Pancreatico-Pleural Fistula

Anatomy of Pancreas

Retroperitoneal structure found posterior to the stomach and lesser omentum

It has a distinctive yellow/tan/pink color and is multilobulated

The gland is divided into four portions The head The neck The body The tail

The pancreas has an extensive arterial system arising from multiple sources and venous drainage follow the arterial anatomy

Pancreatic Duct

Main duct (Duct of Wirsung) runs the entire length of pancreas Joins Central Bile Duct at the ampulla of Vater 2 – 4 mm in diameter, 20 secondary branches

Lesser duct (Duct of Santorini) drains superior portion of head and empties separately into 2nd portion of duodenum Drains the uncinate process and lower part of head

Blood Supply of Pancreases

Pancreatitis Pancreatitis is inflammation of pancreas in which

pancreatic enzyme get activated in situ before releasing into duodenum and begin attacking the pancreas

Etiology Alcohol consumption, Gall stone (most common) Other: Medication, Infection, trauma, metabolic disorder,

Idiopathic Patient may presents with acute colicky abdominal pain

associated with nausea, vomiting, anorexia, fever On Examination – tenderness in epigastric region with

guarding and abdominal distension, tachycardia, hypotension

Most common complication is pseudocyst formation/ fluid collection

Pseudocyst of Pancreas Pseudocysts are best defined as a localized fluid collection that is

rich in amylase and other pancreatic enzymes, that has a nonepithelialized wall consisting of fibrous and granulation tissue

Appears after several week of pancreatitis Most common complication of pancreatitis Pseudocyst can be single or multiple (17%) Site of cyst : lesser sac (M/C), duodenum, jejunum, colon spleen In most of the cases pseudocyst communicating with pancreatic

duct(80%) May give rise to form fistula tract with other cavities like pleura,

peritoneal , skin Presents with swelling in epigastric region, abdominal pain, fever

(if it is infected 50 % of pseudocyst may show spontaneous resolution It can be treated by endoscopic management / surgical

Introduction

Pancreaticopleural fistula is a condition in which pancreatic secretions drain directly into the pleural cavity.

It occurs either as a complication in acute and chronic pancreatitis, or after traumatic or surgical disruption of the pancreatic duct.

Incidence rate:

0.4% of patient with chronic pancreatitis 2.5 – 4.5% of patient with pseudopancreatic cyst

Etiology

Chronic alcoholism – Chronic pancreatitis – Pancreatic pseudocyst

Trauma Iatrogenic Non- Iatrogenic

Pancreatic duct anomaly Causes of Pancreatitis

Classification of Pancreatic fistula

Pathophysiology

Presentation

Age group: 40 – 50 years / Male H/O chronic alcoholism

About half of the patients do not have history of pancreatitis

Most commonly patient with moderate to massive effusion presents with dyspnea, cough, chest pain, fever (chest discomfort) Pulmonary symptoms are more common than abdominal symptoms

as a presenting symptoms Rarely do patients complain of abdominal pain (25-30%) The average duration of symptoms is 5-6 weeks  

On Examination Percussion: Dullnote Auscultson : Decreased breath sounds

Pleural effusion are predominately left sided; however, right-sided and bilateral effusion can occurs As there is PPF, Pleural effusion of this nature tends to be large

and recurrent despite repeated thoracocentesis. Delay in diagnosis

Investigation Chest xray

S/O fluid collection in pleural cavity

Pleural fluid Analysis Pleural fluid amylase, lipase

>1000 U/L - most important diagnostic test

high albumin content (>3 g/dL)

CT scan of the chest and abdomen

 Gold standard for pleural effusion

very useful in determining the site and size of effusion

CT abdomen in addition will reveal changes of pancreatitis and identify other associated abnormalities such as pancreatic pseudocysts 

but overall ability to provide accurate delineation of the fistula is disputable

MRCP (Magnetic resonance cholangial pancreaticography ) Visualizes the duct beyond the

strictures, depicts parenchymal atrophy, ductal anatomy and small intrapancreatic and extrapancreatic pseudocyst, peripancreatic collection, or pancreaticopleural fistula.

noninvasive alternative to ERCP useful where ERCP fails to give

adequate information  Disadvantage : Only diagnostic, No

therapeutic role

ERCP (Endoscopic Retrograde Cholangiopancreatography)

provides information about the ampulla besides depicting ductal anatomy

Moreover, with the advent of pancreatic duct stents, ERCP attains a therapeutic role as well

It fails if fistula is located beyond the site of obstruction

Treatment Available Treatment modalities

Conservative/medical management Thoracocentesis

Octreotide

ERCP / Endoscopic management ERCP Stenting

Duct dilation

Sphinterectomy

Nasopancreatic drain

 Surgery

Conservative/Medical management

Aim To reduce Pancreatic stimulation/Secretion Drianage of Fluid

Constitute of Thoracocentesis/Tube thoracostomy

encourage apposition of serosal surfaces Somatostatin analogue – Octreotide

Inhibits exocrine secretion. No effect on closure rate. Reduces output and improves fistula control Start with 50MCG tds and then adjust the dose

according to drain output.

ERCP/Endoscopic management Aim : Relive the obstruction site/ bypass disruption site

achieve drainage of ducts with fistulae in short term and drainage of the stenosed pancreatic duct in long term

Constitute of papillary sphincterotomy - sphincter of Oddi dysfunction dilatation of stenosis – Stricture/obstruction of pancreatic duct extraction of stones from duct with/without lithotripsy Pancreatic stenting – disruption of duct

Advantage Pain due to increased duct pressure gets reduced Pseudocyst that communicating with duct may get drained It also allows us to do cholangiodram before and after the stent

or drain placement Closure rates as high as 82%.

Nasopancreatic Drainage It is another endoscopic method in which naso pancreatic

drain placed into pancreatic duct beyond the site of obstruction

NP drain Facilitate drainage of duct and fistula and thus help in closure of fistula

NP Drain should kept in situ for a week followed by endoprothesis

Advantage: Can do repeated pancreatogram to confirm the fistula closure without need for repeated ERCP

Disadvantage: patient discomfort due to nasal tube and the necessity for continued nursing care

Surgical management of PPF

Indication Failure of medical / Endoscopic Management Obstruction of pancreatic duct that cannot be managed

endoscopically  Symptomatic fit patient.

Aim of Surgery To decompress the obstructed duct with or without excision of

involved part of the obstructed pancrease Type of Surgery

Cystogastrostomy / Cystojejunostomy Mid / Distal pancreatomy with pancreatico - jejunotomy

Conclusion

PPF is difficult to diagnose and at times difficult to treat Recurrent pleural effusions with coexisting history of pancreatitis

or alcohol abuse one should suspect PPF Pulmonary symptoms are predominant Early pleural fluid amylase testing will avoid delayed diagnosis Initial line of treatment: drainage of the effusion+ the inhibition of

pancreatic secretions with octreotide and possibly ERCP plus stenting of the pancreatic duct.

Surgery of pancreas is generally considered to be appropriate when medical measures fail

Referances Norman Oneil Machado, “Pancreaticopleural Fistula:

Revisited,” Diagnostic and Therapeutic Endoscopy, vol. 2012, Article ID 815476, 5 pages, 2012. doi:10.1155/2012/815476

JOP. Journal of the Pancreas - http://www.serena.unina.it/index.php/jop - Vol. 16 No. 1 – Jan 2015. [ISSN 1590-8577]