Resolution of mediastinal pancreatic pseudocysts with transpapillary stent placement

The Role of Endoscopic Ultrasound in the Interventional Management of Mediastinal Collections: A Narrative Review

The numerous causes underlying mediastinal lesions require different diagnostic and therapeutic approaches, including conservative, minimally invasive, and surgical interventions. Solid lesions of a malignant nature, mostly located in the anterior mediastinum, are properly treated with surgical resection either with or without adjuvant schemes. In contrast, a surveillance program is usually recommended with solid benign tumors, depending on their size and related symptomatology. In the management of mediastinal collections, when a drainage intervention is required (suspicion of infection and symptomatology), a minimally invasive nonsurgical procedure or thoracic surgery is considered. The minimally invasive nonsurgical procedures that can be available are percutaneous radiology-guided imaging (abdominal ultrasound (US) or computed tomography (CT) scan), complete single-aspiration guided by endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS), and transmural drainage guided by EUS. Surgical debridement is feasible to treat collections, but as this entails considerable risk of postoperative complications, it is chosen only when other minimally invasive therapies are not possible. The published literature related to the interventional endoscopic approach to mediastinal lesions is scarce. Nevertheless, reports in this field reveal that interventional EUS may have a role in both the diagnosis of and therapeutic approach to mediastinal lesions, mainly in the management of mediastinal collections.

Endoscopic Management of Complications in Chronic Pancreatitis

PURPOSE OF REVIEW

Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP.

LITERATURE FINDINGS

CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.

Large pancreatic pseudocyst penetrating into posterior mediastinum

We report a rare case of a large mediastinal pancreatic pseudocyst compressing the left atrium and the esophagus and causing dyspnea, palpitations, and emesis. Chest radiograph was non-diagnostic, esophagogastroduodenoscopy showed diffuse extrinsic compression of the distal esophagus and gastric corpus, but a definitive diagnosis was confirmed by computed tomography. We decided to perform surgery due to the recurrence of the pancreatic pseudocyst, a history of unsuccessful radiologically guided external drainage a few years earlier, and a very large diameter of the pseudocyst causing acute cardio-pulmonary distress syndrome.

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.

Pancreatic mediastinal pseudocyst presenting as a posterior mediastinal mass with recurrent pleural effusions: a case report and review of the literature

Introduction

A rare complication of chronic pancreatitis is the formation of single or multiple mediastinal pseudocysts, which are fueled from the pancreas through anatomical openings of the diaphragm. We present a rare case with a difficult diagnosis, treatment and potentially catastrophic complications.

Case presentation

A 53-year-old Caucasian man was referred to our hospital for further investigation and treatment of a large heterogeneous mass situated in the posterior mediastinum, and bilateral pleural effusions which had developed after recent multiple episodes of pancreatitis. He had a history of chronic alcoholism. Laboratory and imaging modalities established the diagnosis of a pancreatic mediastinal pseudocyst.

Conclusions

Despite successful initial conservative treatment, our patient had a relapse and underwent emergency surgical intervention due to internal hemorrhage. We present his diagnostic and imaging workup, along with the multidisciplinary intervention, and a literature review referring to the diagnosis and treatment of mediastinal pancreatic pseudocysts.

Anatomic pathways of peripancreatic fluid draining to mediastinum in recurrent acute pancreatitis: visible human project and CT study

Background

In past reports, researchers have seldom attached importance to achievements in transforming digital anatomy to radiological diagnosis. However, investigators have been able to illustrate communication relationships in the retroperitoneal space by drawing potential routes in computerized tomography (CT) images or a virtual anatomical atlas. We established a new imaging anatomy research method for comparisons of the communication relationships of the retroperitoneal space in combination with the Visible Human Project and CT images. Specifically, the anatomic pathways of peripancreatic fluid extension to the mediastinum that may potentially transform into fistulas were studied.

