Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis

Pancreatic enzymatic mediastinitis followed by total gastrectomy with splenectomy: report of two cases

BACKGROUND

Acute mediastinitis is a rare disease that rapidly progresses with a high mortality rate. Its most common cause is direct injury of the mediastinum, including iatrogenic causes such as cardiac surgery or upper endoscopy. Enzymatic mediastinitis is a rare complication of a pancreatic fistula caused by the inflammatory digestion of the parietal peritoneum spreading to the mediastinum. Here, we present two cases of enzymatic mediastinitis caused by total gastrectomy with splenectomy. One of them was successfully treated and cured after early diagnosis and transabdominal drainage.

CASE PRESENTATION

Case 1 was that of a 60-year-old man (body mass index [BMI] 27) with a medical history of diabetes and hypertension who was diagnosed with advanced gastric cancer in the upper body of the stomach. A total gastrectomy with splenectomy was performed. The patient experienced acute respiratory failure 24 h after surgery. Pulmonary embolism was suspected, so a computed tomography (CT) scan was performed; however, no relevant causes were found. Although he was immediately intubated and treated with catecholamine, he died in the intensive care unit (ICU) 40 h after surgery. Post-mortem findings revealed retroperitonitis caused by a pancreatic fistula spreading towards the mediastinum, causing severe mediastinitis; a review of the CT scan revealed pneumomediastinum. We concluded that the cause of death was enzymatic mediastinitis due to post-gastrectomy pancreatic fistula. Case 2 involved a 61-year-old man (BMI 25) with a medical history of appendicitis who was diagnosed with advanced gastric cancer at the gastric angle between the lesser curvature and the pylorus, spreading to the upper body of the stomach. A total gastrectomy with splenectomy was also performed. The patient had a high fever 3 days after the surgery, and a CT scan revealed pneumomediastinum, indicating mediastinitis. As the inflammation was below the bronchial bifurcation, we chose a transabdominal approach for drainage. The patient was successfully treated and discharged.

CONCLUSION

Acute mediastinitis caused by gastrectomy is rare. The acknowledgment of abdominal surgery as a cause of mediastinitis is important. In treating mediastinitis caused by abdominal surgery, transabdominal drainage may be a minimally invasive yet effective method if the inflammation is mainly located below the bifurcation of the trachea.

Endoscopic retrograde cholangiopancreatography in the treatment of pancreaticopleural fistula in children

BACKGROUND

Pancreaticopleural fistula (PPF) is a rare disease, especially in children. Conservative treatment and surgery are traditional therapies, but surgery is invasive. The emergence of endoscopic retrograde cholangiopancreatography (ERCP) has provided a new noninvasive treatment for PPF and may become the first choice for children with PPF.

AIM

To explore the treatment response to ERCP for PPF in children.

METHODS

Seven children with PPF were hospitalized in the Gastroenterology Department of Beijing Children’s Hospital from December 2007 to May 2019. Data on these seven patients’ clinical characteristics, diagnosis, treatments, and outcomes were analyzed, and their treatment responses following surgery and ERCP were compared. The correlation between the length of hospital stay and conservative treatment was analyzed. Peer-reviewed articles written in English and Chinese published from January 2009 to December 2019 were obtained from various open data sources and reviewed.

RESULTS

The seven patients comprised three boys and four girls with a mean age of 6.57 ± 3.26 years. The main symptoms were chest tightness and pain (n = 4), intermittent fever (n = 3), dyspnea (n = 3), and abdominal pain (n = 1), and all patients had bloody pleural effusion. All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography, and all were initially treated conservatively for a mean of 34.67 ± 22.03 d with a poor response. Among five patients who underwent ERCP, one required surgery because of intubation failure; thus, the success rate of ERCP was 80%. Two patients were successfully treated with surgery (100%). The postoperative hospital stay of the two patients treated by surgery was 20 and 30 d, respectively (mean of 25 d), and that of the four patients treated by ERCP ranged from 12 to 30 d (mean of 19.25 ± 8.85 d). The recovery time after ERCP was short [time to oral feeding, 4-6 d (mean, 5.33 ± 1.15 d); duration of closed thoracic drainage, 2-22 d (mean, 13.3 d)]. Analysis of previous cases of PPF published worldwide during the past decade showed that the treatment success rate of ERCP is not lower than that of surgery. There was no significant difference in the postoperative hospital stay between surgery (16 ± 10.95 d) and ERCP (18.7 ± 6.88 d, P > 0.05). A positive linear correlation was found between the overall hospital stay and ERCP intervention time (R² = 0.9992).

CONCLUSION

ERCP is recommended as the first-choice treatment for PPF in children. ERCP should be performed as early as possible if conditions permit.

