Pancreatic-pleural fistula is best managed by early operative intervention

Pancreatic-pleural fistula is an uncommon complication of chronic pancreatitis occurring as a result of disruption of the main pancreatic duct and tracking of pancreatic fluid through the retroperitoneum into 1 or both thoracic cavities. The optimal treatment strategy for pancreatic-pleural fistula is unknown; it has traditionally been medical management followed by operative therapy for patients who fail to respond to conservative treatment. Our objective was to compile the case reports of pancreatic-pleural fistula in the literature in order to better define clinical management strategy.

The case management of pancreatic-pleural fistula was reviewed and a structured MEDLINE search for published studies was performed. Descriptive statistical analysis was performed on compiled data.

Review of the literature revealed 63 adult patients with pancreatic-pleural fistula published in English between 1970 and 2008. The majority of patients were male (71%) and there was a predominance of alcohol-associated chronic pancreatitis (51%). There were 10 complications (16%) and 2 deaths (3%) reported. Most patients were treated initially with medical therapy (87%). Medical therapy was deemed to have failed after an average period of 35+/-5 days. Total duration of therapy for patients in whom operative intervention was required after attempted medical management was 40+/-6 days, which was greater than the surgery alone cohort. In total, operative treatment was successful more often than medical therapy (94% vs 31%).

Analysis from this series indicates that a majority of patients recover from pancreatic-pleural fistula without sequelae (81%). Attempts at prolonged periods of medical therapy tend to delay the resolution of the fistula compared with patients who undergo definitive operative intervention early in the course of treatment.