[Thinking about the extent and technique of lower mediastinal lymph nodes dissection for adenocarcinoma of esophagogastric junction].

The incidence of esophagogastric junction adenocarcinoma is increasing gradually. The surgical procedures mainly include radical resection of the primary tumor, lymph node dissection, and digestive tract reconstruction. Due to the special anatomical location of esophagogastric junction adenocarcinoma, the pattern of lymph node metastasis is not clear, and regional lymph nodes dissection especially in the lower mediastinum is still controversial, and awaits further high-quality evidence. Meanwhile, due to the special anatomical location of the lower mediastinum, it is often difficult to perform lower mediastinal lymph node dissection. How to complete the lower mediastinal lymph nodes dissection more safely and effectively is the key point for gastric cancer surgeons. In this paper, the progress, consensus, and controversy on the extent of lower mediastinal lymph nodes dissection in patients with esophagogastric junction adenocarcinoma were discussed. Based on our own experience, the current clinically techniques for lower mediastinal lymph nodes dissection were summarized to further improve the quality control of lower mediastinal lymph nodes dissection in patients with esophagogastric junction adenocarcinoma.

Mature Cystic Teratoma of Anterior Mediastinum in a Child: A Case Report and Literature Review.

Mediastinal mature cystic teratomas are rare benign germ cell tumors that predominantly affect children. Despite their low incidence, they present unique diagnostic and management challenges. Early recognition and appropriate surgical intervention are crucial for optimal outcomes. This case report aims to highlight the importance of prompt diagnosis and management of mediastinal mature cystic teratomas in pediatric patients. We present the case of a 10-year-old female patient who presented with persistent chest pain and dyspnea. Imaging studies, including a chest X-ray and contrast-enhanced chest CT scan, revealed a large, well-circumscribed anterior mediastinal mass with calcifications. The patient underwent a right thoracotomy, resulting in the excision of a 6 × 5 × 5 cm mature cystic teratoma. Histopathological examination confirmed the diagnosis. The patient had an uneventful recovery and was discharged in stable condition. Mediastinal mature cystic teratomas pose diagnostic challenges due to their nonspecific symptoms and heterogeneous imaging characteristics. Differential diagnosis includes other mediastinal masses containing fat and calcifications. Surgical excision is the preferred treatment, although complete removal can be challenging due to adhesions to neighboring structures. Close follow-up is necessary to monitor for recurrence and complications. Mediastinal mature cystic teratomas are rare tumors with variable clinical presentations. Early detection and surgical intervention are crucial for optimal outcomes. These tumors should be included in the list of differential diagnoses for mediastinal masses in pediatric patients.

Anatomical factor associated with thoracic procedural difficulty in robot-assisted minimally invasive esophagectomy.

BACKGROUND: Robotic surgical systems with full articulation of instruments, tremor filtering, and motion scaling can potentially overcome the procedural difficulties in endoscopic surgeries. However, whether robot-assisted minimally invasive esophagectomy (RAMIE) can overcome anatomical difficulties during thoracoscopic esophagectomy remains unclear. This study aimed to clarify the anatomical and clinical factors that influence the difficulty of RAMIE in the thoracic region. METHODS: Forty-five patients who underwent curative-intent RAMIE with upper mediastinal lymph node dissection for esophageal cancer were included. Using preoperative computed tomography images, we calculated previously reported anatomical indices to assess the upper mediastinal narrowness and vertebral body projections in the middle thoracic region. The factors influencing thoracic operative time were then investigated. RESULTS: During the thoracic procedure, the median operative time was 215 (124-367) min and the median blood loss was 20 (5-190) mL. Postoperatively, pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred in 17.8%, 2.2%, and 6.7% of the patients, respectively. The multiple linear regression model revealed that a narrow upper mediastinum and greater blood loss during the thoracic procedure were significant factors associated with a prolonged thoracic operative time (P = 0.025 and P < 0.001, respectively). Upper mediastinal narrowing was not associated with postoperative complications. CONCLUSIONS: A narrow upper mediastinum was significantly associated with a prolonged thoracic operative time in patients with RAMIE.

[Thoracoscopic resection of recurrent atypically located parathyroid adenoma of anterior mediastinum in a patient with hyperparathyroidism undergoing renal replacement therapy]. / Torakoskopicheskoe udalenie retsidivnoi atipichno raspolozhennoi adenomy okoloshchitovidnoi zhelezy perednego sredosteniya u patsientki s giperparatireozom, nakhodyashcheisya na zamestitel'noi pochechnoi terapii.

