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Thorac Cardiovasc Surg 2013; 61(07): 619-625
DOI: 10.1055/s-0033-1334996
Original Thoracic
Georg Thieme Verlag KG Stuttgart · New York

Pancreaticopleural Fistula-Induced Empyema Thoracis: Principles and Results of Surgical Management[*]

Michael Schweigert
1   Klinikum Nürnberg Nord, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, Nürnberg, Germany
,
Marcus Renz
1   Klinikum Nürnberg Nord, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, Nürnberg, Germany
,
Attila Dubecz
1   Klinikum Nürnberg Nord, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, Nürnberg, Germany
,
Norbert Solymosi
2   Faculty of Veterinary Science, Szent Istvan University, Budapest, Hungary
,
Dietmar Ofner
3   Paracelsus Medizinische Privatuniversität, Universitätsklinik für Chirurgie, Salzburg, Austria
,
Hubert J. Stein
1   Klinikum Nürnberg Nord, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, Nürnberg, Germany
› Author Affiliations
Further Information

Publication History

08 September 2012

02 January 2013

Publication Date:
08 March 2013 (online)

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Abstract

Objective Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Fistulization occurs either through the esophageal hiatus or straight through the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed diagnosis is frequent. Initial conservative treatment fails in a significant number of cases. Ascending infection via the fistulous tract results in empyema and life-threatening sepsis.

Methods All patients who underwent surgery for pancreaticopleural fistula-induced empyema thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective case study.

Results Altogether six patients with pancreaticopleural fistula and associated pleural empyema were identified. All patients suffered from pancreatitis and received initial medical and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection led to left-sided pleural empyema in four and bilateral empyema in two cases. The contagious spread took place through the fistulous tract connecting the pancreatic duct with the pleural cavity. The patients were referred for surgery with considerable delay and already advanced pleural empyema. Minimally invasive thoracic surgery with pleural debridement was performed in all cases. Furthermore, left pancreatic resection was mandatory in five cases and cystostomy in one case. All patients recovered well and upon follow-up there were no further complications.

Conclusion Surgical management combining minimally invasive thoracic surgery and removal of the fistulous tract is highly effective. If initial medical treatment fails, surgery should be considered early to prevent severe sepsis. Further improvement seems achievable by reducing the time between fruitless conservative efforts and surgical intervention.

Keywords

pancreaticopleural fistula - pancreatitis - pleural empyema - sepsis

* Presented at the Canadian Surgery Forum 2012, Calgary, Alberta, Canada, September 13–16, 2012.


 

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