Intestinal Air in the Mediastinum.

CASE PRESENTATION: A 74-year-old man, in excellent physical condition and doing regular intense cycling, was evaluated for transient episodes of thoracic discomfort over a period of several months. His medical history only included a right inguinal hernia, surgically treated, and an abdominal aortic aneurysm measured at 46 mm and treated medically. Physical examination did not reveal much information. The patient did not report gastroesophageal reflux, dysphagia, or history of digestive occlusion. The patient had normal weight and had no trauma history. He had no nicotine or alcohol-dependent behaviors. Vital signs were within normal values. Laboratory test results were normal. Functional status was normal, without anomalies of pulmonary function tests or arterial blood gases. The ECG did not reveal any anomaly.

Case report: robotic thoracic surgery of posterior mediastinal mass.

We report a 39-year-old male with accidental findings of posterior mediastinum mass at right superior aspects, located at T2 with close proximity to trachea, superior vena cava, azygus vein, right subclavian artery and oesophagus. Apart from intermittent right shoulder pain, there was no other significant symptom. He opted for conservative management initially, given the benign nature and proximity to important structures. We postulated that robotic approach will be of advantage for this particular case which was successfully performed with uneventful recovery. This case illustrated the advantages of robotic-assisted surgery, compared to conventional VATS in otherwise potentially difficult case to undertake.

The Importance of the Mediastinal Triangle in Traumatic Lesions of the Aorta.

Background: Trauma-induced aortic injuries continue to be an important factor in morbimortality in patients with blunt trauma. Objectives: To determine the characteristics of aortic lesions in patients with closed thoracic trauma and associated thoracic injuries. Methods: Multicenter cohort study conducted during the years 1994 to 2014 in the radiology service in the University Hospital Complex of A Coruña. Patients >15 years with closed thoracic trauma were included. Sociodemographic and clinical variables were studied in order to determine the lesion cause, location, and degree. Results: We analyzed 232 patients with a mean age of 46.9 ± 18.7 years, consisting of 81.4% males. The most frequent location was at the level of the isthmus (55.2%). The most frequent causes of injury were traffic accidents followed by falls. Patients with aortic injury had more esophageal, airway, and cardiopericardial lesions. More than 85% of the patients had lung parenchyma and/or chest wall injury, which was more prevalent among those who did not have an aortic lesion. Conclusions: Patients with trauma due to traffic accidents or being run over presented three times more risk of aortic injury than from other causes. Those with an aortic lesion also had a higher frequency of cardiopericardial, airway, and esophageal lesions.

Large Cell Neuroendocrine Carcinoma of the Mediastinum Successfully Treated with Systemic Chemotherapy after Palliative Radiotherapy.

Large cell neuroendocrine carcinoma (LCNEC) is a highly malignant cancer originally found in lung in 1991. In extremely rare occasions, primary LCNEC is found in the mediastinum; approximately 40 of such cases have been reported. Due to the limited number of reported cases, a standardized treatment protocol has yet to be established. We report a case of a 66-year-old woman with primary mediastinal LCNEC who presented with superior vena cava syndrome. Emergent radiotherapy was performed, followed by systemic chemotherapy with cisplatin and etoposide, which resulted in a dramatic tumor reduction. This is the first report describing the achievement of a complete response after systemic chemotherapy in a patient with primary LCNEC.

Near-field impedance accurately distinguishes among pericardial, intracavitary, and anterior mediastinal position.