We present successful surgical treatment of a patient with chronic kidney disease (CKD) and hyperparathyroidism undergoing renal replacement therapy. At baseline, parathyroidectomy via cervical access was performed for parathyroid adenomas. After 6 years, clinical and laboratory relapse of disease required thoracoscopic resection of atypically located anterior mediastinal adenoma. This case demonstrates that this disease is one of the most difficult in modern medicine requiring a special approach in diagnosis and treatment. Patients with CKD and hyperparathyroidism need for follow-up, control of total and ionized serum calcium, inorganic phosphorus and parathormone, osteodensitometry, ultrasound and scintigraphy of thyroid and parathyroid glands, and, if necessary, CT or MRI of the neck and chest organs.

Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch.

OBJECTIVES: The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. METHODS: All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. RESULTS: The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). CONCLUSIONS: Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.

Surgical resection of advanced intrathoracic tumors through a combination of the hemiclamshell and transmanubrial approaches.

PURPOSE: The hemiclamshell (HCS) approach provides a comprehensive view of the anterior mediastinum, whereas the transmanubrial osteomuscular sparing approach (TMA) allows sufficient exposure of the cervico-thoracic transition. We assessed the effectiveness and the outcomes of the combined HCS plus TMA approach to resect thoracic malignant tumors. METHODS: We reviewed five patients with thoracic malignant tumors invading the thoracic outlet who underwent surgery using an HCS and TMA approach between 2018 and 2021. RESULTS: The preoperative diagnosis was myxofibrosarcoma, lung cancer, thymic cancer, thymoma, and neurofibromatosis type1 in one patient each, respectively. Cardiovascular reconstruction was done on the aortic arch in two patients, on the descending aorta in one, and on the superior vena cava in one, combined with resection of the vagus nerve in three patients, of the phrenic nerve in two, and of vertebra in one, with overlap in some cases. The TMA was added because all patients required dissection of the periphery of the subclavian artery, and two had tumor extension to the neck. Macroscopic complete resection was achieved in four patients. There was no postoperative mortality. CONCLUSION: The combination of the HCS and TMA approaches at the same operation provides a comprehensive view of the mediastinum, lung, and cervico-thoracic transition and allows safe access to the thoracic great vessels and subclavian vessels.

Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2).

BACKGROUND: Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. METHODS: Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. RESULTS: A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. CONCLUSION: The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Radicality of mediastinal lymphadenectomy in minimally invasive pulmonary resection: a comparative analysis of uniportal and multiportal thoracoscopic approaches.

INTRODUCTION: Lung cancer is a serious health problem with a high mortality rate. In the context of surgical management, minimally invasive approaches, including uniportal thoracoscopic techniques, offer potential benefits such as faster recovery and increased patient cooperation. The aim of this study was to compare the accessibility of the mediastinal lymph nodes between uniportal and multiportal thoracoscopic approaches and to verify whether the use of the uniportal approach affects the radicality of the lymphadenectomy. METHODS: A comparative study conducted from January 2015 to July 2022 at the University Hospital Ostrava focused on evaluating the radicality of mediastinal lymphadenectomy between subgroups of patients undergoing surgery using the uniportal thoracoscopic approach and the multiportal thoracoscopic approach. RESULTS: A total of 278 patients were included in the study. There were no significant differences in the number of available lymphatic stations between the subgroups. The mean number of lymph node stations removed was 6.46 in the left hemithorax and 6.50 in the right hemithorax. Thirty-day postoperative morbidity for the entire patient population was 24.5%, with 18.3% having minor complications and 3.6% having major complications. The overall mortality rate in the study population was 2.5%, with a statistically significant difference in mortality between uniportal and multiportal approaches (1.0% vs 6.4%, p=0.020). CONCLUSIONS: The uniportal approach demonstrated comparable accessibility and lymph node yield to the multiportal approach. There was also no difference in postoperative morbidity between the two approaches. The study suggests the possibility of lower mortality after uniportal lung resection compared with multiportal lung resection, but this conclusion should be interpreted with caution.

Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study.

BACKGROUND: It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery. METHODS: A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied. RESULTS: There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups. CONCLUSIONS: Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.

Evaluation of mediastinoscopy for cranial mediastinal and tracheobronchial lymphadenectomy in canine cadavers.

