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Mediastinal pancreatic pseudocysts
Mediastinal Pancreatic Pseudocysts
Bernard M. Jaffe, MD, St. Louis, Missouri Thomas B. Ferguson, MD, St. Louis, Missouri Sumner Holtz, MD, St. Louis, Missouri John B. Shields, MD, St. Louis, Missouri
Pancreatic pseudocyst with mediastinal extension is a rare clinical entity, nine cases having been reported previously. As illustrated by the three additional patients described in this report, optimal surgical management should include operative (or preoperative) cystography and internal drainage via laparotomy. Case Reports Case I. The patient (BB), a forty-eight year old white woman, was initially hospitalized in 1964 for alcoholism and hepatomegaly. She was hospitalized three subsequent times between 1964 and 1970 for pancreatitis. On admission to St. Luke’s Hospital on February 2, 1971, her presenting complaints were epigastric pain, dysphagia, nausea, and vomiting which had started thirty-six hours earlier. Physical examination revealed no abnormalities with the exception of a firm liver, enlarged to four fingerbreadths below the right costal margin. The serum amylase was within normal limits. Chest roentgenogram demonstrated a rounded mediastinal mass. (Figure 1.) An upper gastrointestinal series performed shortly after admission revealed spasm of the distal esophagus and suggested the presence of an esophageal ulcer. Treatment with intravenous alimentation did not relieve the vomiting, and repeated barium swallow revealed almost complete obstruction of the distal esophagus by a paraesophageal soft tissue mass. The proximal esophagus was dilated. (Figure 2.) Esophagoscopy confirmed the presence of an extraluminal mass compressing the distal esophagus. A From the Departments of Surgery and Radiology, Washington University School of Medicine: the Department of Radiology, St. Louis University School of Medicine; and the John Cochran Veterans’ Administration Hospital, St. Louis, Missouri. Reprint requests should be addressed to Dr Jaffe, Department of Surgery, Washington University School of Medicine, 4950 Audubon Avenue, St. Louis, Missouri 63110.
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diagnosis of esophageal obstruction due to intramural tumor, probably leiomyoma, was made and operation recommended. At thoracotomy, performed on February 23, 1971, a 5 cm tense cystic mass was found in the posterior mediastinum between the aorta and esophagus and extending from below the diaphragm through the esophageal hiatus. Thin brown fluid aspirated from the cyst had an amylase level greater than 3,500. The cyst wall was incised and 800 cc of fluid evacuated. The cyst was explored from within and was found to communicate with a retroperitoneal pseudocyst arising from the tail of the pancreas. The pseudocyst was treated by external drainage, using a Foley catheter brought out through a subcostal stab wound. The mediastinal portion of this cyst was excised and the diaphragm was closed tightly around the esophagus. Postoperatively, the patient was able to eat without difficulty and the esophagus rapidly returned to normal size. Drainage from the Foley catheter gradually subsided, the cavity decreased in size as demonstrated by injection of the cavity (Figure 3), and the tube was removed three weeks after operation. She was discharged feeling we11 on March 18,197l. In July 1971, dysphagia and vomiting of undigested food recurred. She was admitted to the Maine Medical Center at which time an upper gastrointestinal series revealed anterior displacement of the distal esophagus and displacement of the stomach anteriorly and to the left. Although no mass could be identified on chest roentgenogram, the diagnosis of recurrent pseudocyst was made and, indeed, a mass in the left upper quadrant was palpable. Esophagoscopy confirmed marked displacement of the distal esophagus by an extrinsic mass. On August 8, 1971 exploratory laparotomy was performed. A huge pseudocyst was identified in the lesser sac in the region of the tail of the pancreas. The wall was biopsied and the cyst thoroughly explored to exclude additional smaller cysts; after these maneuvers Roux-en-Y cystjejunostomy was
The American
Journal of Surgery
Mediastinal
Pancreatic
Pseudocysts
Figure 7. A, tomogram of posteroanterior chest roentgenogram; 6, lateral chest roentgenogram. Both reveal rounded mediastinal mass. performed. Her postoperative course was uneventful, and since this internal drainage procedure, she has been asymptomatic. Case II. The patient (CJ), a forty-two year old black male alcoholic, was admitted to Barnes Hospital in June 1965. His presenting complaints were pain in the left side of the chest and dyspnea. He had undergone abdominoperineal resection for carcinoma of the rectum thirteen years previously, but had no evidence of recurrent carcinoma. He had also had several episodes of pancreatitis. Examination of the abdomen showed nothing abnormal, but physical examination of the chest suggested the presence of a large pleural effusion. Chest roentgenogram revealed almost total opacification of the left pleural space by fluid. (Figure 4.) Multiple thoracenteses were performed, yielding several liters of fluid with amylase contents consistently greater than 72,000. Simultaneous serum amylase levels varied between 250 and 400. Because the patient was so short of breath and it was impossible to control fluid accumulation by other means, left pleurectomy was performed without full knowledge of the significance of the elevated pleural fluid amylase. Four months later he was readmitted complaining of cough and pain in the left upper quadrant. No mass was palpated in the abdomen and a chest roentgenogram revealed a large
anterior mediastinal mass. (Figure 5.) An upper gastrointestinal series demonstrated that the mass displaced the stomach downward. Although the biliary tract was normal radiographically, a secretin test suggested chronic pancreatitis. On November 5, 1965 the mediastinal mass was aspirated percutaneously through the third left intercostal space. Amylase content of the fluid was greater than 70,000. The lumen of the cyst was visualized using Hypaque@ (Figure 6); a large pseudocyst with a mediastinal extension was demonstrated. Eleven days later, laparotomy was performed. The pancreas was thick, firm, and nodular. The pseudocyst, which communicated with the mediastinum via the esophageal hiatus, was treated by external drainage. Postoperative sinus injection showed a decrease in the size of the cavity. (Figure 7.) After drainage ceased, the catheter was removed. The patient was well for four years, until April 1969, when he was readmitted with weight loss, abdominal pain, and an epigastric mass. The chest roentgenogram now showed nothing abnormal, but the upper gastrointestinal series again demonstrated a large pseudocyst near the tail of the pancreas. (Figure 8.) At laparotomy the recurrent pseudocyst (without mediastinal component) was drained internally, using a Roux-en-Y cystjejunostomy. Since that operation, he has been asymptomatic.
