Endoscopic transgastric fenestration for the treatment of rare complication of pancreatic pseudocyst: Esophageal stenosis

A 28-year-old male presented to our hospital with deteriorated dysphagia for 1 month. Computed tomography scan revealed a cyst located in the mediastinal cavity and the compressed lower esophagus (Fig. 1a). This cyst extended from the pancreatic pseudocyst to the mediastinal cavity [ [1] Gupta R. Munoz J.C. Garg P. et al. Mediastinal pancreatic pseudocyst–a case report and review of the literature. MedGenMed. 2007; 9: 8 PubMed Google Scholar ] (Fig. 1b). Gastroscopy showed esophageal luminal stenosis located at 40–45 cm from the incisor teeth due to extrinsic compression (Fig. 1c). Endoscopic trans-gastric fenestration was performed after obtaining the informed consent from the patient [ [2] Liu B.R. Song J.T. Zhang X.Y. Video of the month: emergency endoscopic fenestration for treatment of a recurrence pancreatic pseudocyst. Am J Gastroenterol. 2015; 110: 644 Crossref PubMed Scopus (5) Google Scholar ]. First of all, endoscopic ultrasound was performed to confirm the location of the cyst and to select the fenestration point (Fig. 2a). Secondly, the mucosa around the fenestration point was removed with a snare. Then, full thickness resection of gastric wall around the fenestration point and the regarding cystic wall were completed using hook and IT knife, with massive yellowish brown turbid liquid flowing out (Fig. 2b). A fenestration of 20 mm in diameter was created to achieve sufficient drainage. Finally, the endoscope was accessed to the cystic cavity and aspirated the cystic fluid. With the endoscope inverted in the lumen of the pancreatic pseudocyst, the upper cystic cavity extended to the mediastinum was exposed (Fig. 2c). Postoperatively, the dysphagia disappeared and the patient resumed a liquid diet. The patient was discharged from the hospital on postoperative day 7, without any adverse event. Forty days later, CT scan showed that the pancreatic pseudocyst disappeared completely (Fig. 2d). Fig. 2a: Endoscopic ultrasound was performed to confirm the location of the cyst. b: Large amount of yellowish brown turbid liquid flowing out of the pseudocyst. c: With the endoscope inverted in the lumen of the pancreatic pseudocyst, the upper cystic cavity extended to the mediastinum was exposed. d: CT scan showed that the pancreatic pseudocyst disappeared completely. View Large Image Figure Viewer Download Hi-res image