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Mediastinum (Hong Kong, China) 2021Mediastinal injuries are uncommon, rarely encountered and depending on the institution, can be managed by various sub-specialties. The purpose of this narrative review... (Review)
Review
OBJECTIVE
Mediastinal injuries are uncommon, rarely encountered and depending on the institution, can be managed by various sub-specialties. The purpose of this narrative review is to present an overview of traumatic mediastinal injuries, their presentation, and management options from the perspective of a thoracic surgeon.
BACKGROUND
Although infrequent, traumatic mediastinal injuries can pose significant morbidity and mortality. The infrequency of these injuries limits operative exposure for thoracic surgeons and trainees. A concise overview of common presentations and management options is warranted to further solidify important concepts.
METHODS
A search of the literature was conducted using MEDLINE, PubMed, and Embase for relevant articles pertaining to anatomic injuries of the mediastinum. The presentation of mediastinal injuries along with indications for non-operative versus operative management in cardiac injuries, thoracic esophageal injuries, tracheobronchial injuries, and injuries to the lungs and pleura was conducted and literature summarized.
CONCLUSIONS
In providing this review it is hopeful to enhance knowledge and comfort in recognition and management of these uncommon yet potentially lethal injuries. Early involvement of thoracic surgery is recommended to ensure effective and efficient treatment.
PubMed: 35118338
DOI: 10.21037/med-21-13 -
Thorax Jul 1973The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The...
The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The results of these are presented. In 36 patients the operation was done to provide a histological diagnosis in benign conditions. In 51 patients, with probable carcinoma but normal bronchoscopy, mediastinotomy was done to establish a diagnosis and assess operability; 43 had involved mediastinal nodes proven on histology. In a further 29 patients, with positive bronchoscopic biopsies, mediastinotomy was done to assess operability alone. In all, 14 patients (17·5%) were judged suitable for thoracotomy. Of these, nine had operable disease while five were found to be inoperable. The incidence of complications of the operation was low (11%). These were mostly minor, There were no deaths. Most patients, after anterior mediastinotomy alone, were fit for discharge 48 to 72 hours after the operation. The value of an operation that provides both diagnosis and assessment of mediastinum, lung, and pleura is discussed. The operation of anterior mediastinotomy is compared with mediastinoscopy and, in our opinion, the superiority of the former is demonstrated.
Topics: Biopsy; Bronchial Neoplasms; Bronchoscopy; Humans; Lung Diseases; Lung Neoplasms; Mediastinal Neoplasms; Mediastinum; Methods; Postoperative Complications; Sarcoidosis; Surgical Wound Infection
PubMed: 4741446
DOI: 10.1136/thx.28.4.444 -
Journal of Visualized Surgery 2018The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy.
BACKGROUND
The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy.
METHODS
We used a collar neck incision (transcervical) of an average length 5-8 centimeters. The manubrium of the sternum is elevated with a hook connected to the Zakopane II frame (Aesculap-Chifa, B. Braun, Nowy Tomyśl, Poland). The first step is a transcervical extended mediastinal lymphadenectomy (TEMLA), for improved staging and possible improved survival. The nodes removed during TEMLA undergo intraoperative imprint cytology examination. In case of no metastasis a uniportal VATS lobectomy through the neck follows. Ventilation of the operated lung is disconnected and the pleural cavity is entered by opening of the mediastinal pleura. Pleural adhesions, if present are managed with electrocautery. The branches of the pulmonary artery and vein are sequentially dissected and managed with endostaplers or vascular clips. The lobar bronchus and the fissures are divided with endostaplers and the resected lobe is removed in an endobag.
RESULTS
There were 16 patients operated on in the period 1.2.2016-30.7.2016. There were two conversions-in one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. In the other patient undergoing right lower lobectomy there was a conversion to right thoracotomy because of the bleeding from the pulmonary artery. There was no mortality and complications occurred in three patients. The mean operative time was 245.6 min (range, 145-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 175.6 min (range, 75-295 min) for a lobectomy solely.
CONCLUSIONS
A uniportal transcervical VATS approach for pulmonary lobectomy combined with transcervical extended mediastinal lobectomy (TEMLA) provides an opportunity for radical pulmonary resection and superradical extensive mediastinal lymphadenectomy.
PubMed: 29552524
DOI: 10.21037/jovs.2018.02.02 -
The Journal of Experimental Medicine May 1909THE LAST MENTIONED FACT MAY PERHAPS FIND ITS EXPLANATION IN THE FOLLOWING STATEMENTS: the two pleural cavities are separated by the layers of the anterior and posterior...
THE LAST MENTIONED FACT MAY PERHAPS FIND ITS EXPLANATION IN THE FOLLOWING STATEMENTS: the two pleural cavities are separated by the layers of the anterior and posterior mediastinal septa. Between the two lies the heart. In the dog, the posterior seems to be somewhat tougher than the anterior septum, and somewhat more fixed and tense. With violent respiratory movements, it is the anterior septum which more especially flaps to and fro and bulges when an opening in the pleura has been made, and it is the anterior septum which is so apt to rupture and thus cause double pneumothorax and the death of the animal. When the dog is on its back, the heart falls backward and the bulging of the anterior mediastinal septum is made more easy. It is different when the animal is on its belly. The heart falls toward the anterior chest wall and thus supports the anterior septum: hence the flapping of the septum, the interference with the respiration of the lung on the sound side, the bulging on expiration on the open side, can not so readily occur. The danger of the open pneumothorax is greatly lessened when the animal is in the prone position. In the supine position the danger of the pneumothorax is due to the falling back of the heart and thus facilitating the rupture of the fragile anterior mediastinal septum; the danger is therefore obviated by fixing the pericardium to the anterior wall of the thorax.