gastrointestinal Figure 2. Upper series revealing distal esophageal obstruction and deviation of the cardia of the stomach.
Figure 3. Postoperative injection of the cyst cavity.
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Figure 4. Chest roentgenogram revealing almost total obliteration of the left pleural space by fluid.
Figure 5. Chest roentgenogram revealing high mediastinal mass with an air-fluid level.
Figure 6. A and B, posteroanterior and lateral roentgenograms of the preoperative Hypaque injection of the mediastinal mass.
Figure 7, injection ty
Postoperative with Hypaque.
sinus cavi-
Figure 8. Upper gastrointestinal series revealing a mass displacing the upper part of the stomach.
The American Journal of Surgery
Mediastinal
Figure 9. A, poster oanterior chest roentgenogram; gram. All reveal a rounded mediastinal mass.
8, lateral
Case III. The patient (LM), a forty-eight year old man with chronic alcoholism, was admitted to the St. Louis Veterans Administration Hospital in February 1971 with an exacerbation of chronic pancreatitis. Chronic relapsing pancreatitis had been diagnosed five years earlier. A pleural effusion was noted on chest roentgenogram. Plain films of the abdomen demonstrated marked pancreatic calcification, and an upper gastrointestinal series was within normal limits. The episode of pancreatitis subsided rapidly with intravenous alimentation and nasogastric suction, and he was discharged several days later. In May 1971 he was readmitted for elective repair of an inguinal hernia. Since the last admission, he had noted the onset of severe dysphagia. Physical examination was unremarkable except for an inguinal hernia. A chest roentgenogram taken prior to surgery showed a 6 cm posteroinferior mediastinal mass overlying the cardiac silhouette. (Figure 9.) Barium swallow and upper gastrointestinal series demonstrated displacement of the esophagus to the left and displacement of the stomach anteriorly by a
chest roentgenogram;
Pancreatic
C, posteroanterior
Pseudocysts
thoracic
tomo-
larger retrogastric mass. (Figure 10.) Although the mass did not pulsate on fluoroscopy, an aortogram was performed to rule out the presence of an aortic aneurysm. With the preoperative diagnosis of a mediastinal pseudocyst, left thoracotomy was performed. A 7 by 5 by 5 cm soft cystic mass was identified anteriorly, which displaced and splayed out the esophagus and communicated with the retroperitoneum through a diaphragmatic erosion anterior to the aortic foramen and to the right of the esophageal hiatus. Incision into the mass liberated several hundred milliliters of a brown fluid which had an amylase content of greater than 60,000. After aspiration of the fluid both the mediastinal and the retrogastric masses decompressed. The opening into the cyst was sutured, the chest was closed, and laparotomy performed. The pancreatic pseudocyst occupied the entire lesser sac and was firmly adherent to the posterior wall of the stomach. Anterior gastrotomy was performed and an operative cystogram was taken by injecting Hypaque into the cyst cavity; it domonstrated a wide communication between the two
Figure 10. A and 8, upper gasdeviaseries revealing trointestinal esophagus and tion of the distal stomach.
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Figure. 11 lntraoperative Hypaque cystogram revealing a large transdiaphragmatic communication between the mediastinal and the retroperitoneal components of the pseudocyst.
pseudocyst components. (Figure 11.) A cystogastrostomy was accomplished. Two weeks postoperatively the chest roentgenogram was within normal limits (the mediastinal mass was no longer identifiable) and the upper gastrointestinal series demonstrated that the stomach and esophagus had returned to their normal positions. A small amount of dye refluxed into the remaining cyst through the cystogastrostomy. In the last year he has had eipsodes of pancreatitis, but the pseudocyst has not recurred. Comments
With the nine patients described previously [l-9] and the three patients which comprise this series, a total of twelve pancreatic pseudocysts with mediastinal extension have now been reported. The clinical data on these twelve patients are summarized in Table I. Although the initial lesion in all patients was intra-abdominal, the predominant clinical manifestations were related to the thorax. The high incidence of pleural effusion, as will be described, made dyspnea the second most common symptom, described by five of the twelve patients. Epigastric pain was reported by seven patients whereas five complained of chest pain. Two of our three patients complained of dysphagia due to esophageal displacement and obstruction as a primary symptom. With the degree of esophageal displacement that can be caused by mediastinal pseudocysts, particularly those that traverse the esophageal hiatus, it is surprising that symptoms of esophageal obstruction predominated in only two of the nine previously reported patients.
