cases.1 Medical and endoscopic treatment is still the preferred initial management due to high mortality associated with surgery, which is around 10%.2 However, with a success rate of endoscopy of only about 43%, patients should be managed in a step-up approach, with early recognition of failed conservative treatment and proceeding with salvage surgery. Our case demonstrated a rare presentation of this complication, with failed conservative management, impossible endoscopic treatment, requiring salvage surgery.