Is Pneumomediastinum an Expected Finding or a Complication when Cystogastrostomy is Performed at the Gastro-esophageal Junction? A Retrospective Review 167
Purpose: Endoscopic cystenterostomy (ECE) is used worldwide as a minimally invasive technique for draining symptomatic pancreatic pseudocysts. The potential complications include perforation, bleeding, and infection. Perforation is more likely when the pseudocyst wall is not mature and/or has a distance of >10 mm from the gastrointestinal (GI) wall. Here, we report two cases of pneumomediastinum occurred post pancreatic endoscopic cystogastrostomy (ECG) when the stoma site was located at the gastro-esophageal junction (GEJ), despite of well-matured pseudocysts wall and the immediate abutment of the cyst to the gastric wall.
Methods: In a retrospective review of ECE performed by a single endoscopist over the period of 5 years was recorded and analyzed. A total of 27 ECE (18 ECG and 9 endoscopic cystoduodenostomy [ECD]) were performed in 25 patients (15 male and 10 female). Mean age was 45 years (range 14-85 years). Results: No complication was noted in the patient who underwent ECD, however, two patients in ECG group had post procedure pneumomediastinum and both patients had ECG performed at the GEJ ( fig). In both patients the pseudocysts were abutting the wall of the GEJ and the site of <10 mm distance between the pseudocysts and the gastric wall was only found at the GEJ. ECG was performed and double pigtail stents were placed. Both patients had subcutaneous crepitus in the left supraclavicular area immediately after the procedure and had mild to moderate pain around the neck and the chest. They were hemodynamically stable and O2 saturation was normal. CT chest revealed diffuse subcutaneous emphysema involving the mediastinum. Both patients were managed conservatively with NPO, IV hydration, analgesia, and antibiotics. They have completely recovered and discharged home without any symptoms. Follow up CT scan revealed complete resolution of the pneumomediastinum and the pseudocysts. Figure:
 1) Endoscopic picture of Pigtails Stent at GEJ. 2) CAT scan chest with a) White arrow: Pneumomediastinum. b) Black arrow: Pigtail stent at GEJ.
Conclusion: Post ECG pneumomediastinum could be a potential complication when the stoma is located at the GEJ even when the pseudocyst wall is mature and the cyst is abutting wall of the GI tract. Observation and conservative therapy might be an appropriate management for patients with minimal symptoms and no signs of infection. Table: Cystenterostomy © The American College of Gastroenterology 2012. All Rights Reserved. View full article text