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Abnormal physical findings have mainly been limited to those associated with pleural effusion. Although abdominal masses are regularly palpated in patients with pancreatic pseudocysts limited to the retroperitoneum, decompression of the pseudocyst through the diaphragm usually renders it imperceptible to palpation. In only one of the twelve patients was an epigastric mass palpated. The association of hydrothorax with mediastinal pancreatic pseudocysts is quite striking. Two of our patients and six of the previously reported nine patients had pleural effusions. Even with pseudocysts limited to the abdomen, pleural effusions are more commonly present than is generally realized. Individual cases of intra-abdominal pseudocysts associated with hydrothorax have been reported by Bickford [ 101, Traquair [I I], Smith [ 121, Kalser, Roth, and Bockus [13], Dignan [14], Udekwu, Nwankonobi, and Francis [15], Gross, Null and Loeb [16], and Prabhaker and co-wdrkers [17]. In 1955 Mahaffey and his associates [18] reviewed the world literature and were able to document the cases of ten patients with hydrothorax and pseudocysts. Pleural effusions were associated with pseudocysts of the pancreas in two of Howard and Jordan’s 150 patients [19], in four of Kaiser and associates’ thirty-nine patients, and in one of Rosato and Mackie’s twenty patients [20]. On the other hand, the two lesions coexisted in 20 per cent of Thomford and Jesseph’s fifty patients [21] and in 47 per cent of Erb and Grimes’ seventeen patients [22]. The authors reviewed the recent records of Barnes Hospital and found that eight of twentysix patients treated for pseudocysts of the pancreas had pleural effusions and four others had significant atelectasis of the lower lobes of the lung. Although the diagnosis of pancreatic pseudocyst with mediastinal extension was made before operation in only five of the twelve patients (Table I), we contend that a correct preoperative diagnosis should be made in virtually every case. The presence of a retrocardiac mass with associated displacement of the esophagus and stomach, possibly a left pleural effusion, and pancreatic calcification in the appropriate clinical circumstance is diagnostic of mediastinal pancreatic pseudocyst. Aortography excludes aneurysmal dilatation of the aorta and may outline the retroperitoneal component of the pseudocyst. At laparotomy, the full extent of the cyst can be visualized by injecting dye into the cyst cavity and obtaining an intraoperative cystogram. We suggest that intraoperative cystography (or preoperative cystography, as in case II) is essential in planning the proper management of this unusual clinical entity. Despite the fact that thoracic symptoms predominate, mediastinal pseudocysts are best managed
The American Journal of Surgery
I
Clinical
41, M
46, F
2. Clauss and Wilson [2]
3. McClintock, McFee, and Guinby [3] 4. Laird and Clagett [4] 5. Gee, Foster, and Doohen [5] 6. Galligan and Williams [S]
33, M
34, M
48, F
42, M
8. Reynes and Love [B]
9. Weidmann and Rutishauser [9]
Case I (Present report)
Case I I (Present report) Case I I I (Present report)
42, M
44, F
7. Sybers, Shelp, and Morrissey [7]
10, F
46, F
15, M
60, M
Age (yr) and Sex
Patient’s
Data of Twelve
1. Edlin [I]
Investigators
TABLE Cases
-
+ +
Esophageal
Aortic
Esophageal
Esophageal & Aortic
Esophageal
+
-
+
+
?
