SESSION TITLE: Surgery Case Report Posters II
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: Pancreaticopleural fistulae (PPF) are rare communications between the pancreatic duct and the pleural cavity. More commonly the sequelae of alcoholism, PPF occasional results from peripancreatic surgery.
CASE PRESENTATION: A 26-year-old man had elevated liver enzymes, thrombocytosis, and leukocytosis during postoperative follow-up after splenectomy with en bloc diaphragm resection for idiopathic thrombocytosis purpura (ITP). Abdominal CT scan revealed moderate left pleural effusion and segmental portal vein thrombosis. After initiation of intravenous (IV) heparin and left thoracentesis (800 mL), repeat chest imaging studies revealed larger left pleural effusion, right lower lobe pulmonary emboli, and diaphragmatic defect adjacent to intrabdominal fluid around the pancreatic tail. Percutaneous left pleural catheter drainage revealed elevated intrapleural amylase and lipase levels, confirming pancreaticopleural fistula. Intravenous antibiotics and subcutaneous octreotide (100 mcg TID) were initiated. With the patient in lateral decubitus, robotic-assisted video-thoracoscopic surgery was performed via 3 port incisions, including a 4-cm camera port incision, which doubled as an assistant’s access port, along the 6th intercostal space at the anterior axillary line and instrument ports along the 3rd intercostal space at the anterior axillary line and along the 9th intercostal space at the posterior axillary line. The diaphragmatic defect edges were freed from intraperitoneal adhesions and closed primarily with absorbable barbed suture, then oversewn with non-absorbable suture, then imbricated with another absorbable barbed suture. Doxycycline pleurodesis was performed. The patient was reinitiated on IV heparin 4 hours postoperatively. Pleural fluid analysis on postoperative day (POD)#1 revealed low chest tube outputs and normal amylase levels. He underwent ERCP, sphincterotomy, and pancreatic duct stent placement on POD#4 and required left thoracoscopic evacuation of hemothorax and repeat doxycycline pleurodesis on POD#5, with all chest tubes removed by POD#9. The patient was discharged home on POD#13, tolerating regular diet. Outpatient follow-up at 1 week and at 15 months revealed no recurrent pleural effusion or peripancreatic fluid.
DISCUSSION: Multi-modality approach is often required to successfully manage pancreaticopleural fistulae.
CONCLUSIONS: We report the first successful robotic-assisted video-thoracoscopic closure of pancreaticopleural fistula.
Reference #1: None.
DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Christian Sobky, Anna Cheng, Christy Chai, Ian Smithson, Lori Brown, Carla Moodie, Joseph Garrett, Colin Parsons, Pamela Hodul, Mokenge Malafa
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