OBJECTIVE: To report technical feasibility and describe procedural details of a novel single incision minimally invasive approach to the mediastinum in cadaver dogs. STUDY DESIGN: Cadaveric study. ANIMALS: Large breed (25-40 kg) cadaver dogs (n = 10). METHODS: Three of 10 cadavers were used for preliminary technique development without data recording. Cadaver specimens underwent pre- and postoperative thoracic computed tomographic scans. Seven dogs were placed in dorsal recumbency and mediastinoscopy was performed via a SILS port placed cranial to the thoracic inlet with CO2 insufflation of the mediastinum at 2-4 mmHg. Retrieval of all CT and visually identified mediastinal lymph nodes (LN) was attempted; endoscopic compartmental and individual LN dissection times and subjective operative challenges were recorded. Procedural success scores for visualization and dissection as well as NASA-task force index scores were recorded per lymph node, per cadaver. RESULTS: Median time required for initial approach including SILS placement was 5 min (range 5-10 min). Individual LN retrieval times ranged from 2 to 32 min. Mediastinoscopic retrieval of LNs was most commonly successful for the left tracheobronchial LN (7/7), followed by the right tracheobronchial LN (4/7), the left and right sternal LNs (3/7 each), and the cranial mediastinal LNs (1/7). Post-procedure pleural gas was identified on CT in 4/7 cadavers. CONCLUSIONS: Mediastinoscopy as reported was feasible in large breed canine cadavers and retrieval or cup biopsy of a variety of lymph nodes is possible from the described approach. Application in living animals and its associated challenges should be further investigated. CLINICAL SIGNIFICANCE: Mediastinoscopy may provide a novel minimally invasive approach to the evaluation and oncologic staging of the cranial mediastinum in dogs.

Thoracoscopic resection of paraesophageal ectopic mediastinal parathyroid adenoma in the superior posterior mediastinum: a case report.

BACKGROUND: The ectopic superior parathyroid in the tracheoesophageal groove and paraesophageal region is rare. Hyperparathyroidism results when these glands become hyperfunctioning. That may necessitate surgical intervention in the form of parathyroidectomy, which requires a transsternal or transthoracic approach due to a deeply seated mediastinal parathyroid gland. Minimally invasive strategies have emerged recently as an alternative approach with less morbidity. CASE PRESENTATION: We present a case of the paraesophageal ectopic parathyroid gland in the superior posterior mediastinum, which was successfully treated with thoracoscopic resection. CONCLUSION: The current imaging tools improve the thoracoscopic management of mediastinal parathyroid glands. Video-assisted thoracoscopic surgery (VATS) can provide access and exposure to ectopic parathyroid adenoma with low morbidity and financial burden.

Thoracoscopic treatment of mediastinal ectopic parathyroid adenomas: a Latinamerica experience case series and literature review.

BACKGROUND: Hyperparathyroidism (HPT) is a disease caused by hypersecretion of one or more parathyroid glands, it can be associated with ectopic mediastinal parathyroid glands (MEPA) in 2% of cases. The use of video-assisted thoracoscopic surgery (VATS) for the surgical resection of these glands is a safe, cost-effective, and low morbidity option for patients with MEPA. We report a case series of patients with this disease managed with VATS, the first in Mexico and Latinamerica. METHODS: From 2008 to 2022, a retrospective study involving patients with MEPA and treated by VATS approach was performed in a tertiary hospital in Mexico city. Relevant biochemical and clinical variables such as imaging studies, pre and postoperative laboratory results, surgical strategy, outcomes and pathological analysis were analyzed. RESULTS: Four cases of mediastinal parathyroid adenomas causing HPT were included. All patients were female with a median age of 52.5 years-old (range 46-59 years), half of the patients had primary HPT and the others tertiary HPT after kidney transplant. 75% of cases had a MEPA in the medium mediastinum, all had a preoperative positive SPECT-CT 99mTc Sestamibi scan. Mean preoperative PTH was 621.3pg/mL (182-1382pg/mL). All patients successfully underwent parathyroidectomy with a VATS approach, no deaths were reported. CONCLUSIONS: VATS is a minimally invasive surgery that provides adequate access to mediastinal located glands, optimal visualization of mediastinal structures and has a high resection success rate with less complications and morbidity than open approaches.

A approach of gastric conduit via the anterior of pulmonary hilum route during minimally invasive McKeown esophagectomy.

