Endoscopic Ultrasound-Guided Transesophageal Drainage of a Mediastinal Pancreatic Pseudocyst

Abstract

We read with great interest the recent ar− ticle by Jonas et al. [1] which described the endoscopic ultrasound− (EUS−)guided drainage of a cystic metastasis in the mediastinum, and also the article by Mohl et al. [2] reporting their experience of endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst. Both articles reported interesting cases of EUS− guided or EUS−assisted drainage of med− iastinal lesions. We recently managed a similar case, a patient with a large pancre− atic pseudocyst that extended through the diaphragmatic hiatus inside the me− diastinum, which was complicated by a left pleural effusion.A 30−year−old man, with a known history of heavy alcohol consumption, was ad− mitted in the Emergency Department complaining of intense epigastric pain, nausea, and vomiting. He was suspected to have acute pancreatitis. Computed to− mography revealed a large (15 cm) pan− creatic body pseudocyst that extended upward through the diaphragmatic hiatus into the posterior mediastinum, close to the descending aorta ( Figure 1). A large left pleural effusion with a high amylase content was also present, which persisted despite two drainage procedures and 1 month of conservative treatment.Because of the close proximity to the aor− ta and the absence of a clear bulge inside the stomach or esophagus, EUS−guided drainage of the mediastinal pancreatic pseudocyst was performed through the terminal esophagus using a large−channel linear ultrasound endoscope (Olympus GF−UC160T AL5; Olympus, Hamburg, Ger− many) and a one−step drainage system consisting of a diathermic catheter−guide− wire assembly and a mounted 5−cm, 10−Fr stent (Giovannini Needle Wire; Wilson− Cook, Limerick, Ireland). The procedure was technically successful, with good vi− sualization of the stent placement inside the mediastinal pancreatic pseudocyst ( Figure 2) and intermittent drainage of fluid inside the esophagus. After 24 hours, upper gastrointestinal endoscopy and computed tomography with coronal re− construction of the images showed that the stent had rolled over, with the upper esophageal end now inside the stomach, in a good downward−facing position that allowed drainage of the mediastinal col− lection directly into the stomach (Fig− ure 3).The clinical course was favorable and after 1 month there was complete disappear− ance of both the mediastinal pancreatic pseudocyst and the left pleural collection. On computed tomographic scans, the stent was visualized with the upper end in the mediastinum in close contact with the descending aorta, without any fluid collections (Figure 4). The stent was gent− ly pulled inside the stomach and subse− quently removed without any complica− tions. The patient was then followed up for 3 months without any evidence of re− currence.EUS−guided drainage of symptomatic pancreatic pseudocysts is currently con− Figure 4 Control contrast−enhanced axial computed tomographic image after 30 days, showing the stent with its upper end in the mediastinum in close contact with the des− cending aorta, and no flu...

Clinical presentation, radiological features, and endoscopic management of mediastinal pseudocysts: experience of a decade

“…3,6,12 EUS and EUS-guided FNA is an important diagnostic tool for the evaluation of mediastinal pseudocysts, and it can help in determining the extent of solid necrotic debris and thus help in planning the optimal therapy. 8 The ideal management of mediastinal pseudocysts is not entirely clear and depends on the underlying etiology, ductal anatomy, size of the pseudocyst, and availability of expertise. Small pseudocysts may resolve spontaneously, but this is a rare event and requires prolonged conservative management including somatostatin or its analogues.…”

“…6 Literature supporting the endoscopic drainage of mediastinal pseudocysts is scant. 3,5,[7][8][9] We previously reported cases of successful resolution of pancreatic pseudocysts at mediastinal as well as various other atypical locations by endoscopic transpapillary drainage, and these cases are also included here. [2][3][4][5]9 In this case study, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 12 patients (the cases of 4 of these patients were published previously as case reports or their data included in a previously published article) 3,5,9 as well as our experience with endoscopic drainage and clinical outcome in these patients.…”

Endoscopic management of pancreatic pseudocysts at atypical locations

“…While endoscopic drainage has been successfully used in patients with abdominal pseudocysts, there are only a few reports describing successful resolution of mediastinal pseudocysts with endoscopic interventions [3,6,8,19,[30][31][32][33][34][35]. Mallavarapu et al [31] reported two patients with mediastinal pseudocyst.…”

“…Topa et al [6] and Komtong et al [34] also reported successful resolution of mediastinal pseudocyst by endoscopic transgastric drainage. Gupta et al [8] and Saftoiu et al [35] have described successful resolution of mediastinal pseudocyst by EUS-guided transesophageal drainage.…”

EUS-Assisted Rendezvous Stenting of the Pancreatic Duct for Chronic Calcifying Pancreatitis with Multiple Pseudocysts

“…The procedure is safe even in the presence of extensive collateral circulation, since the transgastric puncture of the pancreatic duct does not require coagulation or cutting. Although EUS-assisted or EUS-guided drainage procedures can be done safely, these should be limited for the moment to tertiary centers with trained endoscopists, large caseloads, backed by expertise in interventional radiology and skilled pancreatic surgery support [18] . The utility of these mini-invasive combined endoscopic procedures for the management of difficult cases of chronic pancreatitis should be established by further prospective studies.…”