Thoracoscopic resection of thoracic esophageal duplication cyst containing ectopic pancreatic tissue in adult

Retroperitoneal Foregut Duplication Cyst Containing Gastric, Respiratory, and Pancreatic Tissue Misinterpreted as an Adrenal Mass on Imaging: A Case Report and Review of the Literature

Foregut duplication cyst is most commonly seen in the posterior mediastinum without communication with adjacent organs or presence of other malformations and typically shows ectopic gastric or respiratory epithelium. The finding of ectopic pancreatic tissue is extremely rare. A 15-year-old female patient presented with elevated blood pressure, intermittent right flank pain for 18 months. An abdominal MRI revealed a 4 cm right cystic retroperitoneal mass, initially thought to arise from the right adrenal gland. Intraoperatively, the mass was centered in the retroperitoneum between the right adrenal gland and kidney, without attachments to these organs and no communication with other structures, and it was completely excised. Gross examination revealed a 3.5 cm well-circumscribed solid and cystic mass with orange-white cut surface and cloudy fluid surrounded by variable amounts of adipose tissue. On microscopic examination, the cysts were lined by respiratory and gastric antral/oxyntic-type mucosa, surrounded by muscularis mucosae, submucosal tissue, muscularis propria, and perienteric tissue. Within the muscular propria, exocrine pancreatic tissue was also noted. The patient is well with 7-months of follow up. This case is the first one reporting gastric, respiratory, and pancreatic epithelia.

Ectopic pancreas tissue in the posterior mediastinum

The occurrence of ectopic pancreas in the mediastinum is rare. Herein, we report a 22-year-old female who presented with right shoulder pain, dysphagia, fever and headaches. Chest computer tomography revealed a mass in the posterior mediastinum with accompanying signs of acute mediastinitis. Needle biopsy and fine-needle aspiration revealed ectopic gastral tissue and ectopic pancreas tissue, respectively. Surgical resection was attempted due to recurring acute pancreatitis episodes. However, due to chronic-inflammatory adhesions of the mass to the tracheal wall, en-bloc resection was not possible without major tracheal resection. Since then, recurring pancreatitis episodes have been treated conservatively with antibiotics. We report this case due to its differing clinical and radiological findings in comparison to previous case reports, none of which pertained a case of ectopic pancreas tissue in the posterior mediastinum with recurring acute pancreatitis and mediastinitis.

Severe dysphagia due to an esophageal duplication cyst in sixth decade, unusual presentation of a rare pathology

BACKGROUND

Esophageal duplication cysts are rare congenital tumors usually diagnosed and treated during childhood. Most of them are located in the mediastinum and appear as a mass besides the esophagus. Unfortunately, symptoms are non-specific and depend on the size and location of the mass; therefore, they can easily be missed. If symptoms appear, surgical resection is necessary to prevent troublesome complications.

CASE PRESENTATION

We present the case of a 60-year-old woman who presented with severe progressive dysphagia and epigastric pain. After further evaluation, a paraesophageal cystic mass was found, and surgery was required. Non-communicating esophageal duplication cyst was the final diagnosis.

CONCLUSION

Esophageal duplication cysts are a rare pathology in adults; their symptoms will vary depending on their size and location. Preoperative diagnosis is difficult as symptoms are non-specific and can be missed. If severe dysphagia, pain, or any other complication appears, surgery should not be delayed.

Surgical indications for mediastinal cysts-a narrative review

Background and Objective

Whether and when surgical intervention is indicated for mediastinal cysts is a matter of some debate. While most mediastinal cysts are found incidentally, the anatomic location, clinical presentation, and symptoms, as well as the potential for malignancy, are important considerations that inform decisions related to whether to intervene surgically. The objective of this review is to summarize the current literature regarding the criteria for surgical excision of mediastinal cysts and provide a framework for the clinician and surgeon to arrive at a decision regarding the appropriateness of surgical intervention of mediastinal cysts.

Methods

A review of the published literature in the last 45 years (1977-2022) was conducted through PubMed, MeSh and Google Scholar. We included retrospective reviews, meta-analyses, and case studies published in the English language. A single author identified eligible studies, and those identified were reviewed by the team until consensus was met. Pediatric literature was excluded from this review.

Key Content and Findings

The current literature predominantly contains case studies, small retrospective studies, and meta-analyses describing mediastinal cysts. In the anterior mediastinum, multiloculated thymic cysts should be resected to rule out thymic malignancy. Intralesional fat, smooth borders, and a more midline location are features suggestive of a benign process, while asymmetric cystic wall thickening has been associated with malignancy. Both esophageal and bronchogenic cysts should be excised, taking into account the risk of complications (up to a 45% risk) of infection, rupture, or compression, as well as the rare risk of associated malignancy. Simple thymic and small pericardial cysts can be observed and followed with serial radiographic tools and should be resected if they increase in size, compress surrounding structures, or lead the patient to develop symptoms.

Conclusions

Since mediastinal cysts are rare and often asymptomatic, there are no formal guidelines outlining when surgical intervention should be undertaken. Based on our review of the literature, surgical intervention should be pursued if the patient's symptoms correlate with radiographic findings of a mediastinal cyst, there is compression of the surrounding structures, and concern of malignancy is present.

Esophageal Duplication Cysts in 97 Adult Patients: A Systematic Review

BACKGROUND

Esophageal duplication cysts are a rare congenital cystic malformation from faulty intrauterine recanalization of the esophagus during the 4-8^th weeks of development. They account for 20% of all gastrointestinal duplication cysts and commonly involve the distal esophagus. Presenting symptoms may be related to size and location.

MATERIALS AND METHODS

Following the PRISMA guidelines, a systematic review was performed by searching published literature in various databases. Data from 97 reported case reports were pooled to present a descriptive and statistical analysis.

RESULTS

Patient population was composed of 51(52.5%) males and 46 (47.5%) females, and mean ages was 42.3 years (18-77). Distal cysts were the most prevalent. Seventy-nine (81.4%) patients were symptomatic; common symptoms included dysphagia, chest pain, cough and weight loss. Fifteen (15.5%) patients were treated conservatively and 75 (84.5%) by surgical treatment, among them thoracotomy in 30 (30.9%) patients and VATS in 17 (17.5%) patients. Mean length of hospital stay was 8.6 days (range: 1-26 days). One fatality was registered. Location, unlike size, was not found to influence presenting symptoms or treatment employed. Frequency of conservative treatment was not significantly different between symptomatic and asymptomatic patients. Open approaches were associated with longer stays than their minimally invasive counterparts.

CONCLUSION

Esophageal duplication cysts remain rare in adults and are frequently located in the distal esophagus. Larger cysts are more likely to cause symptoms. Various surgical techniques may successfully be employed in the treatment of this pathology. Minimally invasive procedures have a shorter hospital stay.

Minimally invasive surgery for adult oesophageal duplication cysts: Clinical profile and outcomes of treatment from a tertiary care centre and a review of literature

BACKGROUND

Oesophageal duplication cysts (ODC) are rare in adults. Complete surgical excision is the ideal treatment. Conventionally, it is performed through a thoracotomy. We aimed to study the feasibility and safety of minimally invasive surgery (MIS) in the management of ODC and briefly reviewed the available literature.

MATERIALS AND METHODS

A retrospective study of all adult patients with ODC diagnosed and treated at our tertiary care centre, from 2015 to 2019, was done. All patients were operated on by MIS. Their demographic, clinicopathological, radiological and surgical details and outcomes were analysed.

RESULTS

A total of six patients (four females and two males) were diagnosed to have ODC by contrast-enhanced computed tomography. The mean age was 38 ± 4.4 years. The most common presenting complaint was chest pain (50%). Upper gastrointestinal endoscopy was normal in four patients. Endoscopic ultrasound was performed in five patients. In four patients, the cyst was located in the distal third of the oesophagus. The mean size of the cysts was 5.7 ± 2.02 cm. All the patients were operated upon by video-assisted thoracoscopic surgery (VATS). There was no conversion to open surgery. The resection was complete in all but one patient. The mean duration of surgery was 143.3 ± 35 min, and the average blood loss was 58.33 ± 20.4 mL. One patient had an oesophageal staple line leak on the 9th post-operative day. There was no mortality. The median duration of hospital stay was 7.5 days (range: 3-25 days).

CONCLUSION

MIS is feasible and safe in the management of adult ODC.

Ectopic Anterior Mediastinal Pancreas: An Unusual Case of New Onset Hemoptysis

Ectopic pancreas within the anterior mediastinum is a rare congenital anomaly. We present a case of a solid anterior mediastinal mass that presented with hemoptysis and ground glass parenchymal changes in the right upper lobe. Robotic surgical resection was completed, and final pathology was consistent with benign pancreatic tissue. The patient fully recovered with no recurrence of hemoptysis. Ectopic pancreas, although uncommon, should be included in the differential for solid and cystic anterior mediastinal masses, and surgical resection is often curative and effectively manages symptoms.

A case report of esophageal heterotopic pancreas presenting as recurrent mediastinal abscess, treated by minimally invasive esophagectomy

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Heterotopic pancreas is a rare congenital anomaly.

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Patients may present with complications such as inflammation and abscess.

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The management depends on size, ability to exclude other etiologies and symptoms.

Introduction

Heterotopic pancreas is a rare congenital anomaly. We report a case of esophageal heterotopic pancreas complicated by recurrent mediastinal abscess and treated by minimally invasive resection.

