Mediastinal pancreatobiliary pseudocysts

Abstract

To select the optimal treatment for uninfected and suppurative rare mediastinal pancreatobiliary pseudocysts. There were 10 patients with mediastinal pancreatogenic (n=9) and biliogenic (n=1) pseudocysts formed through esophageal (n=9) and aortic (n=1) hiatus of the diaphragm. All patients were divided into groups: group A - uninfected pancreatic pseudocysts (n=5) formed through esophageal hiatus; group B - 5 patients with suppurative pancreatogenic (n=4) and biliogenic (n=1) mediastinitis complicated by biliopleuroesophageal (n=1), pancreatoesophageal (n=1) and pancreatopleural (n=2) fistulas. In the group A, simultaneous procedures (n=5) were performed depending on pancreatic parenchyma and pancreatic duct destruction. Distal ductal obstruction required Frey procedure (n=3). If distal duct was patent, we resected cyst-containing pancreatic tail (n=2). Early and long-term results were favorable. In the group B, mediastinitis persisted for a long time with normal temperature as a rule. In our opinion, mild course is associated with gradual introduction of purulent tissues into mediastinum and development of a tissue barrier. Two-stage surgeries were performed in patients with pancreatopleural empyema. Mediastinitis lasting 6-8 weeks caused perforation of the lower third of esophagus (n=2) and death of 1 patient. Risk factors of mediastinal pseudocysts: hypertension in pancreatic duct and pseudocysts, immobile cicatricial tissues of omental bursa, proximity of subdiaphragmatic structures to esophageal and aortic hiatus of the diaphragm. Pressure in aortic canal (mmHg) is 10 times higher than in esophageal canal that increases migration through the esophageal hiatus. It is advisable to distinguish pancreatoesophageal and biliopleuroesophageal fistulas. Uninfected mediastinal pseudocysts require simultaneous procedures, pancreatopleural empyema - two-stage interventions. Therapy is recommended in patients with esophageal fistula and no severe symptoms and intoxication.