Initial Experience of Pancreatico-Pleural Fistula, A Rare Complication of Acute on Chronic Pancreatitis with Challenging Diagnosis and Successful Management

Pancreatitis is the most common morbidity in chronic alcoholic patients, with frequent abdominal and thoracic complications. Pleural effusion is a common complication of acute on chronic pancreatitis, but recurrent pleural effusion refractory to repeated thoracocentesis may raise suspicion of pancreatico-pleural fistula (PPF). For demonstration and treatment of such kind of fistula, radiological investigation and minimal invasive diagnostic and therapeutic treatment are needed. We presented three different cases of patients with PPF who came to the emergency department with difficult clinical presentation. Patients were primarily diagnosed with PPFs with pleural effusion. Patients were managed with intercostal drainage tube insertion and then underwent radiological investigation. After a thorough investigation, patients underwent minimally invasive procedures like Endoscopic Retrograde cholangiopancreatography (ERCP) with main pancreatic duct stenting for spontaneous closure of the fistula. All three patients required intercostal drainage tube insertion to drain effusion with intensive medical management. Patients were treated successfully with ERCP-guided main pancreatic duct stenting and managed conservatively for spontaneous closure of the fistula. In this case series, one patient had an unusual presentation and challenging diagnosis of acute pancreatitis with mediastinal pseudocyst extension with a bilateral PPF and severe mediastinitis. Another patient developed PPF after laparoscopic cysto-gastrostomy. The third patient developed PPF after the pancreatic pseudocyst ruptured into the left thoracic cavity, and was managed by ERCP-guided Main Pancreatic Duct (MPD) stenting for spontaneous closure of the internal fistula.