Eur J Cardio-thorac
Surg (1992) 6:46-48
0 Springer-Verlag 1992
Mediastinal pancreatic pseudocyst H. Fiirst I, P. P. Schmittenbecher Department
I, H. Dienemann I, and H. Berger
of ’ Surgery and 2 Radiology,
Ludwig-Maximilian
University,
’
Munich, FRG
Abstract. Pseudocysts of the pancreas are a rare cause of a mediastinal mass. They are clinically characterized by the combination of thoracic symptoms (shortness of breath, dysphagia, pleural effusions) with complaints in the upper abdominal quadrants and weight loss. The diagnosis is usually made by CT scan or MRI including upper abdominal views. Internal drainage via an abdominal route performed either as cystogastrostomy or cystojejunostomy is the treatment of choice. [Eur J Cardio-thorac Surg (1992) 6346-483 Key words: Mediastinum
- Pancreatic pseudocysts - Internal drainage
Mediastinal masses include solid and cystic tumors. In 1970, WaBner found 41% cystic tumors of 15 231 mediastinal masses, with more than half being teratogenic cysts (24.1%). No pseudocysts of the pancreas were found [14]. Following acute or chronic pancreatitis, 40% -50% of patients will present with pancreatic pseudocysts when they are routinely examined by CT scanning [8,9]. These cysts may expand down to the groin and to the scrotum or up to the hypopharynx [12,13,15]. Treatment is usually either external drainage or internal drainage through surgery or via endoscopy [9]. Mediastinal pancreatic pseudocysts were described for the first time by Jones and by Edlin [6, II]. Up to now, only about 100 cases have been reported [4, 5,7]. In spite of this limited number, it is possible to discuss clinical and diagnostic procedures used to recognize and to treat these mediastinal masses.
Case report A 66-year-old male presented with a l-year history of recurrent pain in the lower chest and intermittent shortness of breath. After a barium meal, the esophagus was found to be shifted to the left. Thoraco-abdominal CT-scanning showed a cystic mass in the posterior mediastinum, 5.5 cm in diameter. The size of this mass was reduced caudally. With a diameter of about 1 cm, the mass ultimately touched the corpus of the pancreas. Received for publication: Accepted for publication:
June 27, 1991 August 29, 1991
At admission, the patient reported new belt-like postprandial pain. Concentrations of amylase (265 U/l) and alkaline phosphatase (212 U/l) were increased. At endoscopic retrograde cholangio-pancreaticography, the duodenal papilla was sounded. However, it was not possible to visualize the pancreatic duct. The common bile duct and the duodenal papilla appeared normal. These findings suggested that the patient had pancreatitis as a consquence of an obstruction of the pancreatic duct with formation of a pancreatic pseudocyst. He was initially discharged with a strict diet plan. Four weeks later he was readmitted with continuous elevation of amylase (580 U/l), lipase (193 U/l) and alkaline phosphatase (214 U/l). CT scanning revealed an enlargement of the mediastinal mass and an increased reaction of the surrounding soft tissue. The outlines of the head and the corpus of the pancreas were indistinct. Pleural effusions were found on both sides (Figs. 1, 2). For treatment, we did not consider endoscopic gastrocystostomy because the abdominal portion of the cyst was very small and the reaction of the surrounding soft tissue was significant. Therefore, surgery was recommended. At laparotomy, the cyst was identified at its lowest point in the lesser sac. The anterior wall was excised triangularily to establish adequate drainage in spite of the small caliber. A jejunal loop was connected to the cyst by a Y-Roux procedure (retrocolic pull-through). The concentration of amylase in the cyst fluid was 85000 U/l. On the 2nd postoperative day the amylase (66 U/l) and lipase (46 U/l) had returned to normal values. The postoperative course was uneventful. Control CT scanning prior to discharge showed, in the area of the former cyst, thickened soft tissue as a remnant of the cystic wall without any fluid (Fig. 3). Three month later the CT scan findings were fully normalized.
