[Mediastinitis Associated with Mediastinal Pancreatic Pseudocyst Successfully Treated by Thoracoscopic Mediastinal Drainage].

Pancreatic pseudocysts rarely extend to the mediastinum and can be fatal if mediastinitis is complicated. In this report, we describe a case of mediastinitis associated with mediastinal pancreatic pseudocyst successfully treated by the thoracoscopic mediastinal drainage. The patient was a man in his 40s with a history of alcoholic acute pancreatitis. Chest and abdominal computed tomography (CT) scan taken for his complaints of back pain and dyspnea showed a pancreatic pseudocyst extending to the mediastinum. First, an endoscopic nasopancreatic drainage( ENPD) tube was placed, and then thoracoscopic mediastinal drainage was performed through the right thoracic cavity. After the operation, the pseudocyst in the mediastinum rapidly disappeared even though there was no drainage from the ENPD tube. Postoperative recovery of the patient was uneventful, and the patient was discharged on the 17th postoperatively day. This case suggests that the importance of prompt treatment for mediastinitis and the effectiveness of the thoracoscopic surgery.

Endobronchial Ultrasound-Guided Transbronchial Incision and Drainage in the Treatment of Mediastinal Abscess.

Mediastinal abscess, mostly resulting from esophageal perforation or cardiothoracic surgery, is a serious condition carrying high morbidity and mortality. Antibiotic therapy alone normally did not achieve a satisfactory outcome, due to poor circulation of abscess that hampers drug delivery. Surgical intervention for debridement and drainage is recommended, but it poses a high risk in patients with poor health status and could lead to various complications. Recent studies proposed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as an effective alternative to surgery; however, repeated TBNA procedures are usually needed for complete clearance of the lesion, thus causing increased patient suffering and medical expenses. Here, we present the first case of successful application of EBUS-guided transbronchial incision and drainage, which provides a novel, safe, and effective treatment for patient with mediastinal abscess unwilling or unsuitable to undergo surgical intervention.

Current status of surgical treatment of Boerhaave's syndrome.

BACKGROUND: Surgical treatment is usually required for Boerhaave's syndrome (post-emetic esophageal perforation), and the technique should be chosen based on the local infection status and patient's general condition. This study was performed to examine the current status of surgical treatment of Boerhaave's syndrome in Japan. METHODS: Ninety-five patients with Boerhaave's syndrome who underwent surgical treatment from January 2010 to December 2015, obtained from a national survey were retrospectively analyzed. The details of each surgical treatment and the type of treatment performed according to the patients' characteristics were examined. RESULTS: Primary closure was performed in 75 (78.9%) patients, T-tube insertion in 15 (15.8%), and esophagectomy in 5 (5.3%). The length of the postoperative stay was significantly shorter in patients who underwent primary closure (p = 0.0011). Esophagectomy tended to be performed more often in patients with a long perforation and was performed significantly more often in patients with a high C-reactive protein concentration (p = 0.0118). The postoperative hospital stay was significantly longer in patients with leakage of the primary closure site (p < 0.0001). As a result, leakage of the primary closure site was significantly correlated with a long duration from symptom onset to patient presentation (p = 0.042), diagnostic imaging of the intrathoracic perforation (p = 0.013), and abscess formation in the mediastinal cavity (p = 0.006). CONCLUSIONS: Selection of an appropriate surgical procedure may contribute to reduced mortality rates in patients with esophageal rupture. With regard to primary closure, it is necessary to understand that leaks are likely to occur in patients with a long duration from symptom onset to presentation or with severe intrathoracic/mediastinal inflammation, and to select an appropriate surgical procedure in consideration of the degree of invasiveness and QOL.

[Laparoscopic transchiatal access in Boerhaave syndrome]. / Laparoskopicheskii transkhiatal'nyi dostup pri sindrome Burkhave.