PubMed: 19867258
DOI: 10.1084/jem.11.3.444 -
The British Journal of Radiology Feb 2023Advances in imaging technology have dramatically increased the resolution of CT and improved detection of disease; these advances also have led to an increase in...
Advances in imaging technology have dramatically increased the resolution of CT and improved detection of disease; these advances also have led to an increase in incidentalomas or incidental findings that often do not represent significant disease. Incidental findings on thoracic CT are common and can be problematic and expensive to evaluate. Thoracic imagers often are having to make recommendations for appropriate management which adds to the burden. Thoracic CT incidental findings are broad and include those of the lungs, heart, mediastinum, pleura, chest wall, thoracic soft tissues as well as the lower neck and upper abdomen. Of these, incidental pulmonary nodules have garnered the most interest over the years, but all incidentals may be proven to represent significant disease. In the USA, the American College of Radiology has generated white papers on incidentals that have proven useful. Currently, a number of investigations to utilize artificial intelligence for qualification and management of incidentals are ongoing. Likewise, the radiology/imaging community must support efforts to collaboratively address incidental findings and management concerns. As such, continued efforts to establish guidelines for appropriate identification, classification and management of incidentals is important to improve patient care and assure fiscally responsible assessment.
Topics: Humans; Artificial Intelligence; Tomography, X-Ray Computed; Neck; Mediastinum; Thoracic Wall; Incidental Findings
PubMed: 35315291
DOI: 10.1259/bjr.20211368 -
Turkish Thoracic Journal Jul 2020Immunoglobulin G4 related disease (IgG4-RD) is a relatively newly defined disease known for multiple organ involvement. Histopathologically, the disease is characterized...
Immunoglobulin G4 related disease (IgG4-RD) is a relatively newly defined disease known for multiple organ involvement. Histopathologically, the disease is characterized by lymphoplasmatic inflammation, fibrosis, and enhanced levels of IgG4-positive plasma cells in tissues. IgG4-RD has been reported in almost every organ system. With pulmonary involvement, lesions have been described in the lung parenchyma, airways, pleura, and the mediastinum. Glucocorticoids are the first choice of treatment, but additional immunosuppressive drugs may be administered in refractory patients. In this article, we report a patient with IgG4 syndrome who had lung parenchyma, mediastinum, aorta wall, and pancreatic involvement. Histopathological findings and high serum IgG4 level established the diagnosis of IgG4-related disease. The patient was treated successfully with glucocorticoids.
PubMed: 32687790
DOI: 10.5152/TurkThoracJ.2019.190115 -
Modern Pathology : An Official Journal... Nov 2022Myxoid pleomorphic liposarcoma (MPLPS) is a recently described and extremely rare subtype of liposarcoma with a predilection for the mediastinum. However, the genomic...
Myxoid pleomorphic liposarcoma is distinguished from other liposarcomas by widespread loss of heterozygosity and significantly worse overall survival: a genomic and clinicopathologic study.
Myxoid pleomorphic liposarcoma (MPLPS) is a recently described and extremely rare subtype of liposarcoma with a predilection for the mediastinum. However, the genomic features of MPLPS remain poorly understood. We performed comprehensive genomic profiling of MPLPS in comparison with pleomorphic liposarcoma (PLPS) and myxoid/round cell liposarcoma (MRLPS). Of the 8 patients with MPLPS, 5 were female and 3 were male, with a median age of 32 years old (range 10-68). All except one were located in the mediastinum, with invasion of surrounding anatomic structures, including chest wall, pleura, spine, and large vessels. All cases showed an admixture of morphologies reminiscent of PLPS and MRLPS, including myxoid areas with plexiform vasculature admixed with uni- and/or multivacuolated pleomorphic lipoblasts. Less common features included well-differentiated liposarcoma-like areas, and in one case fascicular spindle cell sarcoma reminiscent of dedifferentiated LPS. Clinically, 4 experienced local recurrence, 4 had distant metastases and 5 died of disease. Compared to PLPS and MRLPS, patients with MPLPS had worse overall and progression-free survival. Recurrent TP53 mutations were present in all 8 MPLPS cases. In contrast, in PLPS, which also showed recurrent TP53 mutations (83%), RB1 and ATRX losses were more common. MRLPS was highly enriched in TERT promoter mutations (88%) and PI3K/AKT pathway mutations. Copy number profiling in MPLPS revealed multiple chromosomal gains with recurrent amplifications of chromosomes 1, 19 and 21. Importantly, allele-specific copy number analysis revealed widespread loss of heterozygosity (80% of the genome on average) in MPLPS, but not in PLPS or MRLPS. Our findings revealed genome-wide loss of heterozygosity co-existing with TP53 mutations as a characteristic genomic signature distinct from other liposarcoma subtypes, which supports the current classification of MPLPS as a stand-alone pathologic entity. These results further expand the clinicopathologic features of MPLPS, including older age, extra-mediastinal sites, and a highly aggressive outcome.
Topics: Adult; Humans; Male; Female; Child; Adolescent; Young Adult; Middle Aged; Aged; Lipopolysaccharides; Phosphatidylinositol 3-Kinases; Proto-Oncogene Proteins c-akt; Liposarcoma; Genomics; Loss of Heterozygosity; Liposarcoma, Myxoid
PubMed: 35672466
DOI: 10.1038/s41379-022-01107-6