urmjУральский медицинский журналUral Medical Journal2949-4389Ural State Medical University10.52420/2071-5943-2023-22-4-11-17urmj-1287Research ArticleОригинальные статьи | Original articlesOriginal articlesПринципы диагностики и выбор тактики лечения пациентов с панкреато-плевральными свищамиPrinciples of diagnosis and choice of treatment tactics for patients with pancreatic-pleural fistulashttps://orcid.org/0000-0001-9410-9493РемизовС. И.RemizovS. I.

Станислав Игоревич Ремизов, кандидат медицинских наук,

Краснодар

Stanislav I. Remizov, Ph.D. in medicine,

 

masterr58@myrambler.ruhttps://orcid.org/0000-0003-0945-9400АндреевА. В.AndreevA. V.

Андрей Викторович Андреев, доктор медицинских наук,

Краснодар

Andrey V. Andreev, Doctor of Science (Medicine),

 

avandreev2007@mail.ruhttps://orcid.org/0000-0002-7420-0553ДурлештерВ. М.DurleshterV. M.

Владимир Моисеевич Дурлештер, доктор медицинских наук,

Краснодар

Vladimir M. Durleshter, Doctor of Science (Medicine), 

 

durleshter59@mail.ruhttps://orcid.org/0000-0002-0755-903XГабриэльС. А.Gabriel’S. A.

Сергей Александрович Габриэль, доктор медицинских наук,

Краснодар

Sergey A. Gabriel’, Doctor of Science (Medicine),

 

gabriel-sa@rambler.ruhttps://orcid.org/0000-0003-0625-0791ЗасядькоО. В.ZasyadkoO. V.

Ольга Вячеславовна Засядько, клинический ординатор,

Краснодар

Olga V. Zasyadko, Clinical Resident, 

 

Zasyadkoolga@yandex.ruКраевая клиническая больница № 2; Кубанский государственный медицинский университетРоссияRegional Clinical Hospital № 2; Kuban State Medical UniversityRussian FederationКубанский государственный медицинский университетРоссияKuban State Medical UniversityRussian Federation2023090820232241117Copyright © Ремизов С.И., Андреев А.В., Дурлештер В.М., Габриэль С.А., Засядько О.В., 20232023Ремизов С.И., Андреев А.В., Дурлештер В.М., Габриэль С.А., Засядько О.В.Remizov S.I., Andreev A.V., Durleshter V.M., Gabriel’ S.A., Zasyadko O.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.umjusmu.ru/jour/article/view/1287Введение

Введение. Панкреато-плевральный свищ – редкое осложнение панкреатита, которое не имеет патогномоничных симптомов и единых подходов к выбору тактики лечения.

Цель исследования − сформулировать принципы диагностики и выбора тактики лечения у пациентов с панкреато-плевральными свищами.

Материалы и методы

Материалы и методы. С 2012 по 2022 гг. было пролечено пять человек с панкреато-плевральными свищами. Всем пациентам были выполнены стандартные клинико-лабораторные и инструментальные методы исследования.

Результаты

Результаты. Диагноз панкреато-плевральный свищ был поставлен на 18−65 сутки от начала заболевания на основании активности амилазы в плевральном выпоте от 29 462 до 51 328 Ед/л. Хирургическое лечение заключалось в дренировании плевральной полости и псевдокисты поджелудочной железы у двух пациентов, у одного произведено дренирование плевральной полости и стентирование Вирсунгова протока, одному больному выполнено стентирование панкреатического протока и повторные плевральные пункции, одному – папиллосфинктеротомия, видеоторакоскопия и дренирование плевральной полости. Обсуждение. Диагностика панкреато-плевральных свищей основана на совокупности критериев: приступы острого или обострение хроническиого панкреатита в анамнезе, наличие псевдокисты поджелудочной железы, рецидивирующий гидроторакс, бурый характер плеврального выпота, а также высокая амилазная активность в нем. Тактика хирургического лечения может иметь этапный характер и характеризоваться принципом «от простого к сложному».

Заключение

Заключение. Диагностический алгоритм панкреато-плевральных свищей основывается на данных о перенесенном остром панкреатите, возникновении рецидивирующего гидроторакса, геморрагическом характере выпота и высоком уровне амилазы в нем. Выбор тактики хирургического лечения предполагает сочетание дренирования плевральной полости со стентированием Вирсунгова протока, а также наружное дренирование псевдокисты поджелудочной железы (при ее наличии).

Introduction

Introduction. Pancreatic-pleural fistula is a rare complication of pancreatitis that has no pathognomonic symptoms and unified approaches to the choice of treatment tactics.

The aim of the study was to formulate the principles of diagnosis and choice of treatment tactics in patients with pancreatic-pleural fistulas.

