INTRODUCTION: Broncho-cutaneous fistulas are a rare complication following lobectomy. Pancreatico-pleural fistulas are a more common occurrence and are a known cause of pancreatitis-related pleural effusions. We present the case of a man who developed a pancreatico-broncho-cutaneous fistula as a result of necrotizing pancreatitis.
CASE PRESENTATION: A 49 year old man developed necrotizing pancreatitis from pancreas divisum approximately three years prior to his current presentation. His course was complicated by severe sepsis requiring several operative debridements. He developed splenic vein thrombosis and subsequent left-sided portal hypertension. He also developed recurrent entero-cutaneous fistulas that were managed conservatively with parenteral nutrition and local wound care. Approximately six weeks before his current presentation he had massive hematemesis from perisplenic varices and was taken emergently to the operating room where he underwent open splenectomy. This was complicated by abscess formation requiring percutaneous drain placement and intravenous antibiotics. He was discharged with the drain in place to followup as an outpatient. He presented to our hospital for a second opinion regarding possible surgical management of his persistent fistulas. As part of his evaluation he underwent a sinogram of his four enterocutaneous fistula tracts. During injection of one of the fistula sites he developed a non-productive cough. Under fluoroscopy, contrast material was seen in the left lower lobe bronchus (see Figure 1). He denied any other recent cough, shortness of breath or chest discomfort. He did not smoke and denied any history of prior lung disease. His lung examination was unremarkable. Flexible bronchoscopy was performed with particular attention paid to the basilar segments of the left lower lobe. At the time of bronchoscopy a 10-French foley catheter was inserted under sterile conditions into the same left flank fistula that had resulted in his cough. Normal saline injected through the foley was visualized entering the lateral-basal segment of the left lower lobe (LB9) [see Figure 2 and Video].
DISCUSSIONS: Our patient had a pancreatico-broncho-cutaneous fistula. Broncho-cutaneous fistulas are a rare but recognized late complication of lobectomy and have been described post-operatively in patients with both tumor and invasive infections such as aspergillus.  Pancreatico-pleural fistulas are a more common occurrence and may be a complication of acute pancreatitis or chronic fibrocalcific pancreatitis.  To our knowledge this is the first case reported of a fistulous tract connecting the skin to the broncho-pleural space via the pancreatic bed. We propose that it may have formed in response to diaphragmatic inflammation caused by our patient's emergent splenectomy and subsequent abscess formation. This allowed an already existing pancreatico-cutaneous fistula to gain access to the pleural space and ultimately the left lower lobe bronchial system.
CONCLUSION: Given his lack of pulmonary symptoms the decision was made to conservatively follow the pancreatico-broncho-cutaneous fistula. Our patient subsequently underwent distal pancreatectomy and percutaneous closure of his enterocutaneous fistulas with split-thickness skin grafts. He is currently on parenteral nutrition with persistent drainage from two enterocutaneous fistulas. He has had no further pulmonary complaints since the initial fistula sinogram.
DISCLOSURE: Brian Garibaldi, No Financial Disclosure Information; No Product/Research Disclosure Information