Pancreatic-pleural fistula from tail pseudocyst in a patient with pancreatic head cancer: a case report

A 76-year-old man was diagnosed with resectable pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head. Concurrently, the patient had an approximately 2-cm cystic mass originating from the pancreatic tail. After preoperative chemotherapy for the resectable PDAC, the patient is presented with dyspnea and lower left thoracic pain. Chest X-ray revealed massive left pleural effusion, and laboratory analysis of the pleural fluid showed a very high amylase level. Computed tomography confirmed a fistula directly connecting the pancreatic tail pseudocyst to the left diaphragm. These findings suggested pancreatic-pleural fistula (PPF) from the pancreatic tail to the left pleura. Medical treatments of thoracic drainage, endoscopic pancreatic ductal drainage, and antibiotics were unsuccessful; therefore, a distal pancreatectomy, fistula closure, and thoracoscopic pleural decortication were performed before the pancreaticoduodenectomy for the PDAC. After surgery, the pleural effusion resolved and the symptoms were improved immediately. PPF is an uncommon complication in which pancreatic enzymes drain directly into the pleural cavity. Herein, we present a rare case of PPF after preoperative chemotherapy for PDAC with a review of the literature.