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Multimedia Manual of Cardiothoracic... 2015Pericardial effusion may be associated with many diseases, but sometimes its aetiology is not easy to elucidate. Subxiphoid video-pericardioscopy is useful for the study...
Pericardial effusion may be associated with many diseases, but sometimes its aetiology is not easy to elucidate. Subxiphoid video-pericardioscopy is useful for the study of the pericardial cavity. Through a subxiphoid approach, the pericardium is incised and a rigid (usually a video-mediastinoscope) or a flexible endoscope (flexible bronchoscope or flexible choledoscope) is inserted into the pericardial cavity. The inner surface of the parietal pericardium and the epicardium can be explored and biopsies can be taken under visual control. In addition, a subxiphoid pericardial window can be developed, and sclerosing agents instilled for pericardiodesis, if a malignant aetiology is confirmed. In case of pericardial effusion associated with lung cancer, video-pericardioscopy helps to confirm the absence or presence of pericardial tumour implant or infiltration, and to establish the resectability of the tumour. Other than transient arrhythmias during the procedure, video-pericardioscopy has no major complications. When compared with surgical pericardial drainage, video-pericardioscopy has higher sensitivity without specific risks. Rigid endoscopes are the best devices to explore the posterior and lateral pericardial surfaces, the pulmonary veins being the posterior limit of the exploration. Big anterior mediastinal masses and pericardial symphysis may render the exploration impossible.
Topics: Endoscopy; Humans; Pericardial Effusion; Pericardial Window Techniques; Video-Assisted Surgery
PubMed: 26070990
DOI: 10.1093/mmcts/mmv009 -
Journal of Thoracic Disease Aug 2018Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the...
Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the transthoracic approach has been the most used procedure to study the pleural cavity. The subxiphoid video-thoracoscopy is becoming an alternative to the transthoracic approach. Subxiphoid video-thoracoscopy is a minimally invasive technique that allows us to study both pleural cavities with a single subxiphoid incision. In the supine decubitus, through a small subxiphoid incision, a rigid video-mediastinoscope is introduced. Once all the tissues are dissected, mediastinal pleura can be identified and incised. A 30° thoracoscopy is then inserted into the pleural cavity through the video-mediastinoscope to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules if present. Subxiphoid approach has some advantages compared with the traditional transthoracic approach. On the one hand, contrary to traditional thoracoscopy, in subxiphoid video-thoracoscopy it is not necessary to do a transthoracic approach even for the insertion of a chest tube. Avoidance of intercostal ports probably decreases the risk of post-operative pain and the patients can be discharged 24 hours after surgery with no increase in surgical risk. On the other hand, we can explore both pleural cavities at the same time through a single incision, in case of bilateral pleural effusion. If malignancy is confirmed by frozen-section or by macroscopic evidence of intrapleural tumour infiltration or implants, a pleurodesis to avoid recurrence can be performed prior to tube insertion and closure.
PubