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

A very rare case of an intrathoracic pancreatic pseudocyst

Pancreatic pseudocysts are mostly located in the peripancreatic region, but extra-abdominal intrathoracic extensions can occur and mimic respiratory and ischemic symptoms. Mediastinal location is an example that can present with dyspnea and retrosternal chest pain. Pancreatic-pleural fistulas can form from pseudocysts, often resulting in large and recurrent pleural effusions. In the described case, a 50-year-old man with a previous subdiaphragmatic pseudocyst presented an acute episode of respiratory symptoms and was diagnosed with a newly organized collection located intrathoracically adjacent to the previous one, formed by the fistulization of the abdominal pseudocyst. No similar cases have been described or published in indexed PubMed databases until the year 2023.

Successful treatment of mediastinal pancreatic pseudocyst and pancreatic pleural effusion with endoscopic pancreatic duct drainage: A case report

An 81‐year‐old man with chronic pancreatitis was being treated with a protease inhibitor. He developed an acute exacerbation of chronic pancreatitis and dyspnea. Contrast‐enhanced computed tomography showed disruption of the main pancreatic duct, a cystic lesion connecting the mediastinum to the main pancreatic duct, and left pleural effusion. We diagnosed a pancreatic pseudocyst, mediastinal pancreatic pseudocyst, and pancreatic pleural effusion. Endoscopic retrograde pancreatography showed leakage of contrast medium from the pancreatic body; furthermore, a cystic cavity extending to the mediastinum through a pancreatic duct fistula was visualized. An endoscopic transpapillary nasopancreatic drainage tube was placed in the cystic cavity. Computed tomography showed that the mediastinal pseudocyst and pleural effusion had disappeared. Endoscopic transpapillary pancreatic duct drainage may be useful when a connection between the main pancreatic duct and a mediastinal pseudocyst is confirmed by imaging.

Acute‐on‐chronic pancreatitis complicated with mediastinal pseudocysts and cardiac tamponade: A case report and literature review

The clinical course and severity of pancreatitis might vary largely. Pancreatitis‐related thoracic complications might be life‐threatening but frequently ignored. We report an alcoholic patient who initially presented to the emergency department with community‐acquired pneumonia, acute respiratory failure and acute‐on‐chronic pancreatitis with massive pancreatic pleural effusion. Subsequently, he developed insidiously pancreatitis‐related intra‐abdominal, mediastinal pseudocysts, and unexpectedly sudden onset of cardiac tamponade. Although tamponade‐related haemodynamic instability improved soon after timely diagnosis and emergent pericardial drainage, his recovery period was prolonged. His serum amylase and lipase were persistently elevated until definitive treatment with endoscopic retrograde cholangiopancreatography‐assisted removal of pancreatic duct stones. Pancreatitis‐related cardiac tamponade is rare but lethal without prompt diagnosis and management. We reviewed pancreatitis‐related thoracic complications, particularly for cardiac tamponade, and discussed about the pathophysiology and management options.

Mediastinal Eventration of a Pseudocyst of Pancreas Presenting As Acute Shock Syndrome: Expecting the Unexpected

Pancreatic pseudocyst is a usual complication of chronic pancreatitis. Diagnosis is usually established with the help of cross-sectional imaging. Typical presenting complaints are abdominal pain and vomiting. However, atypical presentations of pseudocyst of the pancreas continue to puzzle clinicians throughout the world, leading to difficulty in diagnosis and hence, the development of life-threatening complications. Here, we report a case of a 47-year-old male who was a known case of chronic pancreatitis related to alcoholism presenting with dyspnea, dysphagia, chest pain, and vomiting with a blood pressure of 70/50 mmHg, which upon evaluation revealed to be a case of peripancreatic pseudocysts extending into mediastinum abutting inferior vena cava and right atrium presenting as acute shock syndrome. The patient was managed with ultrasound-guided pigtail insertion and drainage of pseudocyst of pancreas. Eventually, the patient’s clinical condition did not allow for surgical exploration of the thorax and the patient succumbed.

[Mediastinal pancreatobiliary pseudocysts]

OBJECTIVE

To select the optimal treatment for uninfected and suppurative rare mediastinal pancreatobiliary pseudocysts.

MATERIAL AND METHODS

There were 10 patients with mediastinal pancreatogenic (n=9) and biliogenic (n=1) pseudocysts formed through esophageal (n=9) and aortic (n=1) hiatus of the diaphragm. All patients were divided into groups: group A - uninfected pancreatic pseudocysts (n=5) formed through esophageal hiatus; group B - 5 patients with suppurative pancreatogenic (n=4) and biliogenic (n=1) mediastinitis complicated by biliopleuroesophageal (n=1), pancreatoesophageal (n=1) and pancreatopleural (n=2) fistulas.