INTRODUCTION: Epicardial catheter ablation is increasingly used to treat arrhythmias with an epicardial component. Nevertheless, percutaneous epicardial access remains associated with a significant risk of major complications. Developing a technology capable of confirming proper placement within the pericardial space could decrease complication rates. The purpose of this study was to examine differences in bioimpedance among the pericardial space, anterior mediastinum, and right ventricle. METHODS: An ovine model (n = 3) was used in this proof-of-concept study. A decapolar catheter was used to collect bipolar impedance readings; data were collected between each of five electrode pairs of varying distances. Data were collected from three test regions: the pericardial space, anterior mediastinum, and right ventricle. A control region in the inferior vena cava was used to normalize the data from the test regions. Analysis of variance was used to test for differences among regions. RESULTS: A total of 10 impedance values were collected in each animal between each of the five electrode pairs in the three test regions (n = 340) and the control region (n = 145). The average normalized impedance values were significantly different among the pericardial space (1.760 ± 0.370), anterior mediastinum (3.209 ± 0.227), and right ventricle (1.024 ± 0.207; P < 0.0001). In post hoc testing, the differences between each pair of regions were significant, as well (P < 0.001 for all). CONCLUSION: Impedance values are significantly different among these three anatomical compartments. Therefore, impedance can be potentially used as a means to guide percutaneous epicardial access.

Mediastinal injury is the strongest predictor of mortality in mounted blast amongst UK deployed forces.

BACKGROUND: Blast injury has been the most common cause of morbidity and mortality encountered by UK forces during recent conflicts. Injuries sustained by blast are categorised by the injuring component of the explosion and depend upon physical surroundings. Previous work has established that head injuries and intra cavity haemorrhage are the major causes of death following exposure to under body (mounted) blast but has yet to explore the precise nature of these torso injuries nor the effect of particular injuries upon survival. This study examines the patterns of torso injury within the mounted blast environment in order to understand the effect of these injuries upon survivability. METHODS: This retrospective study examined the UK Joint Theatre Trauma Registry to determine precise injury patterns of mounted blast casualties within a 13year period of UK military deployments. Survival rates of individual injuries were compared and a multivariable logistic regression model was developed in order to assess the effect that each injury had upon likelihood of death. RESULTS: 426 mounted casualties were reviewed of whom 129 did not survive. Median NISS and ISS for non-survivors was found to be 75. Torso injuries were significantly more common amongst non-survivors than survivors and high case fatality rates were associated with all haemorrhagic torso injuries. Multivariable analysis shows that mediastinal injuries have the largest odds ratio for mortality (20.4) followed by lung laceration and head injury. CONCLUSIONS: Non-compressible torso haemorrhage is associated with mortality amongst mounted blast. Of this group, mediastinal injury is the strongest predictor of death and could be considered as a surrogate marker of lethality. Future work to link blast loading characteristics with specific injury patterns will inform the design of mitigating strategies in order to improve survivability of underbody blast.

Imaging guided mediastinal percutaneal core biopsy--technique and complications.

165 percutaneous biopsies of anterior, middle and posterior mediastinum lesions were performed to 156 patients. Procedure was guided by US in 40 cases, by CT - in 125 cases. Hydrodissection was used in 5 cases, artificial pneumothorax - in 3 cases in order to avoid transpulmonary needle pass. Post-biopsy CT scan was performed and patients observed for any complications. Adequate tissue for histological diagnosis was obtained in 156 (94.5%) cases at the first attempt; in 9 (5.5%) cases the repeated procedure was needed. No major complications were detected after biopsy procedures; minor complications (pneumothorax, hemothorax and hemophtysis) were detected in 23 (13.9%) cases. No complications were detected after US guided procedures; In 17 (10.3% of all complications) cases pneumothorax, in 4 (2.4%) cases - hemothorax and in 2 (1.2%) cases hemophtisis was detected on CT guided procedures. All hemothorax and hemophtisis and 10 pneumothorax cases happened to be self-limited; in 3 pneumothorax cases aspiration and in 4 cases - pleural drainage was needed. Percutaneous image-guided core biopsy of mediastinal lesions is an accurate and safe procedure, which enables to get the tissue material from all mediastinum compartments. Ultrasound is the most efficient for biopsy guidance, if the target is adequately imaged by it; the advantages of US guidance are: a) possibility of real-time needle movement control b) possibility of real-time blood flow imaging b) noninvasiveness c) cost-effectiveness d) possibility to perform the biopsy at the bedside, in a semiupright position; so, ultrasound is a "Gold Standard" for procedure guidance if the 'target" can be adequately imaged by this technique. If US guidance is impossible biopsy should be performed under CT guidance. Hydrodissection and artificial pneumothorax enables to avoid the lung tissue penetration related complications. Pneumothorax was associated with multiple Needle passes and larger diameter needle use. The safety and biopsy procedure success high rate proves the use of IGMPCB as a first choice procedure when the mediastinal mass morphology is needed.

