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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 89-91

A Rare Case of Thoraco-Abdominal Pseudocyst of Pancreas: Managed by Roux-En-Y Cystojejunostomy


1 Associate professor, Dept.of surgical gastroenterology, IGIMS, Patna, India
2 Senior Resident, Dept.of surgical gastroenterology, IGIMS, Patna, India
3 Assistant professor, Dept.of surgical gastroenterology, IGIMS, Patna, India
4 Professor, Dept.of surgical gastroenterology, IGIMS, Patna, India
5 Associate professor, AIIMS, Patna, India

Date of Web Publication20-Nov-2020

Correspondence Address:
Qaisar Jamal
Senior Resident, Department of Gastrointes nal Surgery, IGIMS, Patna 800014
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Pancreatic pseudocysts are complications of acute orchronic pancreatitis. Most common site of pseudocyst is lesser sac. Mediastinal extension of pseudocyst is rare. Most pseudocystsresolve spontaneously with conservative management. The size and duration of pseudocyst formation has been present as poor predictors forpseudocyst resolution, but in general, larger cysts are more likely to be symptomatic or cause complications.
This patient presented withheaviness in chest and dysphagia. Computed tomography abdomen and thorax showed a large thoraco-abdominal pseudocyst. It was confirmed to be pancreatic pseudocyst by analyzing fluid for amylase and lipase intraoperatively. In our patient, the pseudocyst was accessible transabdominaly. Cystogastrostomy was not possible as cyst wall was not adhered with stomach. So, we did retrocolic and retrogastric Roux-en-Y cystojejunostomy.

Keywords: Thoracoabdominal pseudocyst; Posterior mediastenal; Roux-en-Y loop Cystojejunostomy.


How to cite this article:
Kumar S, Jamal Q, Singh RK, Mandal M, Anand U. A Rare Case of Thoraco-Abdominal Pseudocyst of Pancreas: Managed by Roux-En-Y Cystojejunostomy. J Indira Gandhi Inst Med Sci 2019;5:89-91

How to cite this URL:
Kumar S, Jamal Q, Singh RK, Mandal M, Anand U. A Rare Case of Thoraco-Abdominal Pseudocyst of Pancreas: Managed by Roux-En-Y Cystojejunostomy. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2020 Nov 26];5:89-91. Available from: http://www.jigims.co.in/text.asp?2019/5/1/89/301088




  Introduction: Top


Pancreatic pseudocysts are localized fluid collections in pancreatic tissue or peripancreatic space. It is surrounded by non-epithelialized wall consisting of fibrous and granulation tissues. It is common sequele of acute or chronic pancreatitis. Most common site of pseudocyst is lesser sac, retro peritoneum; extension of pseudocyst to mediastinum is rare. Presence of inflammation and fibrosis along peripancreatic spaces creates pathways of lesser resistance to mediastinum to form thoracopancreatic fistulas[1]. Thoraco-pancreatic fistulas are divided into four types based on the termination site of the fistula: pancreatico-pleural, mediastinalpseudocyst, pancreatico- bronchial, and pancreatico-pericardial[2]. Most common site of thoracopancreatic fistula is posterior mediastinum, with entry to the mediastinum via the aortic or esophageal hiatus[3].

We report this rare location of pancreatic pseudocystextentended into left side of posterior mediastinum. This patient was managed by transabdominal Roux-en-Y Cystojejunostomy. About 50 cases of mediastenal extension of pancreatic pseudocysts has been reported[4].


  Case Report: Top


A 15 year oldgirl presented with complaints of heaviness with dull aching pain in chest and difficulty in swallowing from last 2-3 months. Upper GI endoscopy revealed external esophageal compression starting from 28 cm upto GE junction. Patient had undergone CECT abdomen and thorax which shows bulky pancreatic body and tail, a 16x10 cm cystic lesion abutting tail of pancreas, abdominal aorta, inferior surface of left lobe of liver extending into thoracic cavity, left side of posterior mediastinum and closely abutting posterior pericardium [Figure 1],[Figure 2]. Blood investigations were normal. Serum Amylase and lipase were within normal limit. Echocardiography was normal.
Figure 1: Computed tomography thorax and abdomen showing thoraco-abdominal cyst of pancreas.

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Figure 2: Computed tomography thorax and abdomen showing thoraco-abdominal cyst of pancreas.

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Figure 3: Buldging pseudocyst transabdominally

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Figure 4: Aspirating cyst fluid.

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Figure 5: Pancreatic pseudocyst with mature wall.

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Since patient was symptomatic and CECT abdomen suggestive of pseudocyst, we planned surgery. On exploration, there was a large cyst starting from tail of pancreas extending above diaphragm into posterior mediastinum posterior to GE junction and esophagus. Cyst fluid was aspirated and sent for analysis intraoperatively. Aspirated fluid was thin in consistency, deep grey coloured and fluid Amylase level was 28342 U/L.

Cystogastrostomy was not possible because cyst wall was not adhered with stomach. So retrocolicretrogastric Roux- en-Y cystojejunostomy was done. Post op recovery was uneventful and patient discharged on 7th postoperative day. Cyst wall biopsy was suggestive of pseudocyst of pancreas with no evidence of malignancy. Patient reviewed after 3 weeks, general condition was good and asymptomatic. Patient is in regular follow up for last 8 months.


  Discussion: Top


Mediastinal cysts can be mature cystic teratoma, cystic neuroblastoma, thymic cyst, pericardial cyst, lymphangioma, esophagealduplication cyst or pancreatic pseudocyst. Mediastinal pancreatic pseudocyst was first described in 1951[5].

Pseudocyst formation is a common complication of acute and chronic complicaion, other causes may be trauma, congenital anomalies like anomalous pancreaticobiliary junction, pancreatic divisum, annular pancreas. Pseudocyst can be formed anywhere. Common sites in peritoneal cavity are lesser sac, peripancreatic spaces,paracolic gutter, etc. Thoracic extension is rare. Extension of a pancreatic pseudocyst into the mediastinum is uncommon. A cystic posterior mediastinal mass that develops over a short interval of time in a patient with history of pancreatitis is likely to be a pseudocyst. Fluids get collected in some cases, it gets walled off with granulation tissue and connective tissue due to inflammatory process. Pancreatic ductal morphology and its communication with the pseudocyst hold the key for successful management. A mediastinalpseudocyst usually occurs in the lower part of the posterior mediastinum, having gained access to the chest via the esophageal or aortic hiatus. Thoracoab dominalpseudocysts causes compression of adjacent structures and symptoms may be chest or abdominal pain, dysphagia, dyspnea, pseudo achalasia, weight loss[6].

CECT is investigation of choice in suspected pseudocyst thorax. CT shows a thin walled, cystic, low-attenuation mass in the posterior mediastinum or adjacent thoracic cavity associated with compression or displacement of the esophagus or splaying of the diaphragmatic crura. MRI can also help in delineating the communication of mediastinalpseudocysts with an abdominal pseudocyst[7]. MRCP also check ductal anomaly of pancreas. Endoscopic ultrasound givedetail overview on pseudocyst and its ductal communication. Endoscopic ultrasound guided aspiration of fluid and fluid analysis will be the definitive diagnostic measure[8].

The management of mediastinalpseudocysts depends on the symptoms, underlying etiology, ductal anatomy, size of the pseudocyst, and availability of expertise. Spontaneous resolution of mediastinalpseudocyst with conservative management is a rare[9]. Endoscopic retrograde cholangiopancreatogram (ERCP) has been employed for transpapillary stenting of the main pancreatic duct (MPD) and few reports have described successful resolution of mediastinalpseudocysts with transpapillary stenting alone[10][11]. ERCP carries complications like pancreatitis, haemorrhage, duodenal perforation, and cholangitis. Endoscopic procedures have significantly influenced the management of mediastinalpseudocysts. EUS assisted endoscopic drainage through either a transoesophageal[10] or transgastric approach has been mentioned with immediate relief in 90-95% of patients and long term success in 85-90% patients[12]. Surgery mainly done for drainage of thoracoabdominalpseudocysteither internal or external. Internal drainage can be cystogastrostomy, Roux- en-Y cystojejunostomy. Thoracoabdominal approach for management of mediastnal extension of pseudocyst used by Kotsis et al[13]. Management of complex mediastinal cyst by cystogastrostomywas reported by Sadat et al[14]. Only two cases of transdiaphragmatic Roux-en-Y cysto-jejunostomy in adult for mediastinalpseudocyst were reported in literature[15],[16].

In our patient diagnosis was not confirmed initially, she consulted physician with complain of heaviness in chest and dysphagia that referred herto a cardiologist to rule out cardiac anomaly. Since echo and other cardiac findings was normal , then patient was referred to our department. CECT abdomen suggestive of pseudocyst. UGI Endoscopy done to rule out fore gut duplication cyst. We successfully treated our patient with retrocolicretrogastric Roux-en-Y cystojejunostomy. Patient is on regular followup from last eight months and she is doing well.


  Conclusion: Top


To conclude, a mediastinalpseudocyst is a rare complication of acute or chronic pancreatitis which can be treated by drainage procedure like cystogastrostomy or Roux-en-Y Cystojejunostomy. Other modalities of treatment like endoscopic drainage has also given good result but needs experties. Internal drainage is a definitive mode of management with minimal recurrence.



 
  References Top

1.
Anatomic pathways of peripancreatic fluid draining to mediastinum in recurrent acute pancreatitis: visible human project and CT study. Xu H, Zhang X, Christe A, Ebner L, Zhang S, Luo Z, Wu Y, Li Y, TianFPLoS One. 2013; 8(4):e62025.  Back to cited text no. 1
    
2.
Thoracopancreatic fistula: clinical and imaging findings. Fulcher AS, Capps GW, Turner MA J Comput Assist Tomogr. 1999 Mar-Apr; 23(2):181-7.  Back to cited text no. 2
    
3.
Pancreaticopleural fistula and mediastinalpseudocyst: an unusual presentation of acute pancreatitis. Moorthy N, Raveesha A, Prabhakar KAnn Thorac Med. 2007 Jul; 2(3):122-3.  Back to cited text no. 3
    
4.
Mediastinal extension of a pancreatic pseudocyst. Rose EA, Haider M, Yang SK, Telmos AJ Am J Gastroenterol. 2000 Dec; 95(12):3638-9.  Back to cited text no. 4
    
5.
Endoscopic transgastric drainage of a pancreatic pseudocyst with mediastinal and cervical extensions. Topa L, László F, Sahin P, Pozsár JGastrointestEndosc. 2006 Sep; 64(3):460-3.  Back to cited text no. 5
    
6.
Pancreatic pseudocyst presenting as odynophagia. Chettupuzha AP, Harikumar R, Kumar SK, Thomas V, Devi SRIndian J Gastroenterol. 2004 Jan-Feb; 23(1):27-8.  Back to cited text no. 6
    
7.
Geier A, Lammert F, Gartung C, Nguyen HN, Wildberger JE, Matem S. Magnetic resonance imaging and magnetic resonance cholangiopancreaticography for diagnosis and pre-interventional evaluation of a fluid thoracic mass. Eur J GastroenterolHepatol 2003; 15:429-31.  Back to cited text no. 7
    
8.
Resolution of a complex mediastinalpseudocyst in a patient with alcohol-related chronic pancreatitis following abstinence from alcohol. Groeneveld JH, Tjong A Lieng JG, de Meijer PHEur J GastroenterolHepatol. 2006 Jan; 18(1):111-3.  Back to cited text no. 8
    
9.
Mediastinalpseudocysts in chronic pancreatitis with spontaneous resolution. Santoshkumar S, Seith A, Rastogi R, Khilnani GCTrop Gastroenterol. 2007 Jan-Mar; 28(1):32-4.  Back to cited text no. 9
    
10.
Esophageal stricture following successful resolution of a mediastinalpseudocyst by endoscopic transpapillary drainage. Rana SS, Bhasin DK, Rao C, Singh H, Sharma V, Singh K Endoscopy. 2012; 44 Suppl 2 UCTN():E121-2.  Back to cited text no. 10
    
11.
A case of complete resolution of mediastinalpseudocyst and pleural effusion by endoscopic stenting of pancreatic duct. Kim DJ, Chung HW, Gham CW, Na HG, Park SW, Lee SJ, Chung JP, Song SY, Chung JB, Kang JKYonsei Med J. 2003 Aug 30; 44(4):727-31.  Back to cited text no. 11
    
12.
Bhasin D., Rana S. Endoscopic management of pancreatic fluid collections. Journal of Digestive Endoscopy. 2012;3(5):40-43. doi: 10.4103/0976-5042.95030.  Back to cited text no. 12
    
13.
Transdiaphragmatic cyst-jejunostomy with Roux-en-Y loop for an exclusively mediastinal pancreatic pseudocyst. Kotsis L, Agocs L, Kostic S, Vadasz PScand J ThoracCardiovasc Surg. 1996; 30(3-4):181- 3.  Back to cited text no. 13
    
14.
Mediastinal extension of a complicated pancreatic pseudocyst; a case report and literature review. Sadat U, Jah A, Huguet EJ Med Case Rep. 2007 Apr 25; 1():12.  Back to cited text no. 14
    
15.
Transdiaphragmatic cyst-jejunostomy with Roux-en-Y loop for an exclusively mediastinal pancreatic pseudocyst. Kotsis L, Agocs L, Kostic S, Vadasz PScand J ThoracCardiovasc Surg. 1996; 30(3-4):181- 3.  Back to cited text no. 15
    
16.
An unusual cause of dysphagia: transabdominal Roux-en-Y cyst- jejunostomy in the surgical management of a symptomatic mediastinal cyst. Baker CR, Gossage JA, Mason RCJ SurgCase Rep. 2013 Mar 15; 2013(3).  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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