Abstract Introduction Pancreaticopleural Fistula (PPF) is a rare complication of chronic pancreatitis which involves leakage of pancreatic fluid into the pleural space through a fistulous tract from compromise of the pancreatic duct or rupture of a pseudocyst. As a result, recurrent symptomatic pleural effusions can form. Treatment approach usually involves conservative management followed by endoscopic therapy and abdominal surgery for refractory cases. Chest thoracostomy can be performed for symptomatic relief, but pleural effusions often persist with drainage. Here we present a case of PPF managed with a novel approach of video-assisted thoracoscopic surgery (VATS) with decortication and pleurodesis resulting in resolution of symptoms. Case A 60-year-old male with alcohol use disorder and chronic pancreatitis was admitted to the hospital after an outpatient esophagogastroduodenoscopy with endoscopic ultrasound (EUS) showed peripancreatic and peri-gastric fluid collections communicating with the gastroesophageal junction, with extension into the pleural space causing a large left pleural effusion. During the hospitalization, a thoracentesis revealed an exudative effusion with elevated amylase level 3,429 units/L and lipase 7,600 units/L, confirming a PPF. The patient underwent cystogastrostomy creation with stent placement resulting in decreased pseudocyst size but persistent pleural effusion. Subsequently, thoracic surgery performed VATS exploration, which revealed serous fluid and fibrinous material on the left lower lung surface. He underwent fluid evacuation, decortication, washout, and chemical pleurodesis with hydrogen peroxide irrigation. Two coaxial French drains were left in place and removed a few days later. After the procedure, respiratory symptoms were resolved, and the pleural effusion did not recur. Discussion Here we demonstrate a rare case of PPF with pleural effusion successfully managed by pleurodesis, a treatment strategy not well documented for this indication. The consensus from case studies describes a stepwise treatment approach with conservative management, followed by endoscopic therapy, and if refractory, by surgical repair of the pancreas, pancreatic duct, or fistula. Cystogastrostomy can result in fistula closure, but in cases like this with refractory pleural effusion, options are limited. Chest thoracostomy has been suggested for symptomatic relief for recurrent pleural effusion, but no definitive thoracic intervention strategies, such as pleurodesis, have been described in available literature. This case suggests that direct pleural intervention with pleurodesis can provide a definitive management option for patients with symptoms refractory to conservative management. Further research is necessary to better define the utility of pleurodesis in PPF, but this case highlights a new potential management strategy in complex PPF cases. This abstract is funded by: None
Brotherton et al. (Fri,) studied this question.