Looking at the frame after the picture: "retrocardiac echocardiography".

We report three cases of mediastinal structures encroaching on the left atrium without haemodynamic compromise. These cases emphasize the potential role of echocardiography for the diagnosis and the management of several extracardiac mediastinal abnormalities.

Accuracy of endobronchial ultrasound guided-transbronchial needle aspiration in mediastinal lymph node diagnosis.

OBJECTIVE: To evaluate the efficacy of Endobronchial ultrasound guided-transbronchial needle aspiration (EBUS-TBNA) for biopsy specimens with adequate evaluable lymphocytes and mediastinal lymph node diagnosis. MATERIAL AND METHOD: Prospective cohort study. Over 18 year old patients with mediastinal or hilar lymphadenopathy, with short axis diameter greater than 10 mm on chest CT were indicated to undergo EBUS-TBNA. When a node was detected, an aspiration was performed under ultrasound guided. The primary end point was the percentage of biopsy specimen with adequate evaluable lymphocytes that had been evaluated by cytopathologist. Secondary endpoint was the percentage of EBUS-TBNA diagnosis result. RESULTS: 82 patients with mediastinal or hilar lymphadenopathy underwent EBUS-TBNA. Average size of lymph node was 1.57 x 1.49 cm. The overall of the diagnostic accuracy was a percentage of biopsy specimen with adequate evaluable lymphocytes as 97.7%. For mediastinal lymph node diagnosis, the cytological evaluation demonstrated that the positive for malignancy, atypical or suspicious for malignancy, negative for malignancy and non-diagnosis were 37.2%, 9.3%, 2.3% and 51.2%, respectively. In case of positive for malignancy, non-small cell carcinoma, adenocarcinoma, bronchoalveolar cell carcinoma and small cell carcinoma were found 62.5%, 15.6%, 3.1% and 18.8%, respectively. Additionally, the pathological examination showed that positive for malignancy, atypical or suspicious for malignancy, negative for malignancy and non-diagnosis were found 35.4%, 7.3%, 3.6% and 53.7%, respectively. There were no complications during all of the procedures. CONCLUSION: High percentage of biopsy specimen with adequate evaluable lymphocytes can be obtained in EBUS-TBNA. This finding suggested that this method should be considered for mediastinal lymph node diagnosis.

Saphenous vein graft aneurysm-an unusual cause of mediastinal mass.

We report the case of a 78-year-old man who was incidentally found to have a large, ovoid mass on a chest X-ray. Nineteen years before, he had undergone a coronary artery bypass graft (CABG). A chest computed tomography (CT) scan revealed a 6.8 x 6.7 cm aneurysm of the saphenous vein bypass graft anastomosed to the distal right coronary artery with contrast filling only the proximal end of the graft. The inferior wall of the left ventricle was akinetic on echocardiography, suggesting prior myocardial infarction of this vascular bed. Because of the patient's comorbidities, occlusion of the graft, and prior inferior infarction, clinical observation was elected.

[Noncardiac ST elevation during the ileus operation].

A 59-year-old man had undergone the esophagectomy for esophageal carcinoma. Subsequently, he was scheduled to undergo the operation for ileus. He had midazolam 1 mg intramuscular injection before the surgery. General anesthesia was induced with thiamylal 62.5 mg and vecuronium 6 mg and maintained with sevoflurane, fentanyl, air and oxygen. ST elevation up to 0.3 mV occurred 45 minutes after the start of the operation, but his hemodynamic status was stable. We administered a nitrovasodilator, but the ST elevation rose gradually without hemodynamic instability until the end of the operation. He was then admitted to the cardiac care unit. The evidence of acute coronary syndrome (ACS) was not found, althrough the ST elevation did not decline to the baseline. Suddenly, a physician watching the patient and his ECG compressed his chest and interrupted its motion. Surprisingly, the ST elevation was improved. In this case, the gastric tube after esophagectomy had been extended to the ileus and the movement of the heart was influenced in the crowded mediastinal space. When ST elevation was found with no evidence of ACS, we must consider other reason than ACS.

