Endoscopic Transhiatal Drainage of a Mediastinal Pancreatic Pseudocyst

Transgastric drainage of pancreatic pseudocysts guided by endoscopic ultrasound is now a standard procedure in experienced hands [1] [2]. Mediastinal pancreatic pseudocysts are relatively rare; they result from extension of pancreatic pseudocysts into the mediastinum [3] [4] [5]. Most patients are symptomatic with abdominal pain or dysphagia. In the cases reported in the literature, treatment was mostly surgical; there were some reports of minimally invasive transcutaneous or transpapillary procedures and of conservative approaches.

Our patient was admitted with a suspected diagnosis of achalasia. Endoscopic ultrasound (EUS) showed a typical mediastinal pseudocyst. This was confirmed by aspiration from the cyst of fluid which had an excessive amylase level. Cytological investigation of another, more cranial, mediastinal mass confirmed a small-cell lung cancer as an incidental additional finding. We decided to perform a transgastric transhiatal puncture of the cyst. After location by EUS, the walls of the stomach and cyst were cut with the needle-knife, using a large-bore endoscope. This resulted in the drainage of large amounts of fluid. Because of this and in view of the presence of the lung cancer, a pigtail catheter was not inserted. The dysphagia resolved immediately.

The patient presented 4 months later with recurrence of dysphagia. The cyst was punctured again as described above, and a guide wire was introduced under fluoroscopic guidance. After bougienage, a 7-Fr double-pigtail catheter was inserted over the wire (Fig. [1]). Large amounts of chocolate-like fluid emerged (Fig. [2]) and once again the dysphagia resolved immediately. The pigtail catheter was removed after 2 weeks and the cyst caused no further symptoms. The patient died from progressive cancer about 8 months later.

Figure 1 Radiological view showing a double-pigtail catheter connecting the mediastinal pseudocyst and the stomach. The transhiatal position can be clearly seen.

Figure 2 Endoscopic view showing the gastric end of the pigtail catheter and the chocolate-colored discharge.

This case shows that transhiatal drainage of mediastinal pseudocysts is a technically feasible, minimally invasive technique that may provide full symptomatic relief.

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References

• 1 Lo S K, Rowe A. Endoscopic management of pancreatic pseudocysts.  Gastroenterologist. 1997;  5 10-25
• 2 Giovannini M, Pesenti C, Rolland A-L. et al . Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope.  Endoscopy. 2001;  33 473-477
• 3 Satz N, Largiader F, Vorburger C. et al . Mediastinal pancreatic pseudocysts: report of two cases and review of the literature.  Schweiz Med Wochenschr. 1983;  113 1095-1100 [in German with English abstract]
• 4 Mallavarapu R, Habib T H, Elton E. et al . Resolution of mediastinal pancreatic pseudocysts with transpapillary stent placement.  Gastrointest Endosc. 2001;  53 367-370
• 5 Olah A, Nagy A S, Racz I. et al . Cardiac tamponade as a complication of pseudocyst in chronic pancreatitis.  Hepatogastroenterology. 2002;  49 564-566