The usefulness of a bilateral trans-cervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option.

OBJECTIVE: We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy. METHODS: Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. RESULTS: The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted. CONCLUSIONS: Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

Mediastinal Parathyroidectomy Using a Cervical Approach Under a Pneumomediastinum.

Video-assisted thoracoscopic surgery (VATS) and robotic surgery are minimally invasive surgeries for mediastinal parathyroid adenomas. However, a transthoracic approach is often difficult in the cervicothoracic transition area because of the limited visual field. We report a novel minimally invasive surgery for an ectopic parathyroid adenoma in the middle mediastinum using a cervical approach under a pneumomediastinum.

Siphoning diesel: a fatal mistake.

Diesel is commonly used as fuel for engines and is distilled from petroleum. Diesel has toxic potential and can affect multiple organs. Exposure can occur after ingestion, inhalation or through the dermal route. The practice of siphoning diesel using a rubber tubing and the mouth is common in rural communities. This can lead to accidental ingestion and aspiration. Here we report a case of a patient who accidentally ingested diesel during siphoning, which caused extensive erosion of the oral cavity and oesophagus leading to pneumomediastinum and severe chemical lung injury. The patient responded well initially to steroids and supportive care but required prolonged hospitalisation. He developed complications of nosocomial infection and succumbed 23 days after admission.

Clinical presentation of air leak in an infant with undiagnosed cystic fibrosis: a case report.

INTRODUCTION: Air leak is a well-recognized complication of advanced cystic fibrosis in older children and adults but is extremely rare in infants. To the best of our knowledge, this is the youngest reported pediatric case of an air leak from a major airway. CASE PRESENTATION: A 4-month-old Yamani baby girl with a family history of cystic fibrosis initially presented with a history of a persistent paroxysmal cough for 3 weeks and vomiting for 1 week. Laboratory evaluation indicated pseudo-Bartter's syndrome. Imaging showed a tracheal tear with pneumomediastinum and subcutaneous emphysema that was treated conservatively. CONCLUSIONS: This case highlights the possibility of air leak in the population of young patients with cystic fibrosis and it shows a successful conservative management of tracheal tear. Physicians should consider cystic fibrosis in infants presenting with air leak.

[Thoracoscopic thymectomy with carbon dioxide insufflation in the mediastinum]. / Timectomía toracoscópica con insuflación de dióxido de carbono.

The case is presented of a 71 year-old male, diagnosed with a thymoma. A thoracoscopic thymectomy was performed using the carbon dioxide insufflation technique in the mediastinum. During the procedure, while performing one-lung ventilation, the patient's respiration worsened. The contralateral lung had collapsed, as carbon dioxide was travelling from the mediastinum to the thorax through the opened pleura. Two-lung ventilation was decided upon, which clearly improved oxygenation in the arterial gases and airway pressures. Both pH and pCO2 stabilized. The surgical approach and the carbon dioxide technique were continued because 2-lung ventilation did not affect the surgical procedure. This technique has many serious complications and it should always be performed using 2-lung ventilation.

Update on anesthetic complications of robotic thoracic surgery.

In the last decade, there has been increasing use of the da Vinci® robot surgical system to perform minimally invasive thoracic surgery. The robotic technology can be applied for surgery of the lungs, mediastinum, and esophagus. A number of case reports have been shown steep learning curve, and promising surgical outcome with this new technology. However, anesthesia management of the robotic thoracic surgery can be complex and requires further education. For example, most of the cases require sufficient lung collapse in order to provide adequate surgical field. In addition, a unique operative setting, such as patient positioning and capnothorax can make anesthesia management further challenging. Hence, anesthesiologists should have better awareness of adverse events or complications related to the robotic surgery to accomplish successful anesthesia management. This review will focus on the potential complications of robotic thoracic surgery involving the lungs, mediastinum and esophagus.

Bilateral bullectomy through uniportal video-assisted thoracoscopic surgery combined with contralateral access to the anterior mediastinum.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy. METHODS: Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes. RESULTS: All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion. CONCLUSIONS: Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Typical bronchial carcinoid tumour presenting as pneumomediastinum.