Semi-automated algorithm for calculating heart-to-mediastinum ratio in cardiac Iodine-123 MIBG imaging.

BACKGROUND: We have developed novel software for semi-automatically measuring heart-to-mediastinum (H/M) ratio in cardiac Iodine-123 (¹²³I)-labeled meta-iodobenzylguanidine (MIBG) imaging. Our aim is to improve the reproducibility of the H/M ratio using the semi-automated method as opposed to the manual method. METHODS AND RESULTS: The software algorithm automatically determined the mediastinal region of interest (ROI) using information from ¹²³I-MIBG uptake of the heart, lung, liver, and thyroid after a cardiac circular ROI was manually set. A total of 37 patients who underwent both early and delayed ¹²³I-MIBG imaging was retrospectively selected. The heart-to-mediastinum (H/M) ratios were calculated by both semi-automated and manual methods and assessed for the intra- and inter-observer variability. All H/M ratios were classified into three groups: normal, slight abnormality, and severe abnormality. The H/M ratios with the new method were higher than those obtained manually (P < .001). In the test-retest reliability, the intra-class correlation coefficient from the semi-automated method showed excellent reproducibility for early (0.99) and delayed (0.99) imaging. The Bland-Altman plots demonstrated better agreement using the semi-automated method (a range of 95% limits -0.11 to 0.10) than that in the manual method (-0.34 to 0.27). The inter-observer agreement was also good using the semi-automated method (κ = 0.866). CONCLUSIONS: The H/M ratio using the semi-automated method showed high reproducibility in both early and delayed imaging.

Lipomatose simétrica benigna: doença de Madelung: relato de caso / Benign symmetric lipomatosis: Madelung's disease: case report

JUSTIFICATIVA E OBJETIVOS: A lipomatose simétrica benigna (LSB) foi descrita inicialmente por Madelung em 1888 e possui patogênese ainda desconhecida. É caracterizada por múltiplos depósitos de gordura indolor não encapsulado com disposição simétrica, localizados preferencialmente na região cervical e tronco superior, podendo causar sintomas compressivos e aparência pseudoatlética. O tratamento cirúrgico é o mais efetivo, por ressecção ou por lipossucção. O objetivo deste relato foi apresentar a importância do caso descrito, devido à sua exuberância clínica, apesar de assintomática e sem alterações significativas laboratoriais.RELATO DO CASO: Paciente do sexo masculino, 77 anos, agricultor, natural de Pernambuco. Relatou que há oito meses apresentava crescimento progressivo de massa indolor na região cervical, occipital e superior do tórax, negando outros sintomas que pudessem acompanhar o crescimento e sem história familiar. Hipertenso, etilista e tabagista. Ao exame constatou-se massa volumosa simétrica cervical fibroelástica, na região cervical, não aderida a planos profundos e sem sinais flogísticos.CONCLUSÃO: A LSB foi classificada por Enzi e col. em dois tipos, o paciente em questão foi classificado como tipo I, lipoma predominantemente cervical. A ingesta de álcool consumida pelo paciente tem forte associação com a etiologia da doença de acordo com Enzi e col. Foi realizada lipectomia, com abordagem em dois tempos cirúrgicos devido a invasão de estruturas nobres. O paciente evoluiu bem clinicamente, sem complicações, com bom resultado estético. O presente caso apresentava uma exuberância clínica não condizente com os parâmetros laboratoriais e sintomatologia descrita na literatura.(AU)