Diagnosis of spontaneous rupture of the esophagus (Boerhaave syndrome) followed by purulent mediastinitis and pleural empyema has now been greatly simplified due to CT. The main thing is to suspect this syndrome in a timely manner. Methods of surgical treatment of this disease are still being discussed. We present successful laparoscopic treatment of spontaneous rupture of the esophagus.

Omitting Chest Tube Drainage after Subxiphoid Thoracoscopic Thymectomy.

BACKGROUND: This study investigated the feasibility and safety of omitting chest tube drainage after subxiphoid thoracoscopic thymectomy. METHODS: From July 2018 through October 2018, 20 patients underwent subxiphoid thoracoscopic thymectomy without chest tube drainage. The clinical characteristics and perioperative outcomes of these patients are presented. RESULTS: All patients (10 males, 10 females; average age: 53.25 ± 12.50 years old) completed the operation. Chest tube drainage was omitted in a total of 20 patients. The operative time was 89.45 ± 49.80 minutes. No adverse events were observed. The bed-side ultrasound examination of the pleural cavity on the day of surgery showed a thimbleful of effusion and did not require thoracentesis. A postoperative chest roentgenogram on the next morning showed full expansion without pneumothorax in all patients. None of the patients required reintervention with chest drainage through the time of discharge. CONCLUSION: The omission of chest tube drainage may be an alternative procedure for selected patients undergoing thoracoscopic thymectomy. The omission of chest tubes in thymectomy is safe, but further investigation is required.

Autologous pericardium used for reconstruction of left innominate vein in patient with mediastinal venous aneurysm:a case report.

BACKGROUND: Mediastinal venous aneurysm is a very rare disease and can be easily misdiagnosed. Patients are often asymptomatic while venous aneurysm of large size with adjacent structures oppressed can lead to discomfort. The surgical treatment for aneurysm of large vessels is often complex and challenging. CASE PRESENTATION: We reported a 52-year-old man with mediastinal mass who received operation on July 2019 in our hospital. Left innominate vein aneurysm was diagnosed during operation with superior vena cava involved. The aneurysm was resected and pericardium was taken to repair part wall of superior vena cava and reconstruct left innominate vein. The patient's postoperative course was uneventful. CONCLUSIONS: Venous aneurysm should be considered when mediastinal mass has no clear boundary with large veins or even seems to connect with them. Magnetic resonance imaging, computed tomographic angiography and invasive venography can be performed to further evaluate the mass once diagnosis of venous aneurysm was suspected. Using pericardium to repair large veins is a good choice which is safe and costless.

Mediastinal calcified hydatid cyst.

Mediastinal hydatid cyst is a rare disease and should be considered in differential diagnosis of mediastinal cystic lesions especially in endemic regions. This localization is very serious because of the surrounding vital structures. Surgery must be indicated immediately using conservative techniques without extensive resection when progression of dissection is difficult or dangerous. Medical treatment is necessary to prevent recurrence.

Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome).

BACKGROUND: Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain. METHODS: Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed. RESULTS: Ten patients (80% male) with a mean age of 61.3 years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 ± 12 h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8 days (range 3-26), while inpatient LOS was 23.1 ± 12.5 days (range 14-46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%. CONCLUSION: Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.

Mediastinal Mucormycosis: Case report, review of literature and treatment with continuous liposomal amphotericin B irrigation.

Mediastinal mucormycosis is an uncommon but lethal infection associated with an 83% mortality. We describe a case of fatal Rhizopus microsporus mediastinitis despite three exploratory mediastinal surgeries and complementary systemic and mediastinal irrigation with liposomal amphotericin B. We further review the literature on surgical and antifungal management of mediastinal mucormycosis.

Esophageal perforation secondary to malignant gastric outlet obstruction: a case report.

