Optimizing management of pancreaticopleural fistulas

Table 1 The details of conservative management of pancreaticopleural fistulas

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8
NPO1 (d)	19 (6)	0 (22)	7 (27)	0 (26)	6 (9)	0 (25)	8 (0)	14 (22)
TPN1 (d)	-	0 (17)	0 (27)	0 (25)	4 (7)	0 (26)	-	0 (16)
EN1 (d)	16 (6)	-	-	-	-	-	5 (17)	7 (12)
Somatostatin analog1 (d)	-	0 (11)	0 (25)	0 (43)	-	-	-	0 (11)
Pleural fluid management	TD-25 d	TD-4 d	T-twice, TD-11 d	T-1 time, TD-25 d	TD-3 d	T-4 times	TD-30 d	Diagnostic thoracentesis alone

¹Length of treatment after endoscopic retrograde cholangiopancreatography given in the parenthesis. NPO: Nothing per os; TPN: Total parenteral nutrition; EN: Enteral nutrition; T: Thoracenthesis; TD: Tube drainage.

Table 2 Demographic and clinical features of the patients with a pancreaticopleural fistula

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8
Age (yr)	41	63	42	34	50	46	59	52
Gender	M	F	M	M	M	M	M	M
Etiology	CP	CP	AP	CP	CP	CP	CP	CP
Alcohol abuse	+	-	+	+	+	+	+	+
Presentation	Dyspnea	Dyspnea, abdominal pain, chest pain	Dyspnea	Dyspnea, abdominal pain, chest pain	Dyspnea	Dyspnea, abdominal pain	Dyspnea	Dyspnea
Location of pleural effusion	Left	Left	Right	Left	Left	Left	Left	Left
Pleural amylase (IU/L)	6715	34 512	9716	13 000	2072	26 977	10 158	1830
Serum amylase (IU/L)	519	300	251	155	144	248	30	234
Duration of symptoms	4 wk	2 wk	2 wk	8 wk	1 wk	1 wk	6 d	4 d

M: Male; F: Female; CP: Chronic pancreatitis; AP: Acute pancreatitis.

Table 3 Imaging features of pancreaticopleural fistula

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8
Demonstration of fistulous tract	CT	ERCP, CT	CT	ERCP, CT	CT, MRCP	ERCP	ERCP, CT	ERCP, MRCP
Location of pleural effusion	Left	Left	Right	Left	Left	Left	Left	Left
CT	Enlarged pancreatic head, parenchymal calcifications, small peripancreatic fluid collections near the tail	Enlarged body and tail of the pancreas, peripancreatic fluid collections near the body and tail, dilated PD up to 6 mm	Pancreas not enlarged, PD dilated, small pseudocyst in the body	Pancreas not enlarged, small peripancreatic fluid collections near the tail, PD normal	Pancreas not enlarged, parenchymal calcifications, PD mildly dilated, small pseudocyst near the body and tail	Pancreas not enlarged, parenchymal calcifications in the head, PD dilated up to 3 mm, small pseudocyst near the tail	Pancreas not enlarged, PD normal, small pseudocyts near the pancreatic tail	Pancreas not enlarged, PD dilated up to 4 mm in the tail, pseudocyts near the pancreatic body and tail, ascites
MRCP	-	-	-	-	Pancreas not enlarged, PD dilated up to 3 mm in the body upstream to a stone, small pseudocysts near the tail	-	-	Pancreas not enlarged, PD normal, pseudocyts near the pancreatic body and tail, ascites, leak in the body

CT: Computed tomography; MRCP: Magnetic resonance cholangiopancreatography; ERCP: Endoscopic retrograde cholangiopancreatography; PD: Pancreatic duct.

Table 4 The results of primary endoscopic intervention in pancreaticopleural fistulas

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8
Location of fistula	Tail	Body	Body	Body/tail	Tail	Body/tail	Body	Body/tail
ERCP	Dilated proximal PD, blockage of PD in the head due to intraductal stones	Ductal stricture and leak in the body	Cannulation not possible	No ductal stricture, leak in the tail	Normal proximal PD, blockage of PD in the body	No ductal stricture, leak in the body/tail	Ductal stricture in the body, leak within the stenotic duct	No ductal stricture, two leaks in the body/tail
ERCP	Failure (ductal blockage)	Failure (ductal stricture could not be dilated, stent not reached the stenosis and leak)	Failure (ampulla cannulation not possible)	Failure (stent not reached the site of leak, early stent migration)	Failure (ductal blockage precluding stenting)	Successful (stent bridging the site of leak)	Failure (ductal stricture could not be dilated, stent inserted up to the stricture)	Failure (stent bridging the site of one leak, but could not reach the site of the second leak)
Post-ERCP complications	-	Pleural empyema, infected peripancreatic fluid collection	-	Pleural empyema, pancreatitis flare-up	-	-	Pleural empyema, pneumonia, pancreatico-bronchial fistula, infected peripancreatic fluid collection	-
Post-ERCP treatment	Surgery	Surgery	Surgery	Conservative	Conservative	Conservative	Surgery	Percutaneous drainage of peripancreatic fluid collection
Time to fistula closure (d)	30	25	28	11	24	17	26	34

PD: Pancreatic duct; ERCP: Endoscopic retrograde cholangiopancreatography.