Staged Interventional and Surgical Treatment of Patient with Chronic Pancreatitis Complicated by Pancreaticopleural Fistula with Lung Abscesses

Patient: Male, 37-year-old

Final Diagnosis: Chronic alcoholic pancreatitis • pancreaticopleural fistula • left lung abscesses

Symptoms: Fever with a body temperature of 39.1°C • left thoracic pain • severe cough with purulent sputum • shortness of breath • upper abdominal pain

Medication: —

Clinical Procedure: Repeated thoracenteses • chest tube • drainage of lung abscesses • ultrasound-guided drainage of pancreatic pseudocyst • ultrasound-guided transparietal external-internal pancreatic duct stenting • Bern modification of Beger procedure

Specialty: Surgery

Enzymatic mediastinitis as a fearsome complication of pancreatic necrosectomy

Several types of thoracic complications can be associated with severe acute pancreatitis. Some are very common, such as pleural effusion, whilst some others are very rare although life threatening, such as enzymatic mediastinitis (EM). Only a few cases of EM (when related to acute pancreatitis) have been described in the literature. Here we describe the case of a 76-year-old female who developed acute respiratory failure and atrial fibrillation during the postoperative period after an open pancreatic necrosectomy, due to an EM episode. The mediastinal collection was drained by thoracotomy, following an improvement of the patient's general condition. This is the first case of EM following surgical management for acute necrotizing pancreatitis. EM is a rare but life threatening complication that usually requires surgery.

Pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, with dysphagia as initial symptom: A case report

RATIONALE

Pancreaticopleural and pancreaticomediastinal fistulas are rare complications of pancreatitis. They are often misdiagnosed and there are no strict guidelines of treatment. In this study, we present a brief report of a combined pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, causing dysphagia and cervical swelling as initial symptoms.

PATIENT CONCERNS

A 36-year-old female with history of alcohol abuse and pancreatitis presented progressing dysphagia and mild dyspnea on admission.

DIAGNOSIS

Chest X-ray and chest and abdominal computed tomography scan (CT) indicated pancreaticopleural fistula combined with pancreaticomediastinal fistula, a diagnosis confirmed by high amylase levels in pleural fluid.

INTERVENTIONS

Conservative treatment was administered and ERCP was performed but pancreatic duct stenting was impossible. The patient presented rapid anterior cervical swelling with progressing dysphagia and dyspnea. CT showed fistula penetration to the cervical region. The patient underwent urgent surgery and pancreaticojejunal anastomosis was performed.

OUTCOMES

The surgery led to recovery. Six months later, the patient reported good health and weight gain.

LESSONS

Coexistence of pancreaticopleural and pancreaticomediastinal fistula with cervical penetration is an extremely rare pancreatitis complication. It presents with dysphagia and anterior cervical swelling as initial symptoms. It is important to consider this complication in all patients with history of pancreatitis, presenting with dysphagia.

Thoracic complications of pancreatitis

Acute pancreatitis in its severe form may lead to systemic inflammatory response syndrome and multisystem organ dysfunction. Acute lung injury is an important cause of mortality in the setting of severe acute pancreatitis. Besides lung involvement, acute and chronic pancreatitis may also lead to the involvement of other thoracic compartments, including mediastinum, pleura, and vascular structures. These manifestations are an important cause of morbidity and may pose diagnostic and therapeutic challenges. These manifestations have not been discussed in detail in the available literature. In this review, we discuss the thoracic complications of pancreatitis, including lung, pleural, mediastinal, and vascular manifestations.

Spontaneous mediastinitis with multiple esophageal abscess in the esophagus

Acute mediastinitis (AM) is a rare and deadly disease without appropriate treatment. It is usually due to invasive medical procedures, being uncommon the spontaneous onset. We report a case of 49-year-old patient whose starting symptoms were dyspnea and oppressive epigastric pain.

Pancreaticopleural Fistula: A Review of Imaging Diagnosis and Early Endoscopic Intervention

A 49-year-old male with history of chronic alcohol-induced pancreatitis presented with one month of worsening left pleuritic chest pain and shortness of breath. Chest radiograph demonstrated bilateral pleural effusions. Thoracentesis revealed increased amylase in the pleural fluid. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed a fistula tract between the left pleural cavity and pancreas which was confirmed on endoscopic retrograde cholangiopancreatography (ERCP). Patient was treated with placement of a pancreatic stent with complete resolution of the fistula tract approximately in 9 weeks. A systematic literature search was performed on reported cases with pancreaticopleural fistula (PPF) who underwent early therapeutic endoscopy within the last 10 years. Imaging modalities, particularly CT and MRCP, play essential role in prompt preprocedural diagnosis of PPF. Early therapeutic ERCP is an effective and relatively safe treatment option for PPF, so invasive surgery may be avoided.