Discussion
Pancreatic pseudocysts occur mainly after trauma or inflammation. The majority of these cysts results from the
Fig. 1. Preoperative CT-scan (low-thoracic view): Mediastinal cystic mass with a diameter of 5 cm and inflammatory affection of the surrounding soft tissue. The esophagus is compressed and displaced to a left anterior-lateral position Fig. 2. Preoperative CT-scan (subdiaphragmatic view): The very small caudal part of the cyst reaching the pancreas also with marked inflammatory reaction of the surroundings Fig. 3. Postoperative CT-scan (low-thoracic view): Ten days after abdominal cystojejunostomy the same view as in Fig. 1 shows only small amounts of prevertebral soft tissue formation as remnants of the cystic wall without any fluid
autodigestive activity of pancreatic proteolytic enzymes. In rare cases, congenital abnormalities or occlusion of the pancreatic duct may lead to pancreatic pseudocysts [5,7]. The cyst usually spreads towards the area of lowest resistance into the lesser sac. Cysts may however penetrate into the mediastinum via anatomically preformed points of passage such as the aortic and the esophageal hiatus or, more rarely, the foramen Morgagni. They can also spread via posttraumatic defects of the diaphragm or areas of proteolytic destruction [7]. Differential diagnosis includes teratogenic, bronchogenic, enterogenic, pericardial, dermoid and echinococcus cysts and other very rare causes [l, 141. The symptoms are explained by chronic inflammation and by the size of the cyst which can displace other organs. In the history of the patients one can often find the characteristic combination of unspecific upper abdominal complaints with thoracic pain, shortness of breath, dysphagia and weight loss. Two-thirds of the cases present with pleural effusions [4,7, lo]. In two cases, cardiac symptoms were observed due to compression of the left atrium and ventricle [I]. Since thoracic complaints are dominating, diagnostic procedures usually focus on this region. On a standard chest film, shifting of the heart or of the stomach may be identified. After a barium meal, the esophagus may appear narrowed or may be shifted to the left in an anterolateral direction [7, IO]. Ultrasound examination may identify the abdominal portion of a cyst, but rarely visualizes the mediastinal portion. An echocardiogram can be helpful [l]. Ultimately, the cyst can always be diagnosed correctly by MRI or CT scanning if the thoracic and upper abdominal portions of the cyst are examined in-
eluding the pancreatic origin [2, 5, 71. CT-guided puncture of the thoracic portion and subsequent determination of amylase concentration may prove the suspected diagnosis. After acute pancreatitis, additional information may be gained by endoscopic retrograde cholangiopancreaticography, if it can demonstrate a pancreatic leakage with connection to the cyst, a direct communication with the mediastinal portion of the cyst or a high grade narrowing of the pancreatic duct [7]. The danger of infection after endoscopic manipulation should be kept in mind. If there are signs of an acute pancreatitis, conservative treatment may be indicated including total parenteral nutrition [9]. After 4-6 weeks of conservative treatment, 20% of all pseudocysts including two cases of mediastinal cysts showed spontaneous regression [4,5,9]. If this management failes, surgery is recommended because of possible complications such as bleeding, infection, rupture or compression of neighbouring structures. Surgery should always be performed via an abdominal access. The ultimate decision on the adequate procedure can finally be obtained during surgery. In all patients with thoraco-abdominal cysts of the pancreas, the treatment of choice is internal drainage. Cystogastrostomy can be done endoscopically [3, 5,7,9]. Among various surgical procedures, cystojejunostomy shows the lowest morbidity and recurrence rate [9]. In rare cases, an exclusive pancreatico-jejunostomy (Puestow procedure) is required [5]. If the pancreas and the pancreatic duct are not affected and if there is a mediastinal cyst which has lost its connection to the abdomen, the patient may be treated by a transdiaphragmatic cystojejunostomy alone [3]. If, at intraoperative contrast tilling, the pseudocyst does not show any connection to the pancreas or to a stenotic pancreatic duct, external drainage is possible only in combination with internal drainage of the pancreatic duct (Puestow procedure) [4]. Percutaneous drainage, which has been used twice successfully in patients with mediastinal cysts [5], shows high rates of recurrence (loo/ ~ 15%) and fistula formation (60%) when used in abdominal cysts. Percutaneous drainage should only be considered if there is no alteration of the pancreatic duct [4, 91. Follow-up control procedures primarily include thorace-abdominal CT scanning. Sonography and echocardiography represent an alternative. Unimpaired flow of pancreatic fluid via the internal drainage or via the natural way can be examined endoscopically.