BACKGROUND: Esophageal perforation is a rare presenting sign of gastric cancer. To date, only nine case reports of this phenomenon have been previously published. CASE PRESENTATION: Esophageal perforation was diagnosed radiographically during workup for acute chest pain in a 67-year-old man. Emergent endoscopy confirmed esophageal perforation and biopsied a pre-pyloric mass confirmed to be adenocarcinoma. The perforation was managed with endoscopically placed transluminal pleural and mediastinal drains and esophageal stenting. The gastric outlet obstruction was temporized with a transpyloric stent. After the patient recovered from sepsis, distal gastrectomy was performed and he made a full recovery. CONCLUSIONS: Rarely, pre-pyloric gastric cancer can present with Boerhaave syndrome, spontaneous esophageal perforation associated with forceful vomiting. We present the tenth report in the literature of this phenomenon and the first to be initially treated with endoscopic stenting and transluminal thoracoscopic drainage. When endoscopic management is used to treat patients with Boerhaave syndrome, it may be beneficial to examine the entire stomach to evaluate for malignant etiology.

Laparoscopic Management of Boerhaave's syndrome: a case report with an intraoperative video.

BACKGROUND: Boerhaave's syndrome involves a sudden elevation in the intraluminal pressure of the esophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Its treatment is challenging, and early surgical intervention is the most crucial prognostic element. CASE PRESENTATION: We present a case of a 32 year-old male who presented after severe emesis with an acute onset of epigastric pain. He was diagnosed with Boerhaave's syndrome. Displaying signs of shock mandated immediate surgical exploration with laparoscopic primary repair. CONCLUSION: The golden period of the first 24 hrs of the event still applies to cases of esophageal perforation. The scarcity of these cases makes a comparison between the various treatment methods difficult. Our data support the use of laparoscopic intervention with primary repair as the mainstay of treatment for the management of esophageal perforation.

Endoscopic management of Boerhaave's syndrome.

A endoscopically treated Boerhaave's syndrome is reported and a brief review of related literature is made.

An air-containing mediastinal mass in a patient with a primary adenocarcinoma of the right lung.

Objective: The following case report elicits the treatment of a 55-year-old male who was diagnosed with a surinfected mediastinal chyloma as a complication of mediastinoscopy and radiotherapy for a primary adenocarcinoma of the right lung (cT2aN2M0). Methods: The patient was admitted to the hospital after radiographical imaging showed a surinfected mediastinal chyloma. CT-guided percutaneous drainage was performed and via gastroscopy a fistula was diagnosed for which a full covered stent was placed. Then, a right thoracotomy was performed to wash out the chylous cavity, to seal the thoracic duct and to cover the other end of the fistula with an intercostal muscle flap. Results: Postoperative imaging showed a clear reduction of the mediastinal mass with no residual air-fluid level. Realimention was possible three days after placement of the stent. The patient was discharged after 11 days. There was no recurrence of the chyloma. Fistulisation did recur after removal of the stent. Conclusion: Surinfected mediastinal chyloma due to oesopagho-mediastinal fistula is an extremely rare complication after cervical mediastinoscopy and radiotherapy. Open drainage of the chyloma and total coverage of the fistula can control infection and prevent recurrence on short term.

Boerhaave syndrome: A rare postoperative complication.

Spontaneous esophageal perforation, also called Boerhaave syndrome, is a relatively rare condition that can result in significant morbidity or mortality. The tear commonly involves all three layers of the esophagus. It results from increased intraluminal pressure, most commonly from violent retching and vomiting. This article describes a patient with esophageal perforation in the immediate postoperative period following elective hip arthroplasty.

[Mediastinal pancreatic cysts: review and own clinical observations]. / Mediastinal'nye pankreatogennye kisty.

