symptomatic mediastinal lymphatic cyst after esophagectomy

Case Report

Symptomatic mediastinal lymphatic cyst after esophagectomy

D. N. Monk1, D. A. Nicholson2, W. Lee1, J. Bancewicz1

Department of 1Upper Gastrointestinal Surgery and 2Radiology, Hope Hospital, Salford, M6 8HD, UK

INTRODUCTION

Fifty percent of masses in the mediastinum areasymptomatic and discovered incidentally.1 We pres-ent a case of a patient who developed a lymphaticcyst in the posterior mediastinum after esophagec-tomy that was treated by an endoscopic technique.

CASE HISTORY

A 56-year-old man with adenocarcinoma of theesophagus had an Ivor±Lewis esophagectomy. Per-sistent chylous drainage from the chest requiredreoperation on the 10th day. Several lymphatic leakswere closed with sutures, and the patient wasdischarged on the 35th day.

One year later there was dysphagia and a com-puted tomographic (CT) scan of the chest showed acystic mass in the posterior mediastinum. Figure 1shows a CT section at the mid-point of the cyst. It isnext to the gastric conduit and posterior to the heartwith maximal cross-sectional dimensions of 6.4 cmby 9 cm and 15 cm long. Recurrence followed twoCT-guided aspirations. Therefore, an endoscopy andCT were performed simultaneously. The gastric wallabutting the cyst was incised with an endoscopicdiathermy knife and a 7-Ch double J stent was placedacross the cyst gastrostomy. The dysphagia resolved.

DISCUSSION

The posterior mediastinum lies between the per-icardium and the vertebral column. It contains theesophagus, major vessels, nerves, the thoracic ductand paravertebral lymph nodes.

This is only the third reported case of an encystedlymphocele after thoracic surgery.2,3 It has also beenreported as a result of thoracic duct injury after blunttrauma.4 No treatment was described in the previouspost-surgical case reports.

The proximity of the gastric conduit allowed thenovel approach of endoscopic cyst gastrostomy. Thisapproach has previously been described for themanagement of abdominal pancreatic pseudocysts,but this is the ®rst reported case of its application inthe chest. CT was used in this case to con®rm the sitefor incision into the cyst, but endoscopic ultrasoundhas been used and shown to reduce the risk ofhemorrhage, which is the main complication.5

References

1. Rice T W. Benign neoplasms and cysts of the mediastinum(Review). Sem Thor Cardiovas Surg 1992; 4(1): 25±33.

2. Gamroth A, Gorich J. CT diagnosis of the postoperativemediastinal lymphocoele. Rofo Fortschr Geb RontgenstrNuklearmed 1989; 150: 356±357.

3. Sullivan K, Weshler R. CT diagnosis of mediastinal lymph-ocoele. J Comput Assist Tomogr 1985; 1110±1111.

4. HomM, Jolles H. Traumatic mediastinal lymphocele mimickingother thoracic injuries: case report. J Thor Imag 1992; 7(3):78±80

5. Etzkorn K, DeGuzman L, Holderman W et al. Endoscopicdrainage of pancreatic pseudocysts: patient selection andevaluation of the outcome by endoscopic ultrasonography.Endoscopy 1995; 27: 329±333.

Fig. 1ÐThoracic computed tomogram showing posteriormediastinal cyst (MC).

Address correspondence to: Mr J. Bancewicz, ConsultantSurgeon, Hope Hospital, Salford, M6 8HD, UK. Tel: (+44)0161787 5128; Fax: (+44)0161 787 5992.

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Diseases of the Esophagus (1999) 12, 82Ó 1999 ISDE/Blackwell Science Asia