title: Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Klinikum Nürnberg Nord, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, Nürnberg, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Schweigert
authors.forename: Marcus
authors.initials: M
authors.lastname: Renz
authors.forename: Attila
authors.initials: A
authors.lastname: Dubecz
authors.forename: Norbert
authors.initials: N
authors.lastname: Solymosi
authors.forename: Dietmar
authors.initials: D
authors.lastname: Ofner
authors.forename: Hubert J
authors.initials: HJ
authors.lastname: Stein
mesh_terms: D000328:Adult; D000368:Aged; D003559:Cystostomy; D003646:Debridement; D016724:Empyema, Pleural / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy; D010185:Pancreatic Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D010195:Pancreatitis / Q000150:complications / Q000601:surgery; D010995:Pleural Diseases / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D016156:Respiratory Tract Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult