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Endoscopic management of pancreatic duct disruption with large mediastinal pseudocyst

Open AccessPublished:March 15, 2018DOI:https://doi.org/10.1016/j.vgie.2018.01.013
      A 47-year-old woman with schizophrenia and a history of chronic pancreatitis, alcohol use disorder, chronic portal vein thrombosis, and chronic left-sided pleural effusion presented with a 1-day history of fever, shortness of breath, dysphagia, and abdominal pain. On admission, she was febrile, tachypnic, and tachycardic. She had shortness of breath and dysphagia. Her physical examination results were significant for diaphoresis, sclera icterus, diffuse abdominal pain, and exquisite back tenderness. Broad-spectrum antibiotics were started, she was given 4 L oxygen by nasal cannula, and she was admitted to the medicine service for further management.
      CT imaging of the chest and abdomen showed a steatotic liver and a pancreas with multiple calcifications indicative of chronic pancreatitis. Near the diaphragmatic hiatus, a fluid collection measuring 10 cm × 7 cm × 7 cm was observed to extend from the head of the pancreas to the mediastinum (Figure 1, Figure 2, Figure 3, Figure 4). Laboratory test results were significant for albumin 1.6, international normalized ratio of 1.3, and white blood cell count of 10.8 with 88% neutrophils. Blood culture grew Escherichia coli and Streptococcus parasinguinis, with no evidence of endocarditis in the transthoracic echocardiogram. However, given the patient’s ongoing low-grade fever despite the administration of broad-spectrum antibiotics, there was concern that the fluid collection could be infected, needing surgical drainage. She was thus transferred to the endoscopy service for possible intervention (Video 1, available online at www.VideoGIE.org).
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      Figure 1CT transverse plane view demonstrating steatotic liver and atrophic pancreas with multiple calcifications consistent with chronic pancreatitis.
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      Figure 2CT transverse plane view of the pancreatic pseudocyst in the mediastinum measuring 10 cm × 7 cm × 7 cm near the diaphragmatic hiatus. Bilateral pleural fluid is demonstrated, larger on the right side.
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      Figure 3CT transverse plane view of the pancreatic pseudocyst at the level of aortic arch and T4 vertebral body. Bilateral pleural fluid collection is seen, larger on the right side.
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      Figure 4CT sagittal plane view of the pancreatic pseudocyst, demonstrating extension of fluid collection to mediastinum.
      EUS showed an irregular pancreas with calcifications from which a fluid collection originated, tracking upward to the mediastinum, consistent with pancreatic pseudocyst from a possible pancreatic duct leak. The large fluid collection in the mediastinum was identified with visible debris. EUS-guided transesophageal aspiration was performed with subsequent decrease in fluid collection. The fluid extracted was cloudy (Fig. 5) with elevated amylase to 4900 U/L, but with no growth on culture and absence of malignant cells. After aspiration, the patient’s oxygen requirement improved from 4L to 2L by nasal cannula.
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      Figure 5Pancreatic pseudocyst turbid aspirate.
      ERCP with pancreatogram demonstrated extravasation of contrast material from the main pancreatic duct at the genu into the peripancreatic collection, tracking upward toward the mediastinum through an internal pancreatic fistula. Guidewire placement was difficult because of the tortuous pancreatic duct and the location of the stricture proximal to the leak. ERCP dialing and balloon catheters were attempted, but they failed because of their floppy composition and the tight stricture. The Soehendra stent retriever (Cook Medical, Bloomington, Ind) is a catheter that has a stiff metal sheath (Fig. 6), which is normally used to retrieve stents, manually rotated by the operator. In this case, however, the Soehendra stent retriever’s rotating action allowed access to this stricture and subsequent placement of a 7F, 12-cm plastic pancreatic stent across the stricture and leak site to bridge the communication of the pancreatic cyst with the pancreatic duct. The patient had no post-ERCP adverse events, and follow-up ERCP was scheduled for 2 months after the procedure.
      Repeat ERCP demonstrated a lack of extravasation of contrast material in the pancreatogram and confirmed resolution of the previous duct leak. CT of the chest and abdomen 4 months after intervention showed complete resolution of the pseudocyst, along with resolution of right pleural effusions and decrease in left-sided pleural effusion (Figs. 7 and 8).
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      Figure 7CT abdomen transverse plane view 4 months after ERCP stent placement, showing no pancreatic pseudocyst emerging from pancreas. Hepatic steatosis is notable, but no pleural effusion is noted.
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      Figure 8CT transverse plane view of mediastinum 4 months after ERCP pancreatic duct stent placement, showing resolution of mediastinal pancreatic pseudocyst and near-resolution of bilateral pleural fluid collections.
      This case illustrates 2 endoscopic techniques. First, we bridged the pancreatic duct leaks with a stent to ensure drainage and closure of the leak. Second, we used a Soehendra stent retriever whose stiff metal sheath bore access to this stricture, which was advanced with catheter rotation after failure of the dialing and balloon dilation catheters.
      Thus, management of a symptomatic large fluid collection suspected of being a pancreatic duct leak should undergo drainage either percutaneously or transmurally, which can be done by a plastic stent, lumen-apposing metal stent, or aspiration. After drainage, ERCP ought to be done to determine its anatomy and bridge the pancreatic duct leak with a plastic stent. If bridging is successful, continued monitoring of the fluid collection and clinical course is indicated, but if bridging fails, long-term transmural drainage with a plastic stent, with or without ERCP, should follow (Fig. 9).
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      Figure 9Algorithmic approach to management of symptomatic large fluid collection suspected to originate from a PD disruption. LAMS, lumen-apposing metal stent; PD, pancreatic duct.
      In conclusion, mediastinal extension of a pancreatic pseudocyst is rare.
      • Gupta R.
      • Munoz J.C.
      • Garg P.
      • et al.
      Mediastinal pancreatic pseudocyst—a case report and review of the literature.
      Percutaneous drainage of a mediastinal fluid collection should be avoided if possible because it is associated with a risk of bronchopleural fistula formation.
      • McDermott S.
      • Levis D.A.
      • Arellano R.S.
      Chest drainage.
      Moreover, the use of larger-caliber stents across leaks ensures higher closure success.
      Here, we describe a mediastinal pancreatic pseudocyst treated with transesophageal aspiration and bridging of a pancreatic duct stricture accessed with a Soehendra stent retrieval catheter. Our approach led to complete resolution of the pseudocyst, eliminating compressing symptoms that were causing dysphagia, shortness of breath, and abdominal pain in this patient.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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