Composite mesh a novel innovative bridge approach for refractory pancreatic effusion- sequelae of porous diaphragm syndrome: Case series

Introduction and importance: Managing refractory pancreatic effusion due to porous diaphragm syndrome (PDS) is a challenge. Various surgical interventions such as repairing the defect, sealing with fibrin glue, performing parietal pleurectomy, and talc pleurodesis have been reported however, the use of composite mesh placement in treating PDS has not been described in the literature. Case presentation: All three male patients with a low body mass index were diagnosed with pancreatic disease as described in cases 1-3 and associated pancreatic effusion. These patients required medical treatment as an initial approach and surgical intervention in the form of decortication, sterilization of the thoracic cavity with 20 % betadine and normal saline in the ratio 1:4, followed by warm normal saline washes and composite mesh placement for PDS followed by endoscopic retrograde cholangiopancreatography (ERCP) as a pancreatic intervention after 3 weeks. Only one patient underwent sphincterotomy, while the other two patients had no abnormality on ERCP. Post-operative follow-ups at 3, 6, and 12 months were uneventful with no recurrence. Clinical discussion: The mechanism for pancreatic effusion is explained by pancreatic duct disruption followed by enzyme leak leading to pancreatic-pleural communication mediated by PDS. Various studies have described their role in treating PDS, even thoracoscopic pleurodesis requiring prolong chest tube and repeated talc slurry for better outcome. However, to address this, we performed the above procedure as a bridge approach followed by a pancreatic intervention. Conclusion: Thoracic intervention with composite mesh can serve as a bridge procedure before future pancreatic intervention or surgery.