Nonsurgical management of pancreaticopleural fistula.

CONTEXT Pancreaticopleural fistula is seen in acute and chronic pancreatitis or after traumatic or surgical disruption of the pancreatic duct. Surgery leads to healing in 80-90% of cases but carries a mortality of up to 10%. AIM Our aim was to assess the management of pancreaticopleural fistula on a specialist pancreatic Unit. METHODS Patients presenting with pancreaticopleural fistulae were identified from acute and chronic pancreatitis databases. Management and outcome were compared with previous studies identified in MEDLINE and EMBASE. RESULTS Four patients presented with dyspnoea from large unilateral pleural effusions. Three had a history of alcohol abuse and one of asymptomatic gallstones. All were treated with chest drainage, octreotide and endoscopic retrograde cholangiopancreatography plus/minus pancreatic stent. Two had a pancreatic stent in situ for 5 and 8.5 months respectively. In the third sphincterotomy was performed; in the fourth the pancreatic duct could not be cannulated. The fistula healed in all cases, with no recurrence after 12-30 months, and no deaths. There are 14 reports including 16 cases treated with endoscopic retrograde cholangiopancreatography plus/minus pancreatic stent in the literature, with no recurrence after follow up ranging 4-30 months and no deaths in these 16 cases. CONCLUSIONS A high index of suspicion is necessary to be aware of its presence. These data suggest that endoscopic management is preferable alternative to surgery for pancreaticopleural fistula.