BACKGROUND AND OBJECTIVES: Benign symmetric lipomatosis (BSL) was first described by Madelung in 1888 and still has unknown pathogenesis. It is characterized by multiple unencapsulated painless fat deposits with symmetrical disposition, preferably located in the cervical region and upper trunk and may cause compressive symptoms and pseudoathletic appearance. Surgical treatment is most effective, and it could be done by resection or liposuction. The objective of this study was to present the importance to describe the case due to your clinical exuberance without symptoms or significant changes in laboratory tests.CASE REPORT: Male patient, 77 years old, farmer, born in Pernambuco. Reported that 8 months ago began progressive growth of a painless mass in the cervical region, occipital region and upper chest, with no family history. He has high blood pressure, alcoholic and smoker. On examination, it could be noticed a large fibroelastic symmetric mass, asymptomatic, in the cervical region, not adhered to deep planes and with no signs of inflammation.CONCLUSION: The benign symmetric lipomatosis was rated by Enzi et al. in two types, the patient in this case was classified as type I, predominantly cervical lymphoma. The intake of alcohol consumed by the patient is strongly associated with the etiology of this disease, according to Enzi et al. The patient underwent a lipectomy with a two steps approach due to surgical invasion of vital structures. The patient was stable clinically, without complications, with good aesthetic results. The clinical case described had an exuberance of clinical manifestations, not consistent with laboratory parameters and symptoms described in the literature.(AU)

Natural orifice transluminal endoscopic surgery: cardiopulmonary safety of transesophageal mediastinoscopy.

BACKGROUND AND STUDY AIMS: Physiological reactions during natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy may lead to cardiorespiratory depression. The aim of the current study was to assess cardiopulmonary changes during transesophageal mediastinoscopy in an acute porcine model. METHODS: Transesophageal mediastinoscopy was performed under general anesthesia in eight female pigs with a bodyweight of 39 +/- 6 kg. Mediastinal access was achieved via a submucosal tunnel. The cardiac index and global end-diastolic volume index (reflecting preload) were measured every 3 minutes by transpulmonary thermodilution. The following parameters were also recorded: mediastinal pressure, heart rate, mean arterial pressure, systemic vascular resistance index (SVRI; reflecting afterload), peak inspiratory pressure, pH, pCO (2), and pO (2). RESULTS: In three animals, small tears in the parietal pleura resulted in tension pneumothoraces. The associated cardioplumonary deterioration was fatal in one pig. The other two pigs recovered after decompression with a chest tube. In the remaining five animals there were only mild hemodynamic and respiratory changes during mediastinoscopy. There was a significant ( P = 0.005) but minor transient fall in cardiac index, which correlated with a small rise in SVRI (r = - 0.857, P < 0.001). In the pigs with uncomplicated mediastinoscopy, on-demand insufflation via the endoscope resulted in median mediastinal pressures of 4.5 mm Hg (range 2.3 - 10.2 mm Hg). Overall, mediastinal and thoracic structures could be identified without difficulty via the transesophageal approach. CONCLUSIONS: NOTES mediastinoscopy carries a substantial risk of inadvertent development of a pneumothorax. Otherwise, it leads to negligible hemodynamic and pulmonary changes. In conclusion, close monitoring for the presence of a pneumothorax during NOTES mediastinoscopy appears to be mandatory.

Spinal cord stimulation as a novel approach to the treatment of refractory neuropathic mediastinal pain.

Spinal cord stimulation (SCS) offers new hope for patients with neuropathic pain. SCS "neuromodulates" the transmission and response to "painful" stimuli. The efficacy of SCS has been established in the treatment of a variety of neuropathic pain conditions and more recently in refractory angina pectoris, peripheral vascular disease, and failed back surgery syndrome. Recent publications suggest that visceral pain could be successfully treated with SCS. We report the first successful use of a spinal cord stimulator in the treatment of refractory neuropathic mediastinal, esophageal, and anterior neck pain following esophagogastrectomy.

Postpneumonectomy syndrome: surgical management and long-term results.