48
Conclusions Considering about 100 published individual case reports, we conclude that upper abdominal and thoracic pain and weight loss combined with pleural effusions and shifting of the esophagus represent clinical symptoms and signs of a pancreatic pseudocyst extending into the mediastinum. The diagnosis can be made by CT or MRI scanning if they include views of the upper abdomen in patients presenting with cystic mediastinal masses. Only thus may an unnecessary thoracotomy be avoided. References 1. Aroney CN, Nicholson MR, Shevland JE (1985) Echocardiographic features of a mediastinal pancreatic pseudocyst. Br Heart J 53: 571-583 2. Ball JB, Clark RA (1982) CT of mediastinal pancreatic fluid collection. Comput Radio1 6: 295 - 300 3. Banks PA, McLellan PA, Gerzof SG (1984) Mediastinal pancreatic pseudocyst. Dig Dis Sci 29: 664-668 4. Beauchamp RD, Winsett M, Nealon WH (1989) Operative strategies in the management of mediastinal pancreatic pseudocyst. Surgery 105/106:567-570 5. Crobleholme TM, deLorimier AA, Adzick NS (1990) Mediastinal pancreatic pseudocysts in children. J Ped Surg 25: 843 - 845 6. Edlin P (1951) Mediastinal pseudocysts of the pancreas. Gastroenterology 17:96-102
Pankreaspseu7. Gaa J, Deininger HK (1988) Mediastinale dozyste. Riintgen-B141:406-410 8. Hamm B, Kimmel S (1987) Wertigkeit der Computertomographie bei Pankreatitis: atypische Pseudozysten und Nekrosen. Zbl Radio1 134: 238 -245 9. Hollender LF, Peiper H-J (1988) Zysten und Pseudozysten. In: Hollender LF, Peiper H-J (eds) Pankreaschirurgie. Springer, Berlin New York, pp 343-360 R 10. Johnston RH, Owensby LC, Vargas GM, Garcia-Rinaldi (1986) Pancreatic pseudocyst of the mediastinum. Ann Thorac Surg 41:210-212 11. Jones ES (1944) Pancreatic cysts with report of two unusual cases. J Ind State Med Assoc 37: 175 12. Salvo AF, Nematolaki H (1974) Distant dissection of a pancreatic pseudocyst into the right groin. Am J Surg 126:40-432 13. Steedman RA, Doering R, Carter R (1967) Surgical aspects of pancreatic abscess. Surg Gynecol Obstet 125: 757-762 14. Wal3ner VJ (1970) Mediastinalgeschwiilste. Schattauer, Stuttgart New York 15. Wieler H, Kippels A, Diix A (1988) Ungewijhnliche mediastinale Pankreaspseudozyste im hinteren Mediastinum. Fortschr Riintgenstr 148: 200-202
Dr H. Ftirst Chirurgische Abteilung Klinikum GroDhadern Ludwig-Maximilians-Universitat MarchioninistraDe 15 W-8000 Mtinchen 70 Federal Republic of Germany
Surg (1992) 6:46-48
0 Springer-Verlag 1992
Mediastinal pancreatic pseudocyst H. Fiirst I, P. P. Schmittenbecher Department
I, H. Dienemann I, and H. Berger
of ’ Surgery and 2 Radiology,
Ludwig-Maximilian
University,
’
Munich, FRG
Abstract. Pseudocysts of the pancreas are a rare cause of a mediastinal mass. They are clinically characterized by the combination of thoracic symptoms (shortness of breath, dysphagia, pleural effusions) with complaints in the upper abdominal quadrants and weight loss. The diagnosis is usually made by CT scan or MRI including upper abdominal views. Internal drainage via an abdominal route performed either as cystogastrostomy or cystojejunostomy is the treatment of choice. [Eur J Cardio-thorac Surg (1992) 6346-483 Key words: Mediastinum
- Pancreatic pseudocysts - Internal drainage
Mediastinal masses include solid and cystic tumors. In 1970, WaBner found 41% cystic tumors of 15 231 mediastinal masses, with more than half being teratogenic cysts (24.1%). No pseudocysts of the pancreas were found [14]. Following acute or chronic pancreatitis, 40% -50% of patients will present with pancreatic pseudocysts when they are routinely examined by CT scanning [8,9]. These cysts may expand down to the groin and to the scrotum or up to the hypopharynx [12,13,15]. Treatment is usually either external drainage or internal drainage through surgery or via endoscopy [9]. Mediastinal pancreatic pseudocysts were described for the first time by Jones and by Edlin [6, II]. Up to now, only about 100 cases have been reported [4, 5,7]. In spite of this limited number, it is possible to discuss clinical and diagnostic procedures used to recognize and to treat these mediastinal masses.