OBJECTIVE: To present the results of surgical treatment of patients with mediastinalpancreatogeniccysts (MPC). MATERIAL AND METHODS: There were 5 patients with MPC. RESULTS: Laboratory tests revealed increased blood amylase level by 1.5-2 times in 3 cases, urine diastase by 4-5 times - in 2 cases. Pleural effusion with amylase concentration in the fluid from 5680 to 48 640 units was diagnosed in 4 cases. CT data of preudocysts of pancreatic body and tail were obtained in 3 cases, head and body - in 2 patients. These cysts extended to posterior mediastinum through the hiatal orifice for about 3.5-40 cm. Three patients underwent VATS removal of pleural fragments, one - thoracotomy, lung decortication and MPC drainage through pleural cavity. Three patients underwent pancreatic drainage procedures (cystogastrostomy, pancreaticojejunostomy and external drainage of the cyst). A small pseudocyst has been successfully treated by conservative treatment with octreotide. CONCLUSION: MPC is a rare complication of pancreatitis and often associated with pleural effusion. CT and fluid amylase analysis are the main diagnostic measures. Surgical treatment includes VATS, destruction of pleural fragments and pleural drainage, cystogastrostomy, pancreaticojejunostomy or external drainage of pancreatic pseudocyst.

[Treatment of patient with echinococcosis of lungs and mediastinum]. / Lechenie patsienta s ékhinokokkozom legkikh i sredosteniia.

It is presented diagnosis and treatment of 53-year-old man with multiple echinococcosis of the lungs and mediastinum. The diagnosis was confirmed by chest CT. Patient previously underwent surgery for liver echinococcosis. Excision of echinococcosis lesions in the lungs and mediastinum was performed. Chest wall repair was made by using of pedicled flap from the right lateral surface of the thorax followed by donor site plasty by polypropylene mesh. There were no intraoperative complications. In the postoperative period, intermediate bronchus occlusion mas made by occluder due to persistent air output through the pleural drains. The device was removed after 4 days. The patient was discharged. Multidisciplinary approach is useful to achieve good results in these patients.

The Video-Assisted Thoracic Surgery for Mediastinal Bronchogenic Cysts: A Single-Center Experience.

OBJECTIVE: The aim of this study was to evaluate the outcomes of video-assisted thoracic surgery (VATS) for mediastinal bronchogenic cyst (MBC) excision and investigate the surgical indication for MBC. METHODS: We retrospectively reviewed all consecutive MBC patients who underwent surgical excision between April 2001 and June 2016. One hundred and nineteen patients were enrolled with a median age of 45.4 years and divided into two groups: anterior mediastinum group (n = 48), and middle and posterior mediastinum group (n = 71). VATS technique was initially performed for each patient. The cyst should be resected completely as far as possible. Follow-up was completed by telephone or outpatient clinic every year. The deadline of follow-up was June 2017. RESULTS: One hundred and eighteen patients underwent VATS, and only one patient converted to open thoracotomy. The average operative time was 103.8 ± 41.6 min (40-360 min). The average intraoperative blood loss was 56.6 ± 86.6 ml (5-600 ml). The intraoperative complication rate was 3.4%, and the incomplete excision rate was 5.9%. The multivariate logistic analysis showed that maximal diameter >5 cm was significantly associated with risk of operation time extension (OR = 3.968; 95% CI 1.179-13.355, p = 0.026) and bleeding loss increasing (OR = 12.242; 95% CI 2.420-61.933, p = 0.002). No serious postoperative complications were observed. Follow-up was performed in 102 patients, and the mean follow-up time was 45 months (12-194 months). There was no local recurrence. CONCLUSIONS: The maximal diameter >5 cm increased risk of operation time extension and bleeding loss increasing. Early surgical excision of MBC by VATS is recommended to establish histopathological diagnosis, relieve symptoms, and prevent surgery-related complications.

[An analysis of the new "three tubes" method in the treatment of spontaneous esophageal rupture].

To investigate the clinical efficacy, feasibility and safety of new "three tubes" method in the treatment of spontaneous esophageal rupture. A total of 22 patients with spontaneous esophageal rupture were retrospectively analyzed. Through the new "three tubes" method of treatment, patients achieved leak cured with reduced hospital stay, less medical expenses and early resumption of oral diet. The new "three tubes" method for spontaneous esophageal rupture has the advantages of easy handling, minimal invasion, few complication and exact curative effect.