Transdiaphragmatic cyst-jejunostomy with Roux-en-Y loop for an exclusively mediastinal pancreatic pseudocyst

Pancreatic Pseudocysts in the Mediastinal Space: An Urban Legend?

Pancreatic pseudocysts are a frequent complication of chronic pancreatitis. Nonetheless, they seldom extend beyond the peripancreatic region. However, migration towards the mediastinum may cause heterogeneous and non-specific symptoms, such as dysphagia, chest pain and dyspnoea, which depend on the localization and extension of the cysts. We present the case of a patient with chronic pancreatitis who was admitted to our ward for low-grade fever and mild dyspnoea and who rapidly developed bilateral laterocervical swelling associated with acute dyspnoea and trismus. A total body CT scan showed multiple abdominal pancreatic pseudocysts, one of which had migrated to the mediastinum and towards the retropharyngeal space. Clinicians should always consider the possibility of extra-pancreatic pseudocysts in patients with known pancreatitis so that uncommon clinical presentations with a potentially fatal outcome will be recognized.

LEARNING POINTS

Mediastinal pancreatic pseudocysts are a rare manifestation of acute and chronic pancreatitis.The clinical presentation of mediastinal pancreatic pseudocysts is variable, and they may rarely have a fatal outcome.

Three cases of mediastinal pancreatic pseudocysts

A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP), which is caused by tracking of pancreatic fluids through anatomical openings of the diaphragm into the mediastinum. Herein, we report the imaging characteristics of three cases of this condition. Our results revealed three features in common: (i) the connection between the mediastinum and the pancreatic cystic lesion; (ii) the presence of pleural effusions; and (iii) imaging findings consistent with chronic pancreatitis, such as pancreatic atrophy and calcifications and dilatation and/or stricture of main pancreatic duct (MPD). Serial diameter changes of the MPD and of the adjacent pseudocysts were necessary for the determination of the therapeutic strategy used in each case.

Thoracoabdominal pseudocyst of pancreas: An rare location, managed by retrocolic retrogastric Roux-en-Y cystojejunostomy

Pseudocyst formation is a common complication of acute and chronic pancreatitis. Most common site of pseudocyst is lesser sac; mediastinal extension of pseudocyst is rare. Other possibilities of posterior mediastinal cyst must be considered. This patient presented with computed tomography abdomen with thorax showing a large thoraco-abdominal pseudocyst with right sided pleural effusion. It was confirmed to be pancreatic pseudocyst by analyzing fluid for amylase and lipase during surgery. In our patient, the pseudocyst was accessible transabdominaly. Cystogastrostomy was not possible as it was causing twisting of cardio-esophageal junction; we did retrocolic and retrogastric Roux-en-Y cystojejunostomy. Only two such cases were reported in literature.

An unusual cause of dysphagia: transabdominal Roux-en-Y cyst-jejunostomy in the surgical management of a symptomatic mediastinal cyst

We present a 52-year-old gentleman with an unusual cause of progressive dysphagia, namely due to extrinsic lower oesophageal compression from a cystic mass of the posterior mediastinum. Cystic masses in adults are uncommon, and there is a wide differential diagnosis. This includes neoplastic, such as germ cell tumour (cystic teratoma), and non-neoplastic aetiologies. The later include foregut duplication cysts, lymphatic malformations, infective (hydatid), simple mediastinal cysts or pseudocysts. Management is principally surgical with complete excision, or alternatively, in cases of benign cysts, marsupialization or decompression. In our patient, a simple mediastinal cyst was diagnosed and this case is the first description of a totally transabdominal approach to mediastinal cyst decompression by a Roux-en-Y cyst-jejunostomy.

Mediastinal extension of pancreatic pseudocyst--a case with review of topic and management guidelines

Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. Extension of a pancreatic pseudocyst into the mediastinum is rare. We present a case of a 43-year-old male with a history of pancreatitis, who presented with dysphagia and was found to have a pancreatic pseudocyst. The pseudocyst was extending to the mediastinum and compressing the esophagus. It was successfully drained externally by computed tomography-guided catheter intervention. Depending on the location and size, patients may present with dyspnea, chest pain, palpitations, or dysphagia; sometimes with hemoptysis, acute respiratory compromise, or cardiogenic shock. There are no recommended guidelines for management. Watchful waiting for spontaneous regression, medical therapy, or drainage internally or externally with endoscopic, percutaneous, or open surgical approach are available options. Based on our own experience and literature review of such cases, we present a management strategy that can limit both complications and recurrence rate. This case emphasizes the importance of the possibility of mediastinal extension of a pancreatic pseudocyst and provides reference guidelines to approach the same.

Resolution of a complex mediastinal pseudocyst in a patient with alcohol-related chronic pancreatitis following abstinence from alcohol

We describe a 55-year-old patient with alcoholic chronic pancreatitis, a large mediastinal pseudocyst and a hemorrhagic pleural effusion. A single thoracocentesis and withdrawal of alcohol without other conservative or invasive measures resulted in a complete resolution of the pleural effusion and the mediastinal pseudocyst, which to our knowledge has not been described before.