A 63-year-old man presented with progressive dyspnea, cough and fever.
The patient had a history of smoking, alcoholism and chronic pancreatitis.
A simple chest X-ray in the emergency department revealed a massive left pleural effusion.
Percentesis was performed with the same culture negative, with exudate criteria with 60 % polymorphonuclear, highlighting 12,400 IU/L amylase in the pleural fluid.
A chest CT scan showed an infiltrate in LII and small changes in ground glass.
With suspicion of parapneumonic effusion, medical treatment was initiated.
However, pleural effusion was complicated by recurrent pleural effusion diagnostic and evacuating fluid. Negative cytology for malignant cells, negative culture and pleural biopsy showed no evidence of tumor. High pancreatic amylase was reported in patients with pleural effusion x 56 cm.
Medical treatment was initiated with absolute diet, total parenteral nutrition, chest tube drainage and octeotride at a dose of 100 μg every 8 hours subcutaneous, doubling the dose at high output.
ERCP was performed in an attempt to place a stent in the main pancreatic duct, which was not technically possible because the source of the fistula was found in a pancreatic pseudocyst located in the tail of the pancreas.
Despite the initial medical treatment, the patient did not improve, so he was finally operated two months after the treatment started, showing an orifice in the 2 cm diaphragm that communicated the pseudocystic fistula with the pleural cavity.
Distal pancreatectomy was performed, not being able to respect the spleen due to the great inflammation present, as well as closure of the diaphoric orifice of left pleural drainage, with distal derivation of Wirsung termino-lateral calculi in Y.
The patient recovered satisfactorily, and pleural drainage was removed on the third day without recurrence of the effusion and discharged on the sixth postoperative day.
The patient remains asymptomatic two years after surgery.