Dyspnea, dysphagia. abdominal pain Dysphagia, abdominal pain Dyspnea, chest pain Dysphagia
Aortic
+ Esophageal
Esophageal
+
-
Aortic
+
Aortic
Esophageal
+ -
Hiatus
Pleural Effusion
Pseudocysts
+
+
+
+
Correct Preoperative Diagnosis
of Pancreatic
Abdominal pain
Dyspnea. abdominal pain, Chest pain, weakness Dyspnea, chest pain Vomiting, abdominal pain Abdominal pain weight loss
Dyspnea. abdominal pain Chest and back pain
Symptoms
Reported
Left
-
Left
Thoracoabdominal
+
-
Left
Right
Thoracotomy
+
+
External drainage, cystojejunostomy Cystogastrostomy
External drainage, cystojejunostomy
Cystogastrostomy
+
+
Cystogastrostomy
+
drainage
then
then
External
+
+
+
Excision of thoracic component, sphincterotomy, choledochotomy, external drainage Cystogastrostomy
None
Surgical Therapy
Distal pancreatectomy, external drainage Distal pancreatectomy. external drainage Cystogastrostomy
+
+
+
Laparotomy
Recurred Good Good
Recurred Good
Died, mediastinal component unsuspected Abdominal component recurred Good
Good
Good
Good
Good
Died without treatment
Results
Jaffe
et al
without thoracotomy. Exploration of the thorax was performed in four patients, all of whom subsequently also required laparotomy. Half the pseudocysts traversed the diaphragm through the esophageal hiatus; the other, through the aortic foramen. In case III the presentation was unique in that the pseudocyst eroded through the diaphragmatic musculature. Two of our three patients were treated by external drainage alone, and in both cases the pseudocysts recurred. Both of these patients and the third patient were cured by internal drainage of the cyst into the gastrointestinal tract. In the Barnes Hospital series of intra-abdominal pseudocysts, four of eleven pseudocysts treated by external drainage recurred; all patients treated by internal drainage were cured. It is therefore suggested that the treatment of choice is laparotomy and cystenteric anastomosis. After adequate internal drainage, the mediastinal components rapidly disappear without any treatment specifically directed toward the thorax. Summary Three patients with mediastinal extension of pancreatic pseudocysts are presented. Clinical manifestations included a history of esophageal obstruction and pleural effusion in two patients, and in none of the three could an epigastric mass be palpated. The pseudocysts traversed the diaphragm by way of the esophageal hiatus in two patients and by erosion directly through the diaphragm in the third case. The latter occurrence has never been described before. The diagnosis of mediastinal pseudocyst should be considered in patients with lower mediastinal masses seen on chest roentgenogram, in whom barium studies show displacement of the distal esophagus and stomach by a retrogastric mass. Although the predominant clinical manifestations are related to the chest, proper management should include cystography, laparotomy, and cystenteric anastomoses. Two of our patients underwent thoracotomy and both eventually required laparotomy to cure the pseudocyst. External drainage in two patients was followed by recurrence of the pseudocyst, emphasizing the importance of internal drainage. Although mediastinal extension of a pancreatic pseudocyst, as described in this report, is uncommon, pleural effusion
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and atelectasis are frequent thoracic complications pancreatic pseudocysts limited to the abdomen.
of
Acknowledgment: We would like to thank Dr Ernest Rouse for permission to include case I in this report. References 1. Edlin P: Mediastinal pseudocyst of the pancreas. Gasfroenterology 17: 96, 1951. 2. Clauss RH, Wilson DW: Pancreatic pseudocyst of the mediastinum. J. Thoracic Surg 35: 795, 1958. 3. McClintock JT, McFee JL, Quimby RL: Pancreatic pseudocyst presenting as a mediastinal tumor. JAMA 192: 573, 1965. Laird CA, Clagett OT: Mediastinal pseudocyst of the pancreas in a child: report of a case. Surgery 60: 465, 1966. Gee W, Foster ED, Doohen DJ: Mediastinal pancreatic pseudocyst. Ann Surg 169: 420, 1969. Galligan JJ, Williams HJ: Pancreatic pseudocysts in childhood. Amer J Dis Child 112: 479, 1966. Sybers HD, Shelp WD, Morrissey JF: Pseudocyst of the pancreas with fistulous extension into the neck. New Eng J Med 278: io58,1968. a. Reynes CJ, Love L: Mediastinal pseudocyst. Radiology 92: 1151969. 9. Weidmann P, Rutishauser W, Siegenthaler W, Senning A: Mediastinal pseudocyst of the pancreas. Amer J Med 46: 454,1969. 10. Bickford BJ: Traumatic pseudo-cyst of the pancreas with pleural effusion. Brit MedJ 1: 1134, 1946. 11. Traquair K: Chylothorax following traumatic pseudocyst of the pancreas. Brit J Surg 33: 297, 1946. 12. Smith EB: Hemorrhagic ascites and hemothorax associated with benign pancreatic disease. Arch Surg 67: 52, 1953. 13. Kalser MH, Roth JLA, Bockus HL: Relapsing pancreatitis with pseudocyst of the pancreas and enzyme-containing pleural effusion. Gastroenterology 26: 642, 1955. 14. Dignan AP: Pancreatico-bronchial fistulae. Posfgrad Med J 41: 158, 1965. 15. Udekwu FAD, Nwankonobi F, Francis TJ: Pancreatic pseudocysts in children. Trans Int Co// Surg 44: 123, 1965. 16. Gross RJ, Null R, Loeb W: Pseudocyst of the pancreas associated with hydrothorax. Amer J Roentgenol 67: 565, 1952. 17. Prabhaker KN, Horton DA, Bennet DJ, Talley NA, Wright JS: Pseudocyst of the pancreas associated with hydrothorax. J Thorac Cardiovasc Surg 61: 665, 1971. la. Mahaffey JH, Haynes BW Jr, Mallams J. DeBakey ME: Pseudocyst of the pancreas associated with hydrothorax. Amer Surg 21: 601, 1955. 19. Howard JM, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, Lippincott, 1960, p 291. 20. Kaiser GC, King RD. Kilman JW, Lempke RE. Schumacher HB: Pancreatic pseudocysts. Arch Surg 69: 275, 1964. 21. Thomford NR, Jesseph JE: Pseudocyst of the pancreas. Amer J Surg 116: 66, 1969. 22. Erb WH, Grimes EL: Pseudocysts of the pancreas: a report of 17 cases. Amer J Surg 100: 30. 1960.
