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Interact CardioVasc Thorac Surg 2009;9:144-145. doi:10.1510/icvts.2009.202226 © 2009 European Association of Cardio-Thoracic Surgery
Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocystDivision of General Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nan-Yah S.Rd. Banqiao City, Taipei, Taiwan Received 9 January 2009; received in revised form 29 March 2009; accepted 31 March 2009
*Corresponding author. Tel.: +886-2-89667000 ext. 1317; fax: +886-2-89664355.
Acute mediastinitis is a life-threatening disease. Common etiologies include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Mediastinitis caused by pancreatic disease is rare. The most common thoracic complication of pancreatic disease is reactive pleural effusion. We report a case of acute mediastinitis and bilateral empyema thoracis arising from a pancreatic pseudocyst. We utilized thoracoscopy to drain the mediastinum without drainage of the intra-abdominal cyst. The patient recovered well after operation.
Key Words: Mediastinitis; Pancreatic pseudocyst; Thoracoscopy
Acute mediastinitis is a life-threatening disease. Common causes of acute mediastinitis include surgical infection, esophageal rupture, and descending infection from the pharynx. Ascending infection from an intra-abdominal focus to the mediastinum is very rare. We report a case of acute mediastinitis arising from a pancreatic pseudocyst.
A 41-year-old man was admitted to our emergency department after presenting with intense persistent precordial chest pain radiating to the back, and lasting one day. On admission, he also had high fever (40.4 °C), tachycardia, and dyspnea. There was no past history of trauma, or of symptoms related to the respiratory system or gastrointestinal tract. However, he suffered from alcoholic liver disease and hypertension that had not been treated adequately. On physical examination, he had mild abdominal pain without peritoneal signs. Chest wall expansion and breathing sounds were symmetric and clear. Lab testing showed leukocytosis with a left shift (white blood cells (WBC): 17,310/µl, neutrophils: 92.4%). Blood chemistry showed elevated amylase (310 U/l) and lipase (470 U/l) levels, as well as hyperglycemia (293 mg/dl). Chest film disclosed bilateral pleural effusion. Thoracocentesis was done, and the pleural effusion revealed high levels of lactate dehydrogenase (2866 IU/l), amylase (12,500 U/l), and WBC (58,500/µl, neutrophils: 88%). Other biochemistry studies of the pleural effusion revealed a glucose level of 143 mg/dl and a total protein of 4.8 g/dl. These results suggested an empyema thoracis of esophageal or pancreatic etiology. Chest computed tomography (CT) showed: (1) fluid accumulation in the posterior mediastinum and bilaterally in the pleural cavity, and (2) a pancreatic cyst extending upward into the posterior mediastinum (Fig. 1). Contrast study of the esophagus excluded the possibility of esophageal perforation. A pancreatic pseudocyst extending to the mediastinum, leading to mediastinitis and empyema thoracis, was diagnosed. The patient was empirically commenced on a broad-spectrum antibiotic (Tazocin, 3.375 g IV. q6h). Emergency surgical drainage of the mediastinum and bilateral pleural cavity was performed, using bilateral video-assisted thoracoscopic surgery (VATS), and including bilateral drainage of the pleural cavity, opening of the bilateral mediastinal pleura, and drainage of the mediastinum. Operative findings were necrotic tissue at the paraesophageal area and turbid pleural effusion and fibrin coating in the pleural cavities. Two 28 F chest tubes were placed in the right pleural cavity, and one 28 F chest tube was placed in the left pleural cavity.
The patient stayed in the intensive care unit postoperatively for two days because of systemic inflammatory response syndrome. Fever, chest pain, and toxic signs resolved on the first postoperative day. Chest tubes were removed one week after surgery, and antibiotic treatment continued for 10 days. Pleural effusion culture yielded no microorganism. The patient was discharged two weeks post-operation. Chest CT was performed as follow-up one month after surgery and showed complete resolution of the inflammation in the mediastinum and bilateral pleural cavities (Fig. 2), although the pancreatic pseudocyst persisted.
Extension of a pancreatic pseudocyst into the mediastinum is rare [1, 2]. Drainage of the mediastinal pancreatic pseudocyst is the key to success, and a variety of methods have been reported, including traditional external or internal drainage, and endoscopic stents [3]. Successful treatment of mediastinal pancreatic pseudocyst with sandostatin has also been reported [4]. However, frank mediastinitis arising from pancreatic pseudocyst, as in our case, is even rarer. Common etiologies of acute mediastinitis include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Our case manifested with ascending widespread necrosis and abscess formation, similar to the fulminant course of descending necrotizing mediastinitis. Acute mediastinitis is a serious, life-threatening complication; and surgical drainage of the mediastinum and pleural cavities, and broad-spectrum antibiotic treatment were certainly the appropriate management. Historically, several approaches for mediastinal drainage have been proposed: transcervical, subxiphoid, median sternotomy, and posterolateral thoracotomy [5, 6]. Traditionally, for drainage of posterior mediastinum and bilateral pleural cavity like our case, bilateral thoracotomy has been considered necessary for adequate drainage of mediastinitis and bilateral empyema thoracis. Recently, minimally invasive VATS was shown to achieve similar results with less morbidity [7, 8]. As drainage of descending necrotizing mediastinitis, we applied the VATS to the patient. We successfully treated this patient by draining the pleural cavities and mediastinum using VATS, although the pancreatic pseudocyst was not drained. This is the first reported case in the English literature of mediastinitis arising from a pancreatic pseudocyst that was successfully treated by thoracoscopic drainage alone. Because of a lack of recommendations in the published literature, we applied the experience of treating descending necrotizing mediastinitis to our patient. Repeated CT-scanning is suggested for the patient of descending necrotizing mediastinitis if the clinical manifestations are unstable. Second operation may be necessary if there is residual abscess. Fortunately, the patient had an uneventful postoperative course, and follow-up CT-scan one month postoperation revealed complete resolution of mediastinitis. In conclusion, pancreatic pseudocyst complicated by acute mediastinitis is very rare. Adequate drainage of the mediastinum, broad-spectrum antibiotic therapy, and supportive care for pancreatitis are mandatory. Thoracoscopic surgery can achieve results equivalent to those obtained with the much more invasive approach of thoracotomy.
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Abstract
1. Introduction
