Endoscopic Transesophageal Drainage of Mediastinal Pseudocyst in a Child

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An 11-year-old child presented with intermittent epigastric and retrosternal pain for 2 weeks. History revealed an episode of acute pancreatitis about 7 weeks before this presentation. On etiological evaluation of pancreatitis, there were no gall stones, history of drugs implicated in pancreatitis, trauma, hypercalcemia, hypertriglyceridemia, and family history of pancreatitis. Contrast computed tomography revealed a large pseudocyst near the pancreatic head, extending into the mediastinum. Transgastric drainage was not feasible due to the location of pseudocyst and difficulty in obtaining a good EUS window. Therefore, transesophageal drainage was performed using an adult linear EUS scope (Olympus 180, Japan; outer diameter 14.6 mm, channel 3.7 mm). Needle puncture was performed with a 21G needle. Subsequently, a guidewire with flexible tip (0.025 in.; 450 cm) was coiled inside the cyst cavity and the tract dilated with a cystotome (Endoflex, Voerde, Germany) followed by balloon (Hurricane, 4 mm, Boston, Natick, MA). Finally, a single plastic stent (7 Fr, 5 cm) was deployed under endoscopic and fluoroscopy guidance. Plain computed tomography scan on day-3 revealed reduction in the size of pseudocyst. At week-4, the child remains asymptomatic and chest x-ray reveals stent in position. The removal of stent is planned after 4 to 6 weeks. Endoscopic drainage of pseudocysts is usually performed via transgastric or transduodenal route. Uncommonly, transesophageal drainage has to be performed due to mediastinal extension of the pseudocyst (1). Mediastinal pseudocysts are rare and manifest as chest pain, dysphagia, nausea, and rarely congestive heart failure. Surgical drainage has been advocated for these pseudocysts due to difficulty in endoscopic and radiological access (2,3). Endoscopic transesophageal drainage can be successfully performed in these cases and surgery can be avoided (4) (Supplemental Video: http://links.lww.com/MPG/B233).
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