Post written by Vivian Ortiz, MD, Muhammad Nadeem Yousaf, MD, and Harry R. Aslanian, MD, from the Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA.
A 47-year-old woman with alcohol-related chronic pancreatitis, chronic portal vein thrombosis and, left-sided pleural effusion presented with a 1-day history of fever, shortness of breath, dysphagia, and abdominal pain. On physical exam, she was febrile and tachycardic and had impressive abdominal and back tenderness. CT abdomen showed a large, predominantly mediastinal, fluid collection. EUS-guided transesophageal aspiration of the large mediastinal collection was performed, yielding a cloudy fluid with a high amylase (4900 U/L). ERCP with pancreatogram demonstrated chronic pancreatitis with extravasation of fluid from the main pancreatic duct (MPD), which tracked upwards to the mediastinum. Attempts with a balloon dilator to cross the stricture were unsuccessful. We utilized a Soehendra stent retriever to dilate the MPD stricture, which enabled placement of a 7F, 12-cm plastic pancreatic stent, bridging the MPD disruption. Follow-up ERCP showed resolution of the MPD leak, and CT of abdomen 4 months later showed complete resolution of the mediastinal pancreatic pseudocyst and near-resolution of bilateral pleural effusions.
Large mediastinal pancreatic pseudocysts are rare and the management of pancreas duct disruption and associated pseudocysts can be complex and require an individualized, multidisciplinary approach. We proposed an approach to mediastinal pseudocysts and highlighted the combined use of EUS, ERCP, and the use of a Soehendra stent retriever as a pancreas duct dilator, whose metal composition and rotating motion allowed bridging of the pancreatic duct leak with a plastic stent to ensure successful closure and resolution of the mediastinal pancreatic pseudocyst.
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