RESULTS

In the group A, simultaneous procedures (n=5) were performed depending on pancreatic parenchyma and pancreatic duct destruction. Distal ductal obstruction required Frey procedure (n=3). If distal duct was patent, we resected cyst-containing pancreatic tail (n=2). Early and long-term results were favorable. In the group B, mediastinitis persisted for a long time with normal temperature as a rule. In our opinion, mild course is associated with gradual introduction of purulent tissues into mediastinum and development of a tissue barrier. Two-stage surgeries were performed in patients with pancreatopleural empyema. Mediastinitis lasting 6-8 weeks caused perforation of the lower third of esophagus (n=2) and death of 1 patient. Risk factors of mediastinal pseudocysts: hypertension in pancreatic duct and pseudocysts, immobile cicatricial tissues of omental bursa, proximity of subdiaphragmatic structures to esophageal and aortic hiatus of the diaphragm. Pressure in aortic canal (mmHg) is 10 times higher than in esophageal canal that increases migration through the esophageal hiatus. It is advisable to distinguish pancreatoesophageal and biliopleuroesophageal fistulas.

CONCLUSION

Uninfected mediastinal pseudocysts require simultaneous procedures, pancreatopleural empyema - two-stage interventions. Therapy is recommended in patients with esophageal fistula and no severe symptoms and intoxication.

Mediastinal Extension of a Pancreatic Pseudocyst: A Rare Intrathoracic Complication of Pancreatitis

Pancreatic pseudocysts are a common complication of pancreatitis. However, mediastinal extension of a pseudocyst is rare and often presents with atypical symptoms. We present a case of mediastinal extension of a pancreatic pseudocyst in a 56-year-old woman with a history of alcohol-related chronic pancreatitis, who presented with acute on chronic epigastric abdominal pain and atypical chest pain. Serum lipase was elevated, and imaging by contrast-enhanced computed tomography (CT) demonstrated a paraesophageal fluid collection. This collection was continuous with a peripancreatic pseudocyst and extended into the posterior mediastinum via the esophageal hiatus. Mediastinal extension of a pancreatic pseudocyst was confirmed by magnetic resonance imaging (MRI). The patient was managed conservatively in the hospital with parenteral nutrition therapy, pain control, and close imaging observation. The patient was discharged home to continue conservative management and close imaging follow-up. An initial follow-up CT examination 8 weeks after discharge revealed interval decrease in the posterior mediastinal collection but also interval development of loculated left pleural and pericardial effusions.

Mediastinal Extension of Pancreatic Pseudocyst: A Rare Pediatric Presentation

Pancreatic pseudocysts are cystic cavities which are localized collection of pancreatic secretions, rich in amylase and other enzymes, present in and around pancreas, encased in a false epithelial lining of fibrous or reactive granulation tissue. Extension of a pancreatic pseudocyst into the mediastinum is rare. We are reporting a case of a 5-year-old child with mediastinal pancreatic pseudocyst which was successfully drained by cystojejunostomy.

Pulmonary complications of acute pancreatitis

Introduction: Acute pancreatitis is an inflammatory condition of the pancreas, which runs a severe course in 20% of patients, wherein it is associated with high mortality. It is associated with several pleuro-pulmonary complications with variable severity that may occur either in isolation but are frequently present in combination. Clinicians need to be aware of these complications for early and appropriate management.Areas covered: We performed a systematic search of the PUBMED database (1970-2019) to identify relevant articles focusing on pleuro-pulmonary complications that may occur in patients with acute pancreatitis. We also retrieved articles describing the pathophysiological mechanisms and treatment approach of the various complications.Expert opinion: Acute pancreatitis is usually a self-limiting disease, but the development of organ failure during the course worsens the clinical outcome. Pulmonary complications usually occur early in the course of acute pancreatitis. Clinicians need to recognize the various pulmonary complications of acute pancreatitis, early during the disease, and manage them appropriately and aggressively to improve outcomes.

[Mediastinal pancreatic cysts: review and own clinical observations]

OBJECTIVE

To present the results of surgical treatment of patients with mediastinalpancreatogeniccysts (MPC).

MATERIAL AND METHODS

There were 5 patients with MPC.

RESULTS

Laboratory tests revealed increased blood amylase level by 1.5-2 times in 3 cases, urine diastase by 4-5 times - in 2 cases. Pleural effusion with amylase concentration in the fluid from 5680 to 48 640 units was diagnosed in 4 cases. CT data of preudocysts of pancreatic body and tail were obtained in 3 cases, head and body - in 2 patients. These cysts extended to posterior mediastinum through the hiatal orifice for about 3.5-40 cm. Three patients underwent VATS removal of pleural fragments, one - thoracotomy, lung decortication and MPC drainage through pleural cavity. Three patients underwent pancreatic drainage procedures (cystogastrostomy, pancreaticojejunostomy and external drainage of the cyst). A small pseudocyst has been successfully treated by conservative treatment with octreotide.

CONCLUSION

MPC is a rare complication of pancreatitis and often associated with pleural effusion. CT and fluid amylase analysis are the main diagnostic measures. Surgical treatment includes VATS, destruction of pleural fragments and pleural drainage, cystogastrostomy, pancreaticojejunostomy or external drainage of pancreatic pseudocyst.

