Description:
Background
1 Endoscopic necrosectomy of complicated pancreatic pseudosustic collections have been demonstrated to be a safe primary treatment of necrosis and abscess collections.
2 Transgastric access technique has revolutionized the role of interventional endoscopy in a variety of cases where surgery is too risk or contraindicated.
3 We describe a case of endoscopic trans-gastric treatment of a mediastinal absess in a patient with previous transhiatal esophagectomy
Introduction
Our patient is a 69 year old male with a history of esophageal CA status post trans-hiatal esophagectomy and J-tube placement in 2004
Since August 2008 he had noted recurrent dysphagia and lower chest discomfort following meals requiring multiple EGDs with dilation.
He had also reported low grade fevers, hoarseness, sever dyspepsia, for which he was seen in the local ER and discharged after cardiac etiology was excluded.
Introduction Slide 2
A previous barium esophagram confirmed pharyngeal dysphadia and significant esophageal disorder
The patient present to outpatient surgery clinic where he was observed expectorating copious saliva and was febrile to 38.3 celsius. His initial CBC was significant for white count of 16.3k with corresponding left shift.
CT scan
The initial CT scan of the chest, abdomen, and pelvis on the day or presentation demonstrates a new mixed fluid and air density mass in the superior mediastinum, as designated by the red arrow, measuring 9.8 x 4.5 x 4.5cm.
Adjacent to the mass are several enlarged mediastinal nodes likely reactive in etiology.
The abdominal cross sections are significant or multiple enlarged aortocaval lymph nodes and a 2 x 1.2 cm hypodense fluid collagen along the caudal aspect of the spleen.
Endoscopy
After reviewing the options, risks and benefits with the patient and obtaining consent endoscopic access to the mediastinal abscess was decided as the best, least invasive approach draining the infectious source. An regular adult endoscope was passed into the esophagus, beyond the surgically constructed GE anastomosis. No obvious connection or perforation to an abscess cavity could be readily identified.
Beyond the anastomosis, an obvious bulge was visible just below the anastomosis in the chest. It is best seen on retroflexion with what appears as a bulging mass effect.
EUS imaging
A linear echoendoscope was intubated to the level of the abscess above the heart. A 19-gauge needle is seen puncturing the abscess cavity leaving a guidewire in place. This is confirmed on fluoroscopic imaging as demonstrated in the lower right hand corner of the screen.
Balloon dilation
Following dilation of the tract with the sheath of the needle and 6Fr Sohendra dilator, sequential balloon dilation is performed using an 18-18-20mm balloon over the guidewire.
As the balloon catheter is dilated, pus is seen expressed from the tract (as noted in the lower left hand corner).
Abscess cavity access
Once access to the cavity was achieved, the echoendoscope was exchanged over wire for an adult upper endoscope. Large amounts of saline were used to flush the cavity and completely drain its contents.
Shown here, the contents are being evacuated from the stomach.
Retroflexion 2
Noted on retroflexion the absence of the bulge in the gastric cavity once the abscess space was avacuated
Necrosectomy
Snare debridement was necessary to complete the evacuation of pus and necrotic material
Stent placement
After the abscess cavity was suggiciently cleaned, 2 double pigtail stents were placed using rat-tooth forceps. The proximal end of the stents were dragged back inot the mediastinal cavity.
The final position of the stents was confirmed under fluoroscopy. Continuous drainage was further facilitated by the placement of a 10Fr nasocystic decompression tube.
Follow Up
The post-operative CT scans demonstrate the effectiveness of the mediastinal drainage. Within 24 hours, the patient was relieved of chest and abdominal discomfort and was discharged home on TPN after a 6 days.
Contributed By:
Arnab Biswas, DO, Penn State Milton S. Hershey Medical Center
