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

Abstract

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.

Pancreatic pseudocyst extending into mediastinum and causing complete dysphagia

“…1,5,6 Depending on the size of a pseudocyst, patient can present with a variety of symptoms due to compression on mediastinal organs such as dysphagia, dyspnoea, chest ANZJSurg.com pain, palpitations and arrhythmias. About 50 cases of mediastinal extension of pancreatic pseudocyst have been reported worldwide.…”

“…1,3,5 In our case, the patient presented with isolated compression on oesophagus, and as a result dysphagia was the predominant symptom. 6 With the advent of EUS which is an invaluable diagnostic tool, EUS-guided internal drainage of the pancreatic cyst is now an option for definitive treatment. 7 Pseudocyst can complicate from 7% to 15% of episodes of acute pancreatitis and from 20% to 25% of cases of chronic pancreatitis.…”

“…According to the revised Atlanta Classification (2012), pancreatic pseudocyst is an encapsulated collection of fluid with a well-defined inflammatory wall usually outside the pancreas with minimal or no necrosis. 6 They can be managed by watchful waiting for spontaneous regression, medical treatment and internal or external drainage with percutaneous, endoscopic, open or laparoscopic surgical approach. 8 The best way to diagnose a pancreatic pseudocyst and its mediastinal extension in particular is by performing contrast-enhanced CT scan of the chest and abdomen, which helps to evaluate the cyst itself as well as its relationship with the surrounding structures 6 and plays significant role for planning the right procedure.…”

“…About 50 cases of mediastinal extension of pancreatic pseudocyst have been reported worldwide. 1,5,6 Depending on the size of a pseudocyst, patient can present with a variety of symptoms due to compression on mediastinal organs such as dysphagia, dyspnoea, chest ANZJSurg.com pain, palpitations and arrhythmias. 1,3,5 In our case, the patient presented with isolated compression on oesophagus, and as a result dysphagia was the predominant symptom.…”

“…7 Pseudocyst can complicate from 7% to 15% of episodes of acute pancreatitis and from 20% to 25% of cases of chronic pancreatitis. 8 The best way to diagnose a pancreatic pseudocyst and its mediastinal extension in particular is by performing contrast-enhanced CT scan of the chest and abdomen, which helps to evaluate the cyst itself as well as its relationship with the surrounding structures 6 and plays significant role for planning the right procedure. To assess the pancreatic duct anatomy further, magnetic resonance imaging and magnetic resonance cholangiopancreatography can be done; however, CT scan is usually sufficient to plan the treatment.…”