PANCREATIC PLEURAL EFFUSION SUCCESSFULLY TREATED BY ENDOSCOPIC PANCREATIC DUCT DRAINAGE COMBINED WITH EXTRACORPOREAL SHOCK‐WAVE LITHOTRIPSY: REPORT OF A CASE

A 52-year-old man was admitted with complaints of dyspnea. Physical examination revealed that the breath sounds were reduced at the left lung. The results of the abdominal examination were normal. Chest radiography showed massive left-sided pleural effusion. His white blood cell count was 4600/mm3, serum amylase 666 IU/L, serum C-reactive protein (CRP) 3.7 mg/dL. Thoracentesis yielded bloody fluid with a protein level of 3.7 g/dL and amylase level of 6250 IU/L. Computed tomography showed dilatation of the pancreatic duct with calcifications of the pancreas, mediastinal pancreatic pseudocysts and bilateral pleural effusion. Magnetic resonance cholangiopancreatography demonstrated dilated pancreatic duct with pancreatic calculi and pancreaticopleural fistula. Initial endoscopic retrograde cholangiopancreatography showed obstructing pancreatic calculi of the main pancreatic duct at the head; however, insertion of a naso-pancreatic drain was unsuccessful. A naso-pancreatic drain could be placed beyond the site of obstruction following three extracorporeal shock-wave lithotripsy (ESWL) sessions. Pleural effusion was resolved and the chest tube was removed 5 days following placement of the drain. The naso-pancreatic drain was replaced with a pancreatic stent 20 days later. Endoscopic retrograde cholangiopancreatography after a total of nine ESWL sessions showed a significant reduction of pancreatic calculi at the head. The pancreatic stent was removed 70 days following stent placement and there has been no recurrence during a follow-up period of 2 years. We suggest that endoscopic treatment combined with ESWL is a first-line treatment for pancreatic pleural effusion resulting from obstructing pancreatic calculi, and operation should be reserved as a second-line treatment.