Case report A 66-year-old male presented with a l-year history of recurrent pain in the lower chest and intermittent shortness of breath. After a barium meal, the esophagus was found to be shifted to the left. Thoraco-abdominal CT-scanning showed a cystic mass in the posterior mediastinum, 5.5 cm in diameter. The size of this mass was reduced caudally. With a diameter of about 1 cm, the mass ultimately touched the corpus of the pancreas. Received for publication: Accepted for publication:
June 27, 1991 August 29, 1991
At admission, the patient reported new belt-like postprandial pain. Concentrations of amylase (265 U/l) and alkaline phosphatase (212 U/l) were increased. At endoscopic retrograde cholangio-pancreaticography, the duodenal papilla was sounded. However, it was not possible to visualize the pancreatic duct. The common bile duct and the duodenal papilla appeared normal. These findings suggested that the patient had pancreatitis as a consquence of an obstruction of the pancreatic duct with formation of a pancreatic pseudocyst. He was initially discharged with a strict diet plan. Four weeks later he was readmitted with continuous elevation of amylase (580 U/l), lipase (193 U/l) and alkaline phosphatase (214 U/l). CT scanning revealed an enlargement of the mediastinal mass and an increased reaction of the surrounding soft tissue. The outlines of the head and the corpus of the pancreas were indistinct. Pleural effusions were found on both sides (Figs. 1, 2). For treatment, we did not consider endoscopic gastrocystostomy because the abdominal portion of the cyst was very small and the reaction of the surrounding soft tissue was significant. Therefore, surgery was recommended. At laparotomy, the cyst was identified at its lowest point in the lesser sac. The anterior wall was excised triangularily to establish adequate drainage in spite of the small caliber. A jejunal loop was connected to the cyst by a Y-Roux procedure (retrocolic pull-through). The concentration of amylase in the cyst fluid was 85000 U/l. On the 2nd postoperative day the amylase (66 U/l) and lipase (46 U/l) had returned to normal values. The postoperative course was uneventful. Control CT scanning prior to discharge showed, in the area of the former cyst, thickened soft tissue as a remnant of the cystic wall without any fluid (Fig. 3). Three month later the CT scan findings were fully normalized.
Discussion
Pancreatic pseudocysts occur mainly after trauma or inflammation. The majority of these cysts results from the
Fig. 1. Preoperative CT-scan (low-thoracic view): Mediastinal cystic mass with a diameter of 5 cm and inflammatory affection of the surrounding soft tissue. The esophagus is compressed and displaced to a left anterior-lateral position Fig. 2. Preoperative CT-scan (subdiaphragmatic view): The very small caudal part of the cyst reaching the pancreas also with marked inflammatory reaction of the surroundings Fig. 3. Postoperative CT-scan (low-thoracic view): Ten days after abdominal cystojejunostomy the same view as in Fig. 1 shows only small amounts of prevertebral soft tissue formation as remnants of the cystic wall without any fluid
autodigestive activity of pancreatic proteolytic enzymes. In rare cases, congenital abnormalities or occlusion of the pancreatic duct may lead to pancreatic pseudocysts [5,7]. The cyst usually spreads towards the area of lowest resistance into the lesser sac. Cysts may however penetrate into the mediastinum via anatomically preformed points of passage such as the aortic and the esophageal hiatus or, more rarely, the foramen Morgagni. They can also spread via posttraumatic defects of the diaphragm or areas of proteolytic destruction [7]. Differential diagnosis includes teratogenic, bronchogenic, enterogenic, pericardial, dermoid and echinococcus cysts and other very rare causes [l, 141. The symptoms are explained by chronic inflammation and by the size of the cyst which can displace other organs. In the history of the patients one can often find the characteristic combination of unspecific upper abdominal complaints with thoracic pain, shortness of breath, dysphagia and weight loss. Two-thirds of the cases present with pleural effusions [4,7, lo]. In two cases, cardiac symptoms were observed due to compression of the left atrium and ventricle [I]. Since thoracic complaints are dominating, diagnostic procedures usually focus on this region. On a standard chest film, shifting of the heart or of the stomach may be identified. After a barium meal, the esophagus may appear narrowed or may be shifted to the left in an anterolateral direction [7, IO]. Ultrasound examination may identify the abdominal portion of a cyst, but rarely visualizes the mediastinal portion. An echocardiogram can be helpful [l]. Ultimately, the cyst can always be diagnosed correctly by MRI or CT scanning if the thoracic and upper abdominal portions of the cyst are examined in-