The American Journal of Surgery
Bernard M. Jaffe, MD, St. Louis, Missouri Thomas B. Ferguson, MD, St. Louis, Missouri Sumner Holtz, MD, St. Louis, Missouri John B. Shields, MD, St. Louis, Missouri
Pancreatic pseudocyst with mediastinal extension is a rare clinical entity, nine cases having been reported previously. As illustrated by the three additional patients described in this report, optimal surgical management should include operative (or preoperative) cystography and internal drainage via laparotomy. Case Reports Case I. The patient (BB), a forty-eight year old white woman, was initially hospitalized in 1964 for alcoholism and hepatomegaly. She was hospitalized three subsequent times between 1964 and 1970 for pancreatitis. On admission to St. Luke’s Hospital on February 2, 1971, her presenting complaints were epigastric pain, dysphagia, nausea, and vomiting which had started thirty-six hours earlier. Physical examination revealed no abnormalities with the exception of a firm liver, enlarged to four fingerbreadths below the right costal margin. The serum amylase was within normal limits. Chest roentgenogram demonstrated a rounded mediastinal mass. (Figure 1.) An upper gastrointestinal series performed shortly after admission revealed spasm of the distal esophagus and suggested the presence of an esophageal ulcer. Treatment with intravenous alimentation did not relieve the vomiting, and repeated barium swallow revealed almost complete obstruction of the distal esophagus by a paraesophageal soft tissue mass. The proximal esophagus was dilated. (Figure 2.) Esophagoscopy confirmed the presence of an extraluminal mass compressing the distal esophagus. A From the Departments of Surgery and Radiology, Washington University School of Medicine: the Department of Radiology, St. Louis University School of Medicine; and the John Cochran Veterans’ Administration Hospital, St. Louis, Missouri. Reprint requests should be addressed to Dr Jaffe, Department of Surgery, Washington University School of Medicine, 4950 Audubon Avenue, St. Louis, Missouri 63110.
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diagnosis of esophageal obstruction due to intramural tumor, probably leiomyoma, was made and operation recommended. At thoracotomy, performed on February 23, 1971, a 5 cm tense cystic mass was found in the posterior mediastinum between the aorta and esophagus and extending from below the diaphragm through the esophageal hiatus. Thin brown fluid aspirated from the cyst had an amylase level greater than 3,500. The cyst wall was incised and 800 cc of fluid evacuated. The cyst was explored from within and was found to communicate with a retroperitoneal pseudocyst arising from the tail of the pancreas. The pseudocyst was treated by external drainage, using a Foley catheter brought out through a subcostal stab wound. The mediastinal portion of this cyst was excised and the diaphragm was closed tightly around the esophagus. Postoperatively, the patient was able to eat without difficulty and the esophagus rapidly returned to normal size. Drainage from the Foley catheter gradually subsided, the cavity decreased in size as demonstrated by injection of the cavity (Figure 3), and the tube was removed three weeks after operation. She was discharged feeling we11 on March 18,197l. In July 1971, dysphagia and vomiting of undigested food recurred. She was admitted to the Maine Medical Center at which time an upper gastrointestinal series revealed anterior displacement of the distal esophagus and displacement of the stomach anteriorly and to the left. Although no mass could be identified on chest roentgenogram, the diagnosis of recurrent pseudocyst was made and, indeed, a mass in the left upper quadrant was palpable. Esophagoscopy confirmed marked displacement of the distal esophagus by an extrinsic mass. On August 8, 1971 exploratory laparotomy was performed. A huge pseudocyst was identified in the lesser sac in the region of the tail of the pancreas. The wall was biopsied and the cyst thoroughly explored to exclude additional smaller cysts; after these maneuvers Roux-en-Y cystjejunostomy was
The American
Journal of Surgery
Mediastinal
Pancreatic
Pseudocysts
Figure 7. A, tomogram of posteroanterior chest roentgenogram; 6, lateral chest roentgenogram. Both reveal rounded mediastinal mass. performed. Her postoperative course was uneventful, and since this internal drainage procedure, she has been asymptomatic. Case II. The patient (CJ), a forty-two year old black male alcoholic, was admitted to Barnes Hospital in June 1965. His presenting complaints were pain in the left side of the chest and dyspnea. He had undergone abdominoperineal resection for carcinoma of the rectum thirteen years previously, but had no evidence of recurrent carcinoma. He had also had several episodes of pancreatitis. Examination of the abdomen showed nothing abnormal, but physical examination of the chest suggested the presence of a large pleural effusion. Chest roentgenogram revealed almost total opacification of the left pleural space by fluid. (Figure 4.) Multiple thoracenteses were performed, yielding several liters of fluid with amylase contents consistently greater than 72,000. Simultaneous serum amylase levels varied between 250 and 400. Because the patient was so short of breath and it was impossible to control fluid accumulation by other means, left pleurectomy was performed without full knowledge of the significance of the elevated pleural fluid amylase. Four months later he was readmitted complaining of cough and pain in the left upper quadrant. No mass was palpated in the abdomen and a chest roentgenogram revealed a large
anterior mediastinal mass. (Figure 5.) An upper gastrointestinal series demonstrated that the mass displaced the stomach downward. Although the biliary tract was normal radiographically, a secretin test suggested chronic pancreatitis. On November 5, 1965 the mediastinal mass was aspirated percutaneously through the third left intercostal space. Amylase content of the fluid was greater than 70,000. The lumen of the cyst was visualized using Hypaque@ (Figure 6); a large pseudocyst with a mediastinal extension was demonstrated. Eleven days later, laparotomy was performed. The pancreas was thick, firm, and nodular. The pseudocyst, which communicated with the mediastinum via the esophageal hiatus, was treated by external drainage. Postoperative sinus injection showed a decrease in the size of the cavity. (Figure 7.) After drainage ceased, the catheter was removed. The patient was well for four years, until April 1969, when he was readmitted with weight loss, abdominal pain, and an epigastric mass. The chest roentgenogram now showed nothing abnormal, but the upper gastrointestinal series again demonstrated a large pseudocyst near the tail of the pancreas. (Figure 8.) At laparotomy the recurrent pseudocyst (without mediastinal component) was drained internally, using a Roux-en-Y cystjejunostomy. Since that operation, he has been asymptomatic.
