Nasopancreatic drainage: a novel approach for treating internal pancreatic fistulas and pseudocysts.

Abstract

Internal pancreatic fistulas are rare but debilitating complications of chronic pancreatitis. Fistulous tracts from the pancreatic duct to the peritoneal or pleural cavities have been treated by medical therapy and surgical management, with success rates of 41% and 89%, respectively. Endoscopic stent placement for internal and external pancreatic fistulas has also been shown effective. We report on three patients with histories of chronic alcohol abuse and pancreatitis. Two patients presented with dyspnea and pleuritic chest pain. Imaging studies revealed pleural effusions, and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a patent fistulous tract from the pancreatic duct to the pleural cavity in each patient. Chemical analysis of the pleural fluid indicated pancreatic origin. The third patient, who had left-upper-quadrant abdominal pain and a small pleural effusion, had a large noncommunicating pseudocyst adjacent to the stomach. Nasopancreatic drains, along with chest tube drainage, were placed in the patients with pancreatic pleural fistulas. The patient with the pseudocyst received nasocystic drainage via the stomach. Drainage was measured until closure of the fistulas or cyst. Additionally, simply by injecting contrast medium, we were able to monitor the closure of fistulas without ERCP. The fistulas closed within 7 days, and the pseudocyst resolved within 14 days. Following discharge, all three patients were pain free, without evidence of recurrent fistulas or pseudocyst. In conclusion, the use of nasopancreatic/cyst drainage is an effective and convenient way to treat internal, communicating collections and pseudocysts of pancreatic origin. Furthermore, this method provides a simple means of assessing closure of fistulas and pseudocysts.