Pseudopancreatic Cyst Extending into the Mediastinum in a 7-Year-Old Child

Mediastinal pseudopancreatic cyst (MPP) is the extension of a pancreatic pseudocyst through esophageal or aortic hiatus into the posterior mediastinum. It can produce a range of manifestations caused by compression by the cyst, for instance, odynophagia, dysphagia, pericardial, or pleural effusion. Here we report a case of MPP in a 7-year-old child who was presented with repeated chest infections and left pleural effusion. It was successfully drained by cystogastrostomy.

Pseudocyst of the pancreas masquerading as spontaneous pneumomediastinum

Pseudocyst of the pancreas extending into the thorax represents a rare but potentially catastrophic diagnosis. It can be difficult to both diagnose and manage, with only limited management suggestions within the literature. While pleural effusion is a common complication of pancreatitis, transthoracic extension of a pseudocyst is a rare phenomenon. Herein we discuss a patient with a difficult to recognize extension of pancreatic pseudocyst into the left hemithorax, with unique imaging findings. He had good response to trans-gastric and percutaneous drainage and ultimately proceeded to thoracotomy and decortication. Around this case, the options for investigation and management are discussed.

EUS-guided trans-esophageal drainage of a mediastinal necrotic fluid collection using the axios electrocautery enhanced delivery system™

Mediastinal collection secondary to necrotic acute pancreatitis, is an extremely rare event caused by the posterior rupture of the pancreatic duct into the retroperitoneal space with the penetration of the pancreatic fluid through the diaphragmatic orifices. Infection of the necrotic collection may occur with a consequent substantial increase of the mortality rate. Due to the rarity of this severe condition, no consensus is known about the management of infected mediastinal necrotic collections. We reported the case of a 61-year-old male who was critically unwell secondary to a large mediastinal necrotic collections after necrotic acute pancreatitis with no improvement after surgery. The patient was successfully treated by EUS-guided trans-esophageal drainage using the AXIOS Electrocautery Enhanced Delivery System™. This procedure proved in this case to be a safe and effective option for the management of infected necrotic mediastinal collections.

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.

Mediastinal Pseudocyst: Varied Presentations and Management-Experience from a Tertiary Referral Care Centre in India

Pseudocysts are a recognised complication following acute or chronic pancreatitis. Usually located in peripancreatic areas, they have also been reported to occur in atypical regions like liver, pelvis, spleen, and mediastinum. Mediastinal pseudocysts are a rare entity and present with myriad of symptoms due to their unique location. They are a clinical challenge to diagnose and manage. In this paper, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 7 of our patients, as well as our experience in managing these patients along with their clinical outcome.

Mediastinal Pancreatic Pseudocysts

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

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.

Pancreatico-pericardial fistula as a complication of chronic pancreatitis

Pancreatico-pericardial fistula is an extremely rare complication of chronic pancreatitis. We present a case of a 58-year-old man who presented with syncope. Transthoracic echocardiogram revealed a pericardial effusion with tamponade physiology. Pericardiocentesis and pericardial fluid analysis demonstrated a lipase level of 2321 U/L. Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) was performed, confirming the presence of a pancreatico-pericardial fistula (PPF) from the distal body of the pancreas. A pancreatic duct stent was placed across the duct disruption on two separate occasions; however, despite stent placement, the patient continued to re-accumulate pericardial fluid and deteriorated. While rare, PPFs may complicate chronic pancreatitis, may not respond to pancreatic duct stenting and may portend a poor prognosis.

Pancreatic pseudocyst or a cystic tumor of the pancreas?

Pancreatic pseudocysts are the most common cystic lesions of the pancreas and may complicate acute pancreatitis, chronic pancreatitis, or pancreatic trauma. While the majority of acute pseudocysts resolve spontaneously, few may require drainage. On the other hand, pancreatic cystic tumors, which usually require extirpation, may disguise as pseudocysts. Hence, the distinction between the two entities is crucial for a successful outcome. We conducted this study to highlight the fundamental differences between pancreatic pseudocysts and cystic tumors so that relevant management plans can be devised. We reviewed the data of patients with pancreatic cystic lesions that underwent intervention between June 2007 and December 2010 in our hospital. We identified 9 patients (5 males and 4 females) with a median age of 40 years (range, 30–70 years). Five patients had pseudocysts, 2 had cystic tumors, and 2 had diseases of undetermined pathology. Pancreatic pseudocysts were treated by pseudocystogastrostomy in 2 cases and percutaneous drainage in 3 cases. One case recurred after percutaneous drainage and required pseudocystogastrostomy. The true pancreatic cysts were serous cystadenoma, which was treated by distal pancreatectomy, and mucinous cystadenocarcinoma, which was initially treated by drainage, like a pseudocyst, and then by distal pancreatectomy when its true nature was revealed. We conclude that every effort should be exerted to distinguish between pancreatic pseudocysts and cystic tumors of the pancreas to avoid the serious misjudgement of draining rather than extirpating a pancreatic cystic tumor. Additionally, percutaneous drainage of a pancreatic pseudocyst is a useful adjunct that may substitute for surgical drainage.