Presentation of case

A 31-year-old woman was admitted with a history of recurrent chest pain, dysphagia, and heartburn. CT scan revealed focal confined collection in the lower mediastinum surrounding esophagus. Endoscopic ultrasound revealed a subepithelial lesion. The patient was treated by minimally invasive esophagectomy and made an uneventful postoperative recovery.

Discussion

The management of subepithelial lesions would depend on their size, ability to exclude other etiologies and their associated symptoms. The patient, in this case, was obviously symptomatic and accurate differentiation from malignant etiologies could not be accurately made.

Conclusion

Although pancreatic heterotopia is rare, it should be remembered in the differential diagnosis of various gastrointestinal lesions.

Mediastinal Ectopic Pancreas with Abundant Endocrine Cells Coexisting with Mediastinal Cyst and Thymic Hyperplasia

Mediastinal ectopic pancreas is a rare condition with only 28 cases reported in the literature. Here we report a 21-year-old female patient who presented with dyspnea and intermittent severe chest pain of 7 years' duration. Computerized tomography scan (CT-scan) of the chest revealed a mediastinal cyst. The cyst was resected and it demonstrated on histopathological examination the presence of pancreatic tissue with increased number of islets of Langerhans, coexistent with mediastinal cyst and thymic hyperplasia. We made a review of all previously reported cases of this entity.

Giant retrocardiac foregut duplication cyst presenting with left atrial compression and palpitations

A 35-year-old man presented with a 3-month history of palpitations and shortness of breath. An ECG showed premature atrial contractions and episodes of supraventricular tachycardia. A subsequent echocardiogram showed a retrocardiac cystic mass that was compressing the left atrium. A CT scan confirmed these findings by showing a large left-sided posterior mediastinal cyst compressing the left atrium and pulmonary veins. The cyst was successfully excised from the retrocardiac position via left thoracotomy after which there was complete resolution of the palpitations. Histopathology showed it to be a mediastinal cyst, most likely a foregut duplication of the enterogenic variant. This is an extremely unusual case of foregut duplication cyst presenting with compression of the left atrium and pulmonary veins leading to atrial arrhythmias.

Esophageal duplication cyst with hemivertebrae: A case report and literature review

BACKGROUND

Esophageal duplication cysts (EDCs) are rare congenital anomalies that can be associated with symptomatic spinal abnormalities, but presentations due to EDC symptoms are rarely found in the presence of spinal abnormalities.

CASE SUMMARY

A 6-month-old infant weighing approximately 5.0 kg presented with a 2-month pulmonary infection and more recent difficulty swallowing and nutritional intolerance that did not improve with medical treatment. Contrast-enhanced chest computed tomography showed a well-defined, mediastinal, homogeneous, low-density cystic mass of 11.9 × 5.5 × 5.1 cm, compressing the liver and bending the trachea forward. Hemivertebrae were present (T4 and T3). Diagnostic laparoscopy was performed, but was converted to open surgery. After ensuring that the cyst was not within the abdominal cavity, thoracotomy was performed, and the cyst was completely resected. Pathophysiological examination revealed an EDC. The patient recovered well, without symptoms 6 months later.

CONCLUSIONS

Overall, noninvasive imaging and diagnostic procedures may not be sufficient to define the exact location of an EDC. Although hemivertebrae were present, they were asymptomatic and did not require treatment; only the EDC induced nonspecific symptoms that disappeared after surgery.

True Intramural Esophageal Duplication Cyst

Esophageal duplication is the second most common site of gastrointestinal duplication and most cases present with complications. These complications include bleeding, infection, dysphagia, and dyspnea. We report an incidental case of a true intramural esophageal duplication cyst in a new military recruit. The patient was diagnosed in Armed Forces Hospital, Oman. The patient came for a pre-recruitment routine check-up, he was found to have a suspicious soft tissue lesion on chest X-ray. He was referred to the thoracic surgeon for further investigations. The investigations included computed tomography and magnetic resonance imaging chest scans, barium swallow, endoscopy and, finally, an endoscopic ultrasound. All workup pointed to a diagnosis of esophageal duplication cyst; therefore, the decision was made to excise the lesion after discussion with the patient about the possible diagnosis and nature of the treatment. The cyst was completely excised thoracoscopically with uneventful recovery. The patient was discharged a few days later and was doing well in subsequent visits to the outpatient department. The histopathological exam confirmed the diagnosis of a true congenital duplication cyst, which was lined by pseudostratified ciliated columnar epithelium overlying double layers of thick bundles of smooth muscle fibers.