Materials and methods

Materials and methods. Five patients with pancreatic-pleural fistulas were treated from 2012 to 2022. All patients underwent standard clinical-laboratory and instrumental methods of investigation.

Results

Results. The diagnosis of pancreatic-pleural fistula was made at 18−65th day from the disease on the basic of amylase activity in the pleural effusion from 29462 to 51328 U/L. Surgical treatment consisted of pleural cavity and pancreatic pseudocyst drainage in two patients, in one patient we performed pleural cavity drainage and Virsung’s duct stenting, one patient underwent pancreatic duct stenting and repeated pleural punctures, one patient had papillosphincterotomy, video-thoracoscopy and pleural cavity drainage. Discussion Diagnosis of pancreatic-pleural fistulas is based on a set of criteria: history of acute attacks or exacerbation of chronic pancreatitis, presence of pancreatic pseudocyst, recurrent hydrothorax, brown pleural effusion, and high amylase activity in it. Surgical treatment tactics can be staged and characterized by the principle “from simple to complex”.

Conclusion

Conclusion. The diagnostic algorithm of pancreatic-pleural fistulas is based on the data on acute pancreatitis, recurrent hydrothorax, hemorrhagic nature of the effusion and high level of amylase in it. The choice of surgical treatment tactics implies combination of pleural cavity drainage with Virsung’s duct stenting, as well as external drainage of pancreatic pseudocyst (if any).