gastrointestinal Figure 2. Upper series revealing distal esophageal obstruction and deviation of the cardia of the stomach.
Figure 3. Postoperative injection of the cyst cavity.
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Figure 4. Chest roentgenogram revealing almost total obliteration of the left pleural space by fluid.
Figure 5. Chest roentgenogram revealing high mediastinal mass with an air-fluid level.
Figure 6. A and B, posteroanterior and lateral roentgenograms of the preoperative Hypaque injection of the mediastinal mass.
Figure 7, injection ty
Postoperative with Hypaque.
sinus cavi-
Figure 8. Upper gastrointestinal series revealing a mass displacing the upper part of the stomach.
The American Journal of Surgery
Mediastinal
Figure 9. A, poster oanterior chest roentgenogram; gram. All reveal a rounded mediastinal mass.
8, lateral
Case III. The patient (LM), a forty-eight year old man with chronic alcoholism, was admitted to the St. Louis Veterans Administration Hospital in February 1971 with an exacerbation of chronic pancreatitis. Chronic relapsing pancreatitis had been diagnosed five years earlier. A pleural effusion was noted on chest roentgenogram. Plain films of the abdomen demonstrated marked pancreatic calcification, and an upper gastrointestinal series was within normal limits. The episode of pancreatitis subsided rapidly with intravenous alimentation and nasogastric suction, and he was discharged several days later. In May 1971 he was readmitted for elective repair of an inguinal hernia. Since the last admission, he had noted the onset of severe dysphagia. Physical examination was unremarkable except for an inguinal hernia. A chest roentgenogram taken prior to surgery showed a 6 cm posteroinferior mediastinal mass overlying the cardiac silhouette. (Figure 9.) Barium swallow and upper gastrointestinal series demonstrated displacement of the esophagus to the left and displacement of the stomach anteriorly by a
chest roentgenogram;
Pancreatic
C, posteroanterior
Pseudocysts
thoracic
tomo-
larger retrogastric mass. (Figure 10.) Although the mass did not pulsate on fluoroscopy, an aortogram was performed to rule out the presence of an aortic aneurysm. With the preoperative diagnosis of a mediastinal pseudocyst, left thoracotomy was performed. A 7 by 5 by 5 cm soft cystic mass was identified anteriorly, which displaced and splayed out the esophagus and communicated with the retroperitoneum through a diaphragmatic erosion anterior to the aortic foramen and to the right of the esophageal hiatus. Incision into the mass liberated several hundred milliliters of a brown fluid which had an amylase content of greater than 60,000. After aspiration of the fluid both the mediastinal and the retrogastric masses decompressed. The opening into the cyst was sutured, the chest was closed, and laparotomy performed. The pancreatic pseudocyst occupied the entire lesser sac and was firmly adherent to the posterior wall of the stomach. Anterior gastrotomy was performed and an operative cystogram was taken by injecting Hypaque into the cyst cavity; it domonstrated a wide communication between the two
Figure 10. A and 8, upper gasdeviaseries revealing trointestinal esophagus and tion of the distal stomach.
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Figure. 11 lntraoperative Hypaque cystogram revealing a large transdiaphragmatic communication between the mediastinal and the retroperitoneal components of the pseudocyst.
pseudocyst components. (Figure 11.) A cystogastrostomy was accomplished. Two weeks postoperatively the chest roentgenogram was within normal limits (the mediastinal mass was no longer identifiable) and the upper gastrointestinal series demonstrated that the stomach and esophagus had returned to their normal positions. A small amount of dye refluxed into the remaining cyst through the cystogastrostomy. In the last year he has had eipsodes of pancreatitis, but the pseudocyst has not recurred. Comments
With the nine patients described previously [l-9] and the three patients which comprise this series, a total of twelve pancreatic pseudocysts with mediastinal extension have now been reported. The clinical data on these twelve patients are summarized in Table I. Although the initial lesion in all patients was intra-abdominal, the predominant clinical manifestations were related to the thorax. The high incidence of pleural effusion, as will be described, made dyspnea the second most common symptom, described by five of the twelve patients. Epigastric pain was reported by seven patients whereas five complained of chest pain. Two of our three patients complained of dysphagia due to esophageal displacement and obstruction as a primary symptom. With the degree of esophageal displacement that can be caused by mediastinal pseudocysts, particularly those that traverse the esophageal hiatus, it is surprising that symptoms of esophageal obstruction predominated in only two of the nine previously reported patients.
