Pancreaticopleural Fistula Successfully Treated by Thoracoscopic Drainage and Endoscopic Pancreatic Stenting: Report of a Case

以胸腔鏡引流術和內視鏡胰管支架成功治療胰臟肋膜瘻管：一病例報告

王嘉齊(Chia-Chi Wang) ； 林佳賢(Chia-Hsien Lin) ； 陳志和(Chi-Her Chen) ； 王秀伯(Hsiu-Po Wang) ； 林肇堂(Jaw-Town Lin)

《臺灣消化醫學雜誌》 23卷2期 (2006/06) Pp. 144-150

https://doi.org/10.6557/GJT.200606_23(2).0005

摘要

胰臟肋膜瘻管是慢性胰臟炎罕見的併發症之一，過去治療上分為保守治療和手術治療，最近有文獻報告以內視鏡胰管支架成功治療胰臟肋膜瘻管的病例。本病例是一31歲男性病患，有酗酒的病史，因慢性胰臟炎急性發作而多次入院，此次，是因為最近一星期右側胸痛和進行性的呼吸困難至本院就診，胸部X光顯示右側大量胸水，胸水檢驗澱粉酶高達24800U/L，逆行性胰管攝影證實胰臟肋膜瘻管合併近端胰管狹窄，同時置放了7公分的胰臟支架(Geenen pancreatic stent GPSO-5-7，Wilson-Cook Medical Inc)，此支架只撐開狹窄但沒有跨過瘻管的開口，不幸的，三天後出現發燒和膿胸，胸水陸續培養出alfa-streptococcus、Escherichia coli、Klebsiella pneumoniae和Pseudomonus aeruginosa，可能的原因是顯影劑注射或＋二指腸液經支架、瘻管引起的上行性感染，此病例以抗生素、胸腔鏡引流術和以內視鏡置放另一支較長且跨過瘻管開口的支架(Geenen pancreatic stent GPSO-7-10，Wilson-Cook Medical Inc)，成功的治療肋膜積膿和胰臟肋膜瘻管。胰臟肋膜瘻管併發肋膜積膿是一罕見的病症，雖然內視鏡胰管支架是治療胰臟肋膜瘻管的方法之一，恰當的支架選擇是成功治療的要件之一。

關鍵字

肋膜積膿 ； 胰臟肋膜瘻管 ； 內視鏡胰管支架置入

並列摘要

Pancreaticopleural fistula is a rare complication of chronic pancreatitis. In the past, it was treated by either conservative treatment or surgical intervention. Few cases have been treated with endoscopic stenting successfully in the literature. We report a case of 31 year-old man who suffered from right chest pain and progressive dyspnea for 1 week. He was an alcoholic and has been admitted due to chronic pancreatitis with acute exacerbation several times. The chest X-ray showed right massive pleural effusion. The amylase level of pleural fluid was very high (24800U/L). Endoscopic retrograde pancreatography revealed a pancreaticopleural fistula, a small pseudocyst and stricture of main pancreatic duct in the head of pancreas. A pancreatic stent bridging the stricture, not the orifice of the fistula was inserted at the same time. Unfortunately, fever and pleural empyema occurred 3 days after the procedure. The culture of pleural effusion yielded alfa-streptococcus initially, Escherichia coli, Klebsiella pneumoniae and Pseudomonus aeruginosa later. The possible reasons may be ascending infection related to contrast media injection or the reflux of duodenal juice through the pancreatic stent and the fistula. It was later successfully treated by antibiotics, thoracoscopic decortication and drainage, and another longer pancreatic stent bridging the orifice of a fistula. Although endoscopic pancreatic stenting is an alternative treatment for pancreaticopleural fistula, an appropriate stent is one of the important factors to success.

並列關鍵字

pleural empyema ； pancreaticopleural fistula ； endoscopic pancreatic stenting