A 21 years old male patient presented with left sided massive pleural effusion which was aspirated 1 month ago. He had repeated abdominal pain diagnosed as chronic pancreatitis. Aspiration of a weired effusion10 cc which was analysed and it was exudative in nature with amylase more than 8000. CT chest and abdomen were performed for him which suggested chronic pancreatic calcification and? pancereaticopleural fistula with atrophied pancreas associated with dilated pancreatic duct with multiple stones. ERCP showed dilated pancreatic duct with multiple filling defects with failure to pass the guide wire in. What are the options of treatment we have?
This patient will be quite ill and emaciated from poor nutrition due to the chronic pancreatitis (CP) and the pancreato-pleural fistula. Therefore, management must be multi-pronged and multi-disciplinary approach. First, determine if any other associated CP-related complications such as exocrine and endocrine insufficiencies e.g. steatorrhea, diabetes mellitus. Second determine any other co-morbidity to be treated. Further exclude infection generally and in the pleural fluid. Admit patient and commence management:
Drain pleural effusion with an adequately place intercostal drain. Drain any associated intra-abdominal collections by interventional radiology
Correct nutritional deficiency with semi-elemental diet.
Treat any infection found as per your protocol
Commence therapy for any pancreatic enzyme insufficiency/deficiencies (PEI). Creon at 50,000U with main meals, 25000U with snacks will suffice as a start up if steatorrhea present. Faecal elastase or 24-Hour faecal fat estimation may help in determining early PEI. Get physician to treat diabetes mellitus as necessary if present.
Consider octreotide if pleural fluid/day is more than 300mls.
Consider pancreatic duct stenting to assist with therapy of effusion.
Once fully improved and fit, consider for chronic pancreatitis surgery or refer for such consideration: Options of surgery: Frey procedure or distal pancreatectomy.
Most such patients have small rents in pancreatic duct through which pancreatic juice leaks so the fistula does not heal even by giving IC drain. In such case it is best to do a pancreatic duct stenting after locating the site of rupture at ERCP. In the present case since there are lot of stones, one may do ESWL or other kinds of lithotripsy before removing the stones and putting the stent. Inj. octreotide will help in reducing the output of pancreatic juice and so the collection in pleura and help in healing the fistula. If however the patient is fit for surgery, it should be done for removal of the stones, closure of the fistula and Pancreaticojejunostomy at the same sitting as the patient is having recurrent pain abdomen.
If the effusion is massive. a chest tube. estimate chest fulid and serum amylase to confirm the pancreatic effusion( It should be more than 3X. Start Omeprazole 60 mg twice daily, It will dry uo in 2 weeks. Improve nutrition and control sugar if diabetic. Go in and do a pancreatico- jejunostomy to avoid recurrence.
Aswini Kumar Pujahari A Novel Method for Pain Relief in Chronic Pancreatitis: an Old Drug in a New Pack: a Controlled Study Indian J Surg 2016,DOI 10.1007/s12262-016-1526-6
He is only 21 years expect reasonably fit and not yet a diabetic with pancreatico pleural fistula.Drain the pleural effusion and chest physio and enteral nutrition if necessary, Proceed with Lap/open pancreatico -jejunostomy with ductal clearance in perticular stone in the uncinate process.Please take a pancreatic biopsy.Continue enteral feeds.The longer we wait these pts become sicker.
1.Pleural drainage.
2. Simultaneous or delayed pancreatic stenting.
3. If it is impossible or doesn't work, after improvement of nutritional status - pancreaticojejunostomy alone or combined with pancreatic head resection.
It works.
I have treated several patients with similar problems All of those patients were treated by a pancreatic drainage procedure >In patients with a dilated duct as in the prresent case I would performe a pancreato enterostomy or a Frey procedure
I.agree.with Prof. Marcel Machado. He teach me that. Frey/Partington to be more didatic.
Thanks a lot.
What will we do for the encysted Pleural effusion which is not drainable by chest tubes or pigtails and even by open drainage and Elosseur Flap?
In such case one has to resort to decortication. However since the primary pathology is in the pancreas which is best treated by PD stenting or pancreaticojejunostomy, one can attempt these first along with closure of the fistula during operation (and the pleural collection will reduce by itself) rather than injuring the lung. The encysted effusion if still persisting can be aspirated with needle.
The patient had distal pancreatectomy, lateral pancreatico-jejunostomy, jejuno-jejunostomy and splenectomy 3 weeks ago. Yesterday, we did left sided decortication of the pleura. It was extensively adherent, very thick. Lung fully axpanded. The patient is doing very well now. Thanks a lot for all.
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