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Abnormal physical findings have mainly been limited to those associated with pleural effusion. Although abdominal masses are regularly palpated in patients with pancreatic pseudocysts limited to the retroperitoneum, decompression of the pseudocyst through the diaphragm usually renders it imperceptible to palpation. In only one of the twelve patients was an epigastric mass palpated. The association of hydrothorax with mediastinal pancreatic pseudocysts is quite striking. Two of our patients and six of the previously reported nine patients had pleural effusions. Even with pseudocysts limited to the abdomen, pleural effusions are more commonly present than is generally realized. Individual cases of intra-abdominal pseudocysts associated with hydrothorax have been reported by Bickford [ 101, Traquair [I I], Smith [ 121, Kalser, Roth, and Bockus [13], Dignan [14], Udekwu, Nwankonobi, and Francis [15], Gross, Null and Loeb [16], and Prabhaker and co-wdrkers [17]. In 1955 Mahaffey and his associates [18] reviewed the world literature and were able to document the cases of ten patients with hydrothorax and pseudocysts. Pleural effusions were associated with pseudocysts of the pancreas in two of Howard and Jordan’s 150 patients [19], in four of Kaiser and associates’ thirty-nine patients, and in one of Rosato and Mackie’s twenty patients [20]. On the other hand, the two lesions coexisted in 20 per cent of Thomford and Jesseph’s fifty patients [21] and in 47 per cent of Erb and Grimes’ seventeen patients [22]. The authors reviewed the recent records of Barnes Hospital and found that eight of twentysix patients treated for pseudocysts of the pancreas had pleural effusions and four others had significant atelectasis of the lower lobes of the lung. Although the diagnosis of pancreatic pseudocyst with mediastinal extension was made before operation in only five of the twelve patients (Table I), we contend that a correct preoperative diagnosis should be made in virtually every case. The presence of a retrocardiac mass with associated displacement of the esophagus and stomach, possibly a left pleural effusion, and pancreatic calcification in the appropriate clinical circumstance is diagnostic of mediastinal pancreatic pseudocyst. Aortography excludes aneurysmal dilatation of the aorta and may outline the retroperitoneal component of the pseudocyst. At laparotomy, the full extent of the cyst can be visualized by injecting dye into the cyst cavity and obtaining an intraoperative cystogram. We suggest that intraoperative cystography (or preoperative cystography, as in case II) is essential in planning the proper management of this unusual clinical entity. Despite the fact that thoracic symptoms predominate, mediastinal pseudocysts are best managed
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I
Clinical
41, M
46, F
2. Clauss and Wilson [2]
3. McClintock, McFee, and Guinby [3] 4. Laird and Clagett [4] 5. Gee, Foster, and Doohen [5] 6. Galligan and Williams [S]
33, M
34, M
48, F
42, M
8. Reynes and Love [B]
9. Weidmann and Rutishauser [9]
Case I (Present report)
Case I I (Present report) Case I I I (Present report)
42, M
44, F
7. Sybers, Shelp, and Morrissey [7]
10, F
46, F
15, M
60, M
Age (yr) and Sex
Patient’s
Data of Twelve
1. Edlin [I]
Investigators
TABLE Cases
-
+ +
Esophageal
Aortic
Esophageal
Esophageal & Aortic
Esophageal
+
-
+
+
?