Methods

We explored potential pathways to the mediastinum based on American and Chinese Visible Human Project datasets. These drainage pathways to the mediastinum were confirmed or corrected in CT images of 51 patients with recurrent acute pancreatitis in 2011. We also investigated whether additional routes to the mediastinum were displayed in CT images that were not in Visible Human Project images.

Principal Findings

All hypothesized routes to the mediastinum displayed in Visible Human Project images, except for routes from the retromesenteric plane to the bilateral retrorenal plane across the bilateral fascial trifurcation and further to the retrocrural space via the aortic hiatus, were confirmed in CT images. In addition, route 13 via the narrow space between the left costal and crural diaphragm into the retrocrural space was demonstrated for the first time in CT images.

Conclusion

This type of exploration model related to imaging anatomy may be used to support research on the communication relationships of abdominal spaces, mediastinal spaces, cervical fascial spaces and other areas of the body.

Endoscopic management of pancreatic pseudocysts at atypical locations

BACKGROUND AND AIMS

There is paucity of data on endoscopic management of pseudocysts at atypical locations. We evaluated the efficacy of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of pseudocysts of pancreas at atypical locations.

PATIENTS AND METHODS

Eleven patients with pseudocysts at atypical locations were treated with attempted endoscopic transpapillary nasopancreatic drainage. On endoscopic retrograde pancreatography (ERP), a 5-F NPD was placed across/near the site of duct disruption.

RESULTS

Three patients each had mediastinal, intrahepatic, and intra/perisplenic pseudocysts and one patient each had renal and pelvic pseudocyst. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. The size of the pseudocysts ranged from 2 to 15 cm. On ERP, the site of ductal disruption was in the body of pancreas in five patients (45.4%), and tail of pancreas in six patients (54.6%). All the patients had partial disruption of pancreatic duct. The NPD was successfully placed across the disruption in 10 of the 11 patients (90.9%) and pseudocysts resolved in 4-8 weeks. One of the patients developed fever, 5 days after the procedure, which was successfully treated by intravenous antibiotics. In another patient, NPD became blocked 12 days after the procedure and was successfully opened by aspiration. The NPD slipped out in one of the patient with splenic pseudocyst and was replaced with a stent. There was no recurrence of symptoms or pseudocysts during follow-up of 3-70 months.

CONCLUSION

Pancreatic pseudocysts at atypical locations with ductal communication and partial ductal disruption that is bridged by NPD can also be effectively treated with endoscopic transpapillary NPD placement.

Pancreatic pseudocyst presenting as dysphagia: a case report

Pancreatic pseudocysts are relatively common complications of acute pancreatitis. However, extension of pseudocysts into the mediastinum rarely occurs. In such situations they commonly present with chest pain or shortness of breath. We herein report the case of a patient with a pseudocyst presenting with dysphagia. The clinical presentation, current modalities of diagnosis and management of mediastinal pancreatic pseudocyst is reviewed in this article.

Mediastinal extension of a complicated pancreatic pseudocyst; a case report and literature review

BACKGROUND

Mediastinal pancreatic pseudocyst is a rare complication of acute or chronic pancreatitis.

CASE PRESENTATION

This case report describes the management of a difficult case of pancreatic pseudocyst with a mediastinal extension in a patient having chronic pancreatitis. Different management strategies were used until complete resolution of this complex pseudocyst occurred using open surgical cystogastrostomy.

CONCLUSION

Despite the availablity of different minimally invasive techniques to treat pancreatic pseudocysts, management of complex mediastinal pseudocyst may still require open surgical drainage procedures.

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.

Successful endoscopic treatment of mediastinal pseudocysts

Mediastinal pseudocysts can pose a diagnostic and therapeutic challenge to the clinician and surgeon. Recognizing their presence and instituting appropriate therapy can reduce morbidity and mortality. This report describes unusual clinical features in a patient presenting with multiple mediastinal pseudocysts due to pancreatic duct leak secondary to pancreatic duct stenosis and an entrapment of a pancreatic duct stone. Successful endoscopic therapy averted the need for surgery.

Pancreatic Pseudocysts

Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.