OBJECTIVE: Postpneumonectomy syndrome is a rare syndrome of dynamic airway obstruction caused by extreme rotation and shift of the mediastinum after pneumonectomy, resulting in symptomatic central airway compression. We have treated this syndrome by mediastinal repositioning and placement of saline-filled prostheses into the pneumonectomy space. There is a paucity of outcome data for patients treated surgically, with only a single series of 11 patients previously reported. We analyzed our recent experience with treatment of this syndrome and report on the short and long-term outcomes and quality of life assessment of the largest series ever reported of patients treated by mediastinal repositioning. METHODS: Records were reviewed of all patients who underwent mediastinal repositioning for postpneumonectomy syndrome between January of 1992 and June of 2006. Long-term health-related quality of life was assessed by administration of the Saint George's Respiratory Questionnaire. RESULTS: There were 18 patients (15 women and 3 men) with a median age of 44 years (range 14-67 years). Thirteen patients had undergone right pneumonectomy, and 5 patients had undergone left pneumonectomy. None of the patients in whom postpneumonectomy syndrome developed after left pneumonectomy had a right-sided aortic arch. Five patients had undergone pneumonectomy in childhood (age < 13 years). The median interval between pneumonectomy and mediastinal repositioning was 7.5 years (range 1.1-54.8 years). The median follow-up was 32 months (range 4-143 months). The operative mortality was 5.6% (1/18). Complications occurred in 5 patients (27.8%): pneumonia in 3 patients and acute respiratory distress syndrome in 2 patients. The median hospitalization was 6 days (range 3-155 days). Some 77% (10/13) of patients reported significant improvement in their breathing and overall state of health after surgery; 15.4% of patients (2/13) were somewhat better, and 7.7% of patients (1/13) had no improvement. No patients' condition was worse after surgery. All patients who reported improvement in their symptoms after surgery remained symptomatically improved at the time of the quality of life assessment. Some 92.3% (12/13) were not at all or only slightly limited in their social activities because of breathing problems, and 84.6% (11/13) were not at all or only slightly limited in their ability to work as a result of their physical health. CONCLUSION: Repositioning of the mediastinum with placement of prostheses for postpneumonectomy syndrome can be performed with low mortality and morbidity. Surgical repositioning provides immediate and lasting symptomatic relief to patients in whom postpneumonectomy syndrome develops.

Split notochord syndrome with congenital unilateral Horner's sign.

A 2-year-old boy exhibited congenital right Horner's sign and right finger, wrist, and elbow flexion arthrogryposis. He had dyspnea and feeding difficulty 12 hours after birth. Radiologic examination revealed a thoracoabdominal intestinal tube and mediastinal cystic lesion at the right side, with vertebral anomaly at the cervical level. Histopathologically, the intestinal tube was diagnosed as bowel duplication. Because the mediastinal lesion could not be resected surgically, no histopathological diagnosis was made. Embryologically, the combination of transdiaphragmatic duplication, mediastinal cystic lesion, anterior spina bifida, and hemivertebra suggested notochord malformation. The diagnosis was split notochord syndrome, an extremely rare embryological malformation syndrome. Congenital unilateral Horner syndrome often has unknown etiology. In this case, cervical vertebral anomalies and mediastinal cystic lesion implied a compressed nerve root, resulting in Horner syndrome and right finger, wrist, and elbow flexion joint contracture. Split notochord syndrome should be included in differential diagnosis of congenital unilateral Horner syndrome.

Cardiac sympathetic denervation in bradykinesia-dominant Parkinson's disease.

Cardiac iodine-123-labeled-metaiodobenzylguanidine uptake is reduced in early-stage Parkinson's disease, suggesting sympathetic nerve degeneration. The scintigraphic findings in patients with Parkinson's disease with different clinical features have, however, not been established. Iodine-123-labeled-metaiodobenzylguanidine myocardial scintigraphy was performed in 143 patients with Parkinson's disease. The early and delayed heart to mediastinum ratios were analyzed according to the dominant motor deficit (tremor, bradykinesia, rigidity, and postural instability), age, sex, age at onset, disease duration, and Hoehn and Yahr stage. Both ratios correlated with bradykinesia, age at disease onset, and disease duration; but not with sex, Hoehn and Yahr stage, tremor, rigidity, and postural instability. Our results suggest a close link between myocardial sympathetic degeneration and bradykinesia, age at onset and disease duration.