Dyspnea, dysphagia. abdominal pain Dysphagia, abdominal pain Dyspnea, chest pain Dysphagia
Aortic
+ Esophageal
Esophageal
+
-
Aortic
+
Aortic
Esophageal
+ -
Hiatus
Pleural Effusion
Pseudocysts
+
+
+
+
Correct Preoperative Diagnosis
of Pancreatic
Abdominal pain
Dyspnea. abdominal pain, Chest pain, weakness Dyspnea, chest pain Vomiting, abdominal pain Abdominal pain weight loss
Dyspnea. abdominal pain Chest and back pain
Symptoms
Reported
Left
-
Left
Thoracoabdominal
+
-
Left
Right
Thoracotomy
+
+
External drainage, cystojejunostomy Cystogastrostomy
External drainage, cystojejunostomy
Cystogastrostomy
+
+
Cystogastrostomy
+
drainage
then
then
External
+
+
+
Excision of thoracic component, sphincterotomy, choledochotomy, external drainage Cystogastrostomy
None
Surgical Therapy
Distal pancreatectomy, external drainage Distal pancreatectomy. external drainage Cystogastrostomy
+
+
+
Laparotomy
Recurred Good Good
Recurred Good
Died, mediastinal component unsuspected Abdominal component recurred Good
Good
Good
Good
Good
Died without treatment
Results
Jaffe
et al
without thoracotomy. Exploration of the thorax was performed in four patients, all of whom subsequently also required laparotomy. Half the pseudocysts traversed the diaphragm through the esophageal hiatus; the other, through the aortic foramen. In case III the presentation was unique in that the pseudocyst eroded through the diaphragmatic musculature. Two of our three patients were treated by external drainage alone, and in both cases the pseudocysts recurred. Both of these patients and the third patient were cured by internal drainage of the cyst into the gastrointestinal tract. In the Barnes Hospital series of intra-abdominal pseudocysts, four of eleven pseudocysts treated by external drainage recurred; all patients treated by internal drainage were cured. It is therefore suggested that the treatment of choice is laparotomy and cystenteric anastomosis. After adequate internal drainage, the mediastinal components rapidly disappear without any treatment specifically directed toward the thorax. Summary Three patients with mediastinal extension of pancreatic pseudocysts are presented. Clinical manifestations included a history of esophageal obstruction and pleural effusion in two patients, and in none of the three could an epigastric mass be palpated. The pseudocysts traversed the diaphragm by way of the esophageal hiatus in two patients and by erosion directly through the diaphragm in the third case. The latter occurrence has never been described before. The diagnosis of mediastinal pseudocyst should be considered in patients with lower mediastinal masses seen on chest roentgenogram, in whom barium studies show displacement of the distal esophagus and stomach by a retrogastric mass. Although the predominant clinical manifestations are related to the chest, proper management should include cystography, laparotomy, and cystenteric anastomoses. Two of our patients underwent thoracotomy and both eventually required laparotomy to cure the pseudocyst. External drainage in two patients was followed by recurrence of the pseudocyst, emphasizing the importance of internal drainage. Although mediastinal extension of a pancreatic pseudocyst, as described in this report, is uncommon, pleural effusion
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and atelectasis are frequent thoracic complications pancreatic pseudocysts limited to the abdomen.
of
Acknowledgment: We would like to thank Dr Ernest Rouse for permission to include case I in this report. References 1. Edlin P: Mediastinal pseudocyst of the pancreas. Gasfroenterology 17: 96, 1951. 2. Clauss RH, Wilson DW: Pancreatic pseudocyst of the mediastinum. J. Thoracic Surg 35: 795, 1958. 3. McClintock JT, McFee JL, Quimby RL: Pancreatic pseudocyst presenting as a mediastinal tumor. JAMA 192: 573, 1965. Laird CA, Clagett OT: Mediastinal pseudocyst of the pancreas in a child: report of a case. Surgery 60: 465, 1966. Gee W, Foster ED, Doohen DJ: Mediastinal pancreatic pseudocyst. Ann Surg 169: 420, 1969. Galligan JJ, Williams HJ: Pancreatic pseudocysts in childhood. Amer J Dis Child 112: 479, 1966. Sybers HD, Shelp WD, Morrissey JF: Pseudocyst of the pancreas with fistulous extension into the neck. New Eng J Med 278: io58,1968. a. Reynes CJ, Love L: Mediastinal pseudocyst. Radiology 92: 1151969. 9. Weidmann P, Rutishauser W, Siegenthaler W, Senning A: Mediastinal pseudocyst of the pancreas. Amer J Med 46: 454,1969. 10. Bickford BJ: Traumatic pseudo-cyst of the pancreas with pleural effusion. Brit MedJ 1: 1134, 1946. 11. Traquair K: Chylothorax following traumatic pseudocyst of the pancreas. Brit J Surg 33: 297, 1946. 12. Smith EB: Hemorrhagic ascites and hemothorax associated with benign pancreatic disease. Arch Surg 67: 52, 1953. 13. Kalser MH, Roth JLA, Bockus HL: Relapsing pancreatitis with pseudocyst of the pancreas and enzyme-containing pleural effusion. Gastroenterology 26: 642, 1955. 14. Dignan AP: Pancreatico-bronchial fistulae. Posfgrad Med J 41: 158, 1965. 15. Udekwu FAD, Nwankonobi F, Francis TJ: Pancreatic pseudocysts in children. Trans Int Co// Surg 44: 123, 1965. 16. Gross RJ, Null R, Loeb W: Pseudocyst of the pancreas associated with hydrothorax. Amer J Roentgenol 67: 565, 1952. 17. Prabhaker KN, Horton DA, Bennet DJ, Talley NA, Wright JS: Pseudocyst of the pancreas associated with hydrothorax. J Thorac Cardiovasc Surg 61: 665, 1971. la. Mahaffey JH, Haynes BW Jr, Mallams J. DeBakey ME: Pseudocyst of the pancreas associated with hydrothorax. Amer Surg 21: 601, 1955. 19. Howard JM, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, Lippincott, 1960, p 291. 20. Kaiser GC, King RD. Kilman JW, Lempke RE. Schumacher HB: Pancreatic pseudocysts. Arch Surg 69: 275, 1964. 21. Thomford NR, Jesseph JE: Pseudocyst of the pancreas. Amer J Surg 116: 66, 1969. 22. Erb WH, Grimes EL: Pseudocysts of the pancreas: a report of 17 cases. Amer J Surg 100: 30. 1960.
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