Surgical management of pancreaticopleural fistulas.

BACKGROUND: Pancreaticopleural fistula is defined as a communication between the pancreatic duct and the pleural cavity. Initially, it is treated conservatively and endoscopically. Surgery is performed within a small group of patients in whom other therapeutic approaches failed.

PATIENTS AND METHODS: In this retrospective study, nine patients with pancreaticopleural fistulas were treated. In 8 of nine patients, conservative treatment was used experimentally. Patients were considered as having a pancreaticopleural fistula before operation if a fistulous tract was seen on radiologic examination or if a large exudative pleural effusion was present with an amylase level > 5.000 U/L and total pleural fluid protein content > 3 g/L. All patients were evaluated for computed tomography (CT), ultrasonography (USG) examination and endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS: The mean age of patients was 47 (35-51) years. Pancreatic effusion was present in the left pleural cavity in 6 cases, in the right cavity in 2 and on both sides in 1 case. The causes of fistula formation were as follows : chronic pancreatitis due to alcohol abuse--seven patients, rupture of the pancreas and main pancreatic duct due to trauma--one patient and pancreatolithiasis--1 patient. Endoscopic stenting of the main pancreatic duct was unsuccessful in all patients except one. Five patients underwent distal (n = 4) or corporocaudal pancreatectomy (n = 1) with splenectomy, two underwent pancreatic duct anastomosis with an intestinal loop (the Partington-Rochelle procedure) and one underwent pancreaticoduodenectomy. Postoperative complications were observed in two patients. There were no cases of hospital mortality. The mean time of hospitalization was 16 days. Seven patients reported for the follow-up examination in the postoperative period of 10 to 67 months. No recurrence of pleural effusion was noted in any case.

CONCLUSION: Surgical treatment is effective and safe for the management of a pancreaticopleural fistula when conservative and endoscopic therapy has failed.