A case of pancreatic pleural effusion and mediastinal pancreatic pseudocyst: management by a somatostatin analogue octreotide

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.

Mediastinal pancreatic pseudocyst masquerading as diffuse alveolar haemorrhage

Pancreatic pseudocyst formation with extension into the mediastinum is an uncommon complication of pancreatitis that can result in numerous pulmonary and cardiac complications. We present a case of a 56-year-old man with a history of recurrent pancreatitis who presented with haemoptysis. His initial workup was consistent with diffuse alveolar haemorrhage for which he was treated with glucocorticoids. After failure to improve, further imaging demonstrated a complex fluid collection in the mediastinum consistent with extension of his pre-existing pancreatic pseudocyst, leading to erosion into the right lower lobe of the lung. This case highlights a rare pulmonary complication of pancreatitis and underscores the importance of proper identification of this condition to guide successful management.

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.

Mediastinal pancreatic pseudocyst with hemorrhage and left gastric artery pseudoaneurysm, managed with left gastric artery embolization and placement of percutaneous trans-hepatic pseudocyst drainage

Mediastinal pancreatic pseudocyst (MPP) is a rare, but known, complication of both acute and chronic pancreatitis. Most pseudocysts are associated with alcoholic pancreatitis. Recent advances in endoscopic techniques have shown promising results, with reduced chances of infection and recurrence than with percutaneous drainage, but limited availability restricts widespread use. Left gastric artery pseudoaneurysm with mediastinal pseudocyst has not been described in the literature to date. We report a successful resolution of hemorrhagic MPP with embolization of pseudoaneurysm and percutaneous trans-hepatic pseudocyst drainage.

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.

[Current therapy of the pancreato-pleural fistula]

This case report summarizes therapeutic options for the management of pancreato-pleural fistula (PPF) following a successful conservative treatment of one of our patients. PPF is a rare complication of chronic pancreatitis. The main aetiological factor is alcohol, which causes relapse of chronic pancreatitis associated with dyspnoea. Diagnosis is confirmed by physical examinations, laboratory tests of pleural fluid as well as ERCP being the most important diagnostic procedure. Conservative treatment of PPF consists of endoscopic therapy (endoscopic sphincterotomy with stenting of the pancreatic duct), octreotid combined with continuous enteral nutrition (jejunal feeding). If the above complex therapy fails, surgical treatment of PPF is advised.

Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst

Acute mediastinitis is a life-threatening disease. Common etiologies include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Mediastinitis caused by pancreatic disease is rare. The most common thoracic complication of pancreatic disease is reactive pleural effusion. We report a case of acute mediastinitis and bilateral empyema thoracis arising from a pancreatic pseudocyst. We utilized thoracoscopy to drain the mediastinum without drainage of the intra-abdominal cyst. The patient recovered well after operation.

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.

A case of mediastinal pancreatic pseudocyst successfully treated with somatostatin analogue

A 57-year-old man with a 3-year history of chronic pancreatitis was admitted to our hospital with upper abdominal pain. Based on examination findings, the patient was diagnosed as having pseudocysts in the pancreatic body and the mediastinum that were associated with acute aggravation of chronic pancreatitis. Because of the patient refused an operation, he was submitted to conservative management including intramuscular injection with somatostatin analogue of 100 microg/day. On the 14th day of the treatment, pleural effusion and pseudocyst in the pancreatic head were additionally diagnosed based on the findings of computed tomography, magnetic resonance imaging and other examinations, and the dose of somatostatin analogue was increased to 200 microg/day. As a result, on the 28th day of the treatment, pancreatitis was inactivated, and the pseudocysts in the mediastinum and the pancreas disappeared. The patient has been followed up for 15 months, and there has been no recurrence.

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.