The authors present a case of a 44-year-old man who presented with acute onset shortness of breath. He had severe subcutaneous emphysema and his chest x-ray and CT scan confirmed presence of air in mediastinum. Rigid bronchoscopy revealed a bronchial tumour which was proven to be a carcinoid on histology. Patient recovered following the surgical excision of the tumour.

Artificial pneumomediastinum facilitates thoracoscopic surgery in anterior mediastinum.

A 67-year-old woman underwent a thoracoscopic resection of a large anterior mediastinal cyst. Before surgery, artificial pneumomediastinum was performed with a retrosternal technique. Injection of 400 ml of air from the sternal notch caused emphysema throughout the mediastinum. In those areas, dissection of loose connective tissue was mostly accomplished by the injected air, which formed an air layer around the cyst. On the other hand, emphysema was not apparent in the areas around the left innominate and thymic veins. Artificial pneumomediastinum may be useful as a supplementary technique in a thoracoscopic surgery setting.

Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis.

To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

'Sabre sheath' trachea with mediastinal lipomatosis mimicking a mediastinal tumour.

Two cases of 'sabre sheath' trachea in combination with mediastinal lipomatosis are reported. The initial chest radiographs in both cases were interpreted as showing a mediastinal tumour causing tracheal compression. The correct diagnosis was subsequently made using computed tomography (CT). It is important to be aware of these benign conditions when interpreting chest radiographs, particularly in cases of suspected mediastinal pathology.

[A case of complete absence of the left pericardium coexisting with straight back syndrome].

A case of complete absence of the left pericardium coexisting with straight back syndrome in a 30-year-old female is presented. She had been asymptomatic, but was referred to our hospital because of an abnormal finding on a chest X-ray obtained during a routine physical examination. The posteroanterior view of the chest X-ray showed displacement of the right and left cardiac border to the left and bulging of the left cardiac border. The lateral view showed loss of normal thoracic curvature and also demonstrated the straight back syndrome. Echocardiography showed paradoxical movement of the ventricle septum, hyperkinetic movement of the free wall of the left ventricle and enlargement of the right ventricle. Computed tomography and magnetic resonance imaging with an artificial pneumomediastinum clearly showed rotation of the heart into the left hemithorax, prominence of the pulmonary trunk and pneumopericardium. Hence the diagnosis of the complete absence of the left pericardium coexisting with straight back syndrome was made. Congenital defect or absence of the pericardium are rarely reported. Only about 120 cases have been described in Japan. Only a few cases have been diagnosed antemortem. Most of them were found by chance during operations or on installation of an artificial pneumothorax. We suggest that an artificial pneumomediastinum as well as a pneumothorax is useful for the diagnosis of the absence of the pericardium. This is the first reported case of a complete absence of the left pericardium coexisting with straight back syndrome.

[Mediastinal form of Brill-Symmers disease (giant follicular lymphoma)]. / Mediastinal'naia forma bolezni Brilla-Simmersa (giganto- follikuliarnaia limfoma).

Three clinical cases with the mediastinal form of Brill-Symmers disease are discussed. The variants of its symptomatology and course are described. The methods of diagnosis and surgical tactics are dealt with. Operative treatment of mediastinal giant follicular lymphoma in the stage of a benign course is the method of choice. The late-term results (of up to 20 years) were studied in 2 of the 3 patients.

Traumatic esophageal rupture: unusual cause of acute mediastinal widening.

We have presented the case of a 32-year-old man who sustained blunt trauma to the chest in a motor vehicle accident. Plain roentgenograms showed a widened mediastinum and pneumomediastinum, and an esophagogram with water-soluble contrast material showed an esophageal laceration at the T-4 level.

[CT guided selective pneumomediastinography in thoracic imaging].

We established new approaches for CT guided selective pneumomediastinography; paravertebral, pretracheal and anterior mediastinal approaches. CT would seem to be useful method for assessing the invasion to the neighboring structures in the thoracic neoplasms. But scanty fat in mediastinum often interferes with correct evaluation of mediastinal structures in conventional CT. Pneumomediastinal CT with our methods overcomes the weak point and provides additional information to enable exact diagnosis. The feasibility and security of these methods were confirmed through applying to many cases. Based upon these results, selective pneumomediastinal CT would be considered to be advantageous and advisable on the CT diagnosis in thoracic imaging.