An unusual cause of dysphagia: transabdominal Roux-en-Y cyst-jejunostomy in the surgical management of a symptomatic mediastinal cyst
A 52-year-old gentleman, otherwise well, presented with a 3-month history of progressive dysphagia, unable to tolerate solids. An upper gastrointestinal (GI) endoscopy showed extrinsic compression of the lower oesophagus from the posterior aspect, with normal oesophageal mucosa and no gastric abnormality. CT and MRI scanning (Fig. ) revealed the cause of the compression to be a cystic mass (9.8 × 6.4 × 6.3 cm) in the posterior mediastinum, at the level of the inferior wall of the heart causing compression of the left atrium and displacing the oesophagus to the left (Fig. c). The lesion had low attenuation with dependent calcified debris.\nEndoscopic ultrasound (EUS) confirmed the cyst extended to the diaphragmatic hiatus and showed no clear connection to the oesophagus or adjacent structures, concluding the lesion to be a duplication cyst. Further investigations included negative hydatid serology and a PET-CT scan with no uptake of tracer. EUS-guided fine needle aspirate of the fluid within the cyst was acellular with no microbial growth, but had a raised amylase of 1869 IU/l.\nA diagnosis of a foregut duplication cyst was made and, following multidisciplinary discussion, as the patient was significantly symptomatic surgery was performed. Approaches considered included transthoracic, abdominal or combined. To avoid the potential morbidity of a transthoracic approach, an abdominal approach was performed through a rooftop incision. At surgery, a firm retroperitoneal cyst was evident emerging through the hiatus (Fig. a), anterior to the aorta, displacing the distal oesophagus and gastro-oesophageal junction. The cyst wall was opened and 300 ml of turbid fluid aspirated (Fig. b). Following wall biopsy, a jejunal loop was mobilized and a 60 cm Roux-en-Y cyst-jejunostomy performed with single-layer 2-0 PDS (Fig. c and d). Histology of the cyst wall revealed fibrous tissue with no obvious epithelial or mesothelial lining compatible with a simple mediastinal cyst. There was no evidence of malignancy.\nPostoperatively, the patient experienced immediate relief of his dysphagia and was discharged home with no complications. He remains well and asymptomatic on follow-up.