Ectopic Pancreas Presenting as a Solid Mediastinal Mass

Ectopic pancreas is a well-known developmental anomaly found in approximately 2% of all autopsies, frequently in the gastrointestinal tract. Mediastinal pancreatic ectopia is very rare; only a few cases have been described in the English-language literature. According to previous reports, the pancreatic tissue is detected in the cyst wall or appears as small solid components of cystic masses within the anterior mediastinum. In this report, we present a case of ectopic pancreas appearing as a large solid mass in the anterior mediastinum of a 17-year-old male patient.

Laparoscopic resection of intra-abdominal esophageal duplication cyst near spleen: a case report

Esophageal duplication cysts (EDCs) are congenital malformations of the posterior primitive foregut and often within the thoracic esophagus. Here we describe a rare case of intra-abdominal EDC near spleen in a 20-year-old female patient with a complaint of an asymptomatic abdominal mass for 5 years. The diagnosis of intra-abdominal EDC was confirmed by the Ultrasonography (US) and Magnetic resonance imaging (MRI) as well as Histological examination. Then the patient was received the laparoscopic resection and recovered well after the operation. We conclude that the laparoscopic resection is considered to be feasible and a reasonable treatment for intra-abdominal esophageal duplication cyst.

Esophageal duplication cyst

Esophageal duplication cyst is a rare congenital mediastinal cyst. Most of these cysts become symptomatic in childhood and only rare cases remain asymptomatic until adolescence. They may produce symptoms due to esophageal and respiratory system compression, rupture, and infection. A 25-year-old man presented with pulmonary infection and bronchiectasis that did not improve with medical treatment. A diagnosis of esophageal duplication cyst was made intraoperatively.

Ectopic pancreas in the anterior mediastinum: A report of two cases and review of the literature

Ectopia of the pancreatic tissue is a developmental anomaly found in ~2% of all autopsies, and 70~90% of these anomalies are located in the gastrointestinal tract. Mediastinal localization of an ectopic pancreas is extremely rare. Herein, we report two cases with mediastinal ectopic pancreas clarified by pathology and shown by thoracic contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). In addition, a brief review of the relevant literatures is presented. Although CT and MRI manifestations of this lesion are nonspecific, certain notable findings need to be focused on. When there is a mass in the anterior mediastinum with marked and heterogeneous enhancement, along with necrotic and liquefied non-enhanced areas in the center, ectopic pancreas should be considered and differentiated from other neoplasms in this region.

Double esophageal duplication cysts, with ectopic gastric mucosa: a case report

Esophageal duplication cyst (EDC) is a congenital malformation of the posterior primitive foregut, which mainly occurs in the thoracic esophagus. Here, we describe a 3-year-old Han Chinese boy afflicted with intermittent fever of acute onset and dry cough. Thoracic computed tomography revealed an 10 cm × 5.4 cm × 5.8 cm oval-shaped, cyst-like tumor located in the extrapleural space, extending along the right paravertebral gutter and compressing the trachea forward. An additional small-sized, oval-shaped cyst was identified in the posterior mediastinum, between the esophagus and the spinal column, at the T1 level. During open thoracotomy, under general anesthesia, an opaque, thick-walled, esophageal cyst was revealed not to be in communication with the esophageal lumen or the trachea. This cyst was subsequently resected in an en bloc manner. The small (1-cm) esophageal cyst was left untreated based on a “wait-and-see” policy. Histological analysis showed that the resected cyst was walled by hyperplastic, fibrous tissues and locally lined with gastric mucosa inherent glands. This finding was consistent with a diagnosis of EDC, with ectopic gastric mucosa. The respiratory tract symptoms resolved immediately after the operation. Computed tomography obtained at the 6-month follow-up showed that no disease, residual or recurrence, was present after the resection of the large-sized cyst, and the small-sized cyst remained unchanged in size.

Ectopic pancreatic pseudocyst and cyst presenting as a cervical and mediastinal mass: case report and review of the literature

Ectopic pancreas in the mediastinum is extremely rare. We are reporting on a case of a twenty two year old woman who presented to our clinic with a large cervical mass. The CT scan revealed a cystic lesion in the anterior mediastinum. The patient underwent surgical resection by cervical approach. A Cystic mass with pseudocysts, cysts and complete pancreatic tissue were found in pathology. There were no signs of pancreatitis or malignancy. No recurrence was observed after a follow up of four years. We reviewed the case reports describing this rare condition in the medical literature.We conclude that the possibility of ectopic pancreatic tissue should be included in the differential diagnosis of anterior mediastinal cystic mass, though as a remote possibility. Surgery is probably needed for the diagnosis and treatment. Posterior mediastinal pseudocyst is a different entity associated with acute pancreatitis. In those cases surgery is not recommended. Our third conclusion is that pancreatic tissue should be actively sought, if a structure resembling a pseudocyst is found in an unexpected location.

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