поджелудочная железапанкреатитпанкреато-плевральный свищpancreaspancreatitispancreatic-pleural fistulaReferencesWronski M, Slodkowski M, Cebulski W et al. Optimizing management of pancreaticopleural fistulas. World J Gastroenterol. 2011;17(42):4696−4703. https://doi.org/10.3748/wjg.v17.i42.4696.Wronski M, Slodkowski M, Cebulski W et al. Optimizing management of pancreaticopleural fistulas. World J Gastroenterol. 2011;17(42):4696−4703. https://doi.org/10.3748/wjg.v17.i42.4696.Chmielecki J, Kościński T, Banasiewicz T. Pancreaticopleural fistula as a rare cause of both-sided pleural effusion. Case Rep Surg. 2021;2021):6615612. https://doi.org/10.1155/2021/6615612.Chmielecki J, Kościński T, Banasiewicz T. Pancreaticopleural fistula as a rare cause of both-sided pleural effusion. Case Rep Surg. 2021;2021):6615612. https://doi.org/10.1155/2021/6615612.Романов М.Д., Давыдкин В.И., Киреева Е.М., Пигачев А.В. Особенности диагностики и лечения панкреато-плеврального свища. Новости Хирургии. 2021; 29(1):121-127. https://doi.org/10.18484/2305-0047.2021.1.121.Romanov MD, Davydkin VI, Kireeva, EM, Pigachev, AV. Features of diagnosis and treatment of pancreaticopleural fistula Novosti Khirurgii. 2021;29(1):121−127. (In Russ.). https://doi.org/10.18484/2305-0047.2021.1.121.Koliakos N, Papakonstantinou D, Reppas L et al. Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy. Cureus. 2022;14(3):232−241. https://doi.org/10.7759/cureus.23241.Koliakos N, Papakonstantinou D, Reppas L et al. Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy. Cureus. 2022;14(3):232−241. https://doi.org/10.7759/cureus.23241.King JC, Reber HA, Shiraga S. Hines OJ. Pancreatic-pleural fistula is best managed by early operative intervention. Surgery. 2010;147(1):154−-159. https://doi.org/10.1016/j.surg.2009.03.024.King JC, Reber HA, Shiraga S. Hines OJ. Pancreatic-pleural fistula is best managed by early operative intervention. Surgery. 2010;147(1):154−-159. https://doi.org/10.1016/j.surg.2009.03.024.Subedi A, Manta D, Mandal A et al. Endoscopic management of pancreaticopleural fistula after recurrent acute pancreatitis. Proc (Bayl Univ Med Cent). 2021;34(6):687−688. https://doi.org/10.1080/08998280.2021.1946314.Subedi A, Manta D, Mandal A et al. Endoscopic management of pancreaticopleural fistula after recurrent acute pancreatitis. Proc (Bayl Univ Med Cent). 2021;34(6):687−688. https://doi.org/10.1080/08998280.2021.1946314.Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP. 2005;6(2):152−161.Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP. 2005;6(2):152−161.Vyas S, Gogoi D, Sinha SK et al. Pancreaticopleural fistula: an unusual complication of pancreatitis diagnosed with magnetic resonance cholangiopancreatography. JOP. 2009;10(6):671−673.Vyas S, Gogoi D, Sinha SK et al. Pancreaticopleural fistula: an unusual complication of pancreatitis diagnosed with magnetic resonance cholangiopancreatography. JOP. 2009;10(6):671−673.Sasturkar SV, Gupta S, Thapar S, Shasthry SM. Endoscopic management of pleural effusion caused by a pancreatic pleural fistula. J Postgrad Med. 2020;66(4):206−208. https://doi.org/10.4103/jpgm.JPGM_720_20.Sasturkar SV, Gupta S, Thapar S, Shasthry SM. Endoscopic management of pleural effusion caused by a pancreatic pleural fistula. J Postgrad Med. 2020;66(4):206−208. https://doi.org/10.4103/jpgm.JPGM_720_20.Ayoub M, Ochoa J, Cibich D, Gupta M. Pancreaticopleural fistula: a rare complication of alcoholic pancreatitis. Cureus. 2021;13(10):18729. https://doi.org/10.7759/cureus.18729.Ayoub M, Ochoa J, Cibich D, Gupta M. Pancreaticopleural fistula: a rare complication of alcoholic pancreatitis. Cureus. 2021;13(10):18729. https://doi.org/10.7759/cureus.18729.Silverman MB, Oliver JJ, Belcher CN et al. Pancreaticopleural fistula, a rare mediastinal emergency: A case report. Am J Emerg Med. 2020;S0735−6757(20)30928−1. https://doi.org/10.1016/j.ajem.2020.10.032.Silverman MB, Oliver JJ, Belcher CN et al. Pancreaticopleural fistula, a rare mediastinal emergency: A case report. Am J Emerg Med. 2020;S0735−6757(20)30928−1. https://doi.org/10.1016/j.ajem.2020.10.032.Vasilieva L, Adamidi S, Kittou N et al. Right-sided pancreaticopleural fistula. Ann Gastroenterol. 2014;27(4):436−437.Vasilieva L, Adamidi S, Kittou N et al. Right-sided pancreaticopleural fistula. Ann Gastroenterol. 2014;27(4):436−437.Schweigert M, Solymosi N, Dubecz A et al. Length of nonoperative treatment and risk of pleural empyema in the management of pancreatitis-induced pancreaticopleural fistula. Am Surg. 2013;79(6):614−619.Schweigert M, Solymosi N, Dubecz A et al. Length of nonoperative treatment and risk of pleural empyema in the management of pancreatitis-induced pancreaticopleural fistula. Am Surg. 2013;79(6):614−619.Ramahi A, Aburayyan KM, Said Ahmed TS et al. Pancreaticopleural Fistula: A Rare Presentation and a Rare Complication. Cureus. 2019;11(6):4984. https://doi.org/10.7759/cureus.4984.Ramahi A, Aburayyan KM, Said Ahmed TS et al. Pancreaticopleural Fistula: A Rare Presentation and a Rare Complication. Cureus. 2019;11(6):4984. https://doi.org/10.7759/cureus.4984.Sonoda S, Taniguchi M, Sato T et al. Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment. Intern Med. 2012;51(18):2655−2661. https://doi.org/10.2169/internalmedicine.51.7859Sonoda S, Taniguchi M, Sato T et al. Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment. Intern Med. 2012;51(18):2655−2661. https://doi.org/10.2169/internalmedicine.51.7859Aswani Y, Hira P. Pancreaticopleural fistula: a review. JOP. 2015;16(1):90−94. https://doi.org/10.6092/1590-8577/2915Aswani Y, Hira P. Pancreaticopleural fistula: a review. JOP. 2015;16(1):90−94. https://doi.org/10.6092/1590-8577/2915Chawla G, Niwas R, Chauhan NK et al. Pancreatic pleural effusion masquerading as right sided tubercular pleural effusion. Monaldi Arch Chest Dis. 2019;89(3). https://doi.org/10.4081/monaldi.2019.1125Chawla G, Niwas R, Chauhan NK et al. Pancreatic pleural effusion masquerading as right sided tubercular pleural effusion. Monaldi Arch Chest Dis. 2019;89(3). https://doi.org/10.4081/monaldi.2019.1125Ali T, Srinivasan N, Le V, Chimpiri AR, Tierney WM. Pancreaticopleural fistula. Pancreas. 2009;38(1):26−31.Ali T, Srinivasan N, Le V, Chimpiri AR, Tierney WM. Pancreaticopleural fistula. Pancreas. 2009;38(1):26−31.Wypych K, Serafin Z, Gałązka P et al. Pancreaticopleural fistulas of different origin: Report of two cases and a review of literature. Pol J Radiol. 2011;76(2):56−60.Wypych K, Serafin Z, Gałązka P et al. Pancreaticopleural fistulas of different origin: Report of two cases and a review of literature. Pol J Radiol. 2011;76(2):56−60.Singh S, Yakubov M, Arya M. The unusual case of dyspnea: a pancreaticopleural fistula. Clin Case Rep. 2018;6(6):1020−1022. https://doi.org/10.1002/ccr3.1434.Singh S, Yakubov M, Arya M. The unusual case of dyspnea: a pancreaticopleural fistula. Clin Case Rep. 2018;6(6):1020−1022. https://doi.org/10.1002/ccr3.1434.Valeshabad AK, Acostamadiedo J, Xiao L et al. Pancreaticopleural fistula: a review of imaging diagnosis and early endoscopic intervention. Case Rep Gastrointest Med. 2018;2018:7589451. https://doi.org/10.1155/2018/7589451.Valeshabad AK, Acostamadiedo J, Xiao L et al. Pancreaticopleural fistula: a review of imaging diagnosis and early endoscopic intervention. Case Rep Gastrointest Med. 2018;2018:7589451. https://doi.org/10.1155/2018/7589451.Chebli JM, Gaburri PD, de Souza AF et al. Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol. 2004;38(9):795−800. https://doi.org/10.1097/01.mcg.0000139051.74801.43.Chebli JM, Gaburri PD, de Souza AF et al. Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis. J Clin Gastroenterol. 2004;38(9):795−800. https://doi.org/10.1097/01.mcg.0000139051.74801.43.Chan EE, Shelat VG. Pancreaticopleural fistula causing massive right hydrothorax and respiratory failure. Case Rep Surg. 2016;2016:8294056. https://doi.org/10.1155/2016/8294056.Chan EE, Shelat VG. Pancreaticopleural fistula causing massive right hydrothorax and respiratory failure. Case Rep Surg. 2016;2016:8294056. https://doi.org/10.1155/2016/8294056.Tay CM, Chang SK. Diagnosis and management of pancreaticopleural fistula. Singapore Med J. 2013;54(4):190−194. https://doi.org/10.11622/smedj.2013071.Tay CM, Chang SK. Diagnosis and management of pancreaticopleural fistula. Singapore Med J. 2013;54(4):190−194. https://doi.org/10.11622/smedj.2013071.Cazzo E, Apodaca-Rueda M, Gestic MA et al. Management of pancreaticopleural fistulas secondary to chronic pancreatitis. Arq Bras Cir Dig. 2017;30(3):225−228. https://doi.org/10.1590/0102-6720201700030014.Cazzo E, Apodaca-Rueda M, Gestic MA et al. Management of pancreaticopleural fistulas secondary to chronic pancreatitis. Arq Bras Cir Dig. 2017;30(3):225−228. https://doi.org/10.1590/0102-6720201700030014.Altasan T, Aljehani Y, Almalki A et al. Pancreaticopleural fistula: an overlooked entity. Asian Cardiovasc Thorac Ann. 2014;22(1):98−101. https://doi.org/10.1177/0218492312474453.Altasan T, Aljehani Y, Almalki A et al. Pancreaticopleural fistula: an overlooked entity. Asian Cardiovasc Thorac Ann. 2014;22(1):98−101. https://doi.org/10.1177/0218492312474453.Mihai C, Floria M, Vulpoi R et al. Pancreatico-pleural fistula - from diagnosis to management. a case report. J Gastrointestin Liver Dis. 2018;27(4):465−469. https://doi.org/10.15403/jgld.2014.1121.274.ple.Mihai C, Floria M, Vulpoi R et al. Pancreatico-pleural fistula - from diagnosis to management. a case report. J Gastrointestin Liver Dis. 2018;27(4):465−469. https://doi.org/10.15403/jgld.2014.1121.274.ple.Болдин Б.В., Пономарь С.А., Ревякин В.И. Панкреатикоплевральный свищ — возможная причина острой дыхательной недостаточности. Хирургия. Журнал им. Н.И. Пирогова. 2018;(5):115−116. https://doi.org/10.17116/hirurgia20185115-116.Boldin BV, Ponomar’ SA, Reviakin VI. Pancreaticopleural fistula is a possible cause of acute respiratory failure. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2018;(5):115−116. (In Russ.). https://doi.org/10.17116/hirurgia20185115-116.Varadarajulu S, Noone TC, Tutuian R et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc. 2005;61(4):568−575. https://doi.org/10.1016/s0016-5107(04)02832-9.Varadarajulu S, Noone TC, Tutuian R et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc. 2005;61(4):568−575. https://doi.org/10.1016/s0016-5107(04)02832-9.O’Toole D, Vullierme MP, Ponsot P et al. Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging. Gastroenterol Clin Biol. 2007;31(8−9 Pt 1):686−893. https://doi.org/10.1016/s0399-8320(07)91918-1.O’Toole D, Vullierme MP, Ponsot P et al. Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging. Gastroenterol Clin Biol. 2007;31(8−9 Pt 1):686−893. https://doi.org/10.1016/s0399-8320(07)91918-1.

The authors declare that there are no conflicts of interest present.