eluding the pancreatic origin [2, 5, 71. CT-guided puncture of the thoracic portion and subsequent determination of amylase concentration may prove the suspected diagnosis. After acute pancreatitis, additional information may be gained by endoscopic retrograde cholangiopancreaticography, if it can demonstrate a pancreatic leakage with connection to the cyst, a direct communication with the mediastinal portion of the cyst or a high grade narrowing of the pancreatic duct [7]. The danger of infection after endoscopic manipulation should be kept in mind. If there are signs of an acute pancreatitis, conservative treatment may be indicated including total parenteral nutrition [9]. After 4-6 weeks of conservative treatment, 20% of all pseudocysts including two cases of mediastinal cysts showed spontaneous regression [4,5,9]. If this management failes, surgery is recommended because of possible complications such as bleeding, infection, rupture or compression of neighbouring structures. Surgery should always be performed via an abdominal access. The ultimate decision on the adequate procedure can finally be obtained during surgery. In all patients with thoraco-abdominal cysts of the pancreas, the treatment of choice is internal drainage. Cystogastrostomy can be done endoscopically [3, 5,7,9]. Among various surgical procedures, cystojejunostomy shows the lowest morbidity and recurrence rate [9]. In rare cases, an exclusive pancreatico-jejunostomy (Puestow procedure) is required [5]. If the pancreas and the pancreatic duct are not affected and if there is a mediastinal cyst which has lost its connection to the abdomen, the patient may be treated by a transdiaphragmatic cystojejunostomy alone [3]. If, at intraoperative contrast tilling, the pseudocyst does not show any connection to the pancreas or to a stenotic pancreatic duct, external drainage is possible only in combination with internal drainage of the pancreatic duct (Puestow procedure) [4]. Percutaneous drainage, which has been used twice successfully in patients with mediastinal cysts [5], shows high rates of recurrence (loo/ ~ 15%) and fistula formation (60%) when used in abdominal cysts. Percutaneous drainage should only be considered if there is no alteration of the pancreatic duct [4, 91. Follow-up control procedures primarily include thorace-abdominal CT scanning. Sonography and echocardiography represent an alternative. Unimpaired flow of pancreatic fluid via the internal drainage or via the natural way can be examined endoscopically.
48
Conclusions Considering about 100 published individual case reports, we conclude that upper abdominal and thoracic pain and weight loss combined with pleural effusions and shifting of the esophagus represent clinical symptoms and signs of a pancreatic pseudocyst extending into the mediastinum. The diagnosis can be made by CT or MRI scanning if they include views of the upper abdomen in patients presenting with cystic mediastinal masses. Only thus may an unnecessary thoracotomy be avoided. References 1. Aroney CN, Nicholson MR, Shevland JE (1985) Echocardiographic features of a mediastinal pancreatic pseudocyst. Br Heart J 53: 571-583 2. Ball JB, Clark RA (1982) CT of mediastinal pancreatic fluid collection. Comput Radio1 6: 295 - 300 3. Banks PA, McLellan PA, Gerzof SG (1984) Mediastinal pancreatic pseudocyst. Dig Dis Sci 29: 664-668 4. Beauchamp RD, Winsett M, Nealon WH (1989) Operative strategies in the management of mediastinal pancreatic pseudocyst. Surgery 105/106:567-570 5. Crobleholme TM, deLorimier AA, Adzick NS (1990) Mediastinal pancreatic pseudocysts in children. J Ped Surg 25: 843 - 845 6. Edlin P (1951) Mediastinal pseudocysts of the pancreas. Gastroenterology 17:96-102
Pankreaspseu7. Gaa J, Deininger HK (1988) Mediastinale dozyste. Riintgen-B141:406-410 8. Hamm B, Kimmel S (1987) Wertigkeit der Computertomographie bei Pankreatitis: atypische Pseudozysten und Nekrosen. Zbl Radio1 134: 238 -245 9. Hollender LF, Peiper H-J (1988) Zysten und Pseudozysten. In: Hollender LF, Peiper H-J (eds) Pankreaschirurgie. Springer, Berlin New York, pp 343-360 R 10. Johnston RH, Owensby LC, Vargas GM, Garcia-Rinaldi (1986) Pancreatic pseudocyst of the mediastinum. Ann Thorac Surg 41:210-212 11. Jones ES (1944) Pancreatic cysts with report of two unusual cases. J Ind State Med Assoc 37: 175 12. Salvo AF, Nematolaki H (1974) Distant dissection of a pancreatic pseudocyst into the right groin. Am J Surg 126:40-432 13. Steedman RA, Doering R, Carter R (1967) Surgical aspects of pancreatic abscess. Surg Gynecol Obstet 125: 757-762 14. Wal3ner VJ (1970) Mediastinalgeschwiilste. Schattauer, Stuttgart New York 15. Wieler H, Kippels A, Diix A (1988) Ungewijhnliche mediastinale Pankreaspseudozyste im hinteren Mediastinum. Fortschr Riintgenstr 148: 200-202
Dr H. Ftirst Chirurgische Abteilung Klinikum GroDhadern Ludwig-Maximilians-Universitat MarchioninistraDe 15 W-8000 Mtinchen 70 Federal Republic of Germany