BACKGROUND: The gastric conduit is the most commonly used replacement organ for reconstruction after minimally invasive McKeown esophagectomy. Although the optimal route of gastric conduit remains controversial, the posterior mediastinal route is physiologically preferable but is not without disadvantages. Here, we report the safety and efficacy of a method of gastric conduit reconstruction via the anterior of the pulmonary hilum route. METHODS: We have used the anterior of the pulmonary hilum route since 2021. This procedure involves pulling the gastric conduit up through a substernal tunnel between the right thoracic cavity and the abdominal cavity and passing it into the neck via the anterior of the pulmonary hilum route. In this retrospective study, we compared the clinical outcomes between 20 patients who underwent this procedure and 20 patients who underwent the posterior mediastinal route from 2021 to 2022. RESULTS: No mortality was reported in either group. No significant differences were observed between the two groups in duration of surgery, blood loss, incidence of postoperative complications, and postoperative hospital stay. As a result of the anterior of the pulmonary hilum route, the primary tumor bed and lymph node drainage area were effectively bypassed, which facilitates postoperative adjuvant radiotherapy or chemoradiotherapy. The distance of the gastric conduit accompanying the airway was significantly shorter in the anterior of the pulmonary hilum route group. CONCLUSIONS: Our method is considered to be a safe and useful technique for the reconstruction of gastric conduit.

Right upper lobectomy with mediastinal dissection under uniportal video-assisted thoracoscopic surgery for lung cancer in a patient with a right-sided aortic arch: a case report.

BACKGROUND: A right-sided aortic arch is a rare congenital vascular structure variation. Right lobectomy is not commonly performed on patients with such a condition. Further, there are no reports on lobectomy under uniportal video-assisted thoracoscopic surgery (VATS) in this patient group. CASE PRESENTATION: A 67-year-old man with a right-sided aortic arch and Kommerell diverticulum underwent right upper lobectomy with mediastinal lymph node dissection under uniportal VATS for primary lung cancer. Due to the right descending aorta, which narrows the space of the dorsal hilum, handling of the stapler for stapling the right upper lobe bronchus from the uniport in the 6th intercostal space at the medial axillary line can be challenging. This issue was resolved by manipulating the staple over the azygos vein toward the inferior margin of the aortic arch. Via mediastinal lymphadenectomy, we found that the right recurrent laryngeal nerve branched from the right vagus nerve and hooked around the right-sided aortic arch. CONCLUSIONS: Right lobectomy with mediastinal lymph node dissection under uniportal VATS can be performed for lung cancer in patients with a right-sided aortic arch.

How to do bedside mediastinal decompression in tension pneumomediastinum.

Tension pneumomediastinum is uncommon but it is a rapidly progress condition that can lead to cardiogenic shock. Mediastinal decompression is an emergency procedure and the knowledge of this technique is a life-saving treatment.

Comparison of postoperative complications in mediastinal lymph node dissection versus mediastinal lymph node sampling for early stage non-small cell lung cancer: Protocol for a systematic review and meta-analysis.

INTRODUCTION: Lung cancer is the primary cause of cancer-related deaths worldwide, with high rates of morbidity and mortality. The most effective treatment for early stage (I-II) non-small cell lung cancer (NSCLC) is surgical resection. However, the extent of mediastinal lymph nodes removal required and the impact of their removal remains controversial. This systematic review and meta-analysis aimed to evaluate the postoperative complications in patients with stage I-II NSCLC who received mediastinal lymph node dissection (MLND) or mediastinal lymph node sampling (MLNS). METHODS AND ANALYSIS: According to the predefined inclusion criteria, we will conduct a comprehensive search for randomized controlled trials (RCTs) and observational studies examining the postoperative complications of MLND compared to MLNS in patients with stage I-II NSCLC. The search will be performed across multiple databases including PubMed, Embase, the Cochrane Library, CNKI, WanFang, Sinomed, VIP, Duxiu, and Web of Science from inception to February 2024. Additionally, relevant literature references will be retrieved and hand searching of pertinent journals will be conducted. Screening, data extraction, and quality assessment will be performed by two independent reviewers. Review Manager 5.4 will be applied in analyzing and synthesizing. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to assess the quality of evidence for the whole RCTs and used Newcastle-Ottawa scale to assess the methodologic quality of observational studies. ETHICS AND DISSEMINATION: This study did not include personal information. Ethical approval was not required for this study. This study is based on a secondary analysis of the literature, so ethical review approval is not required. The final report will be published in a peer-reviewed journal. CONCLUSION: This systematic review will contribute to compare the safety and survival benefits of these two surgical techniques for the treatment of early stage NSCLC, to further guide the selection of surgical approaches. TRIAL REGISTRATION: The protocol of the systematic review has been registered on Open Science Framework, with a registration number of DOI https://doi.org/10.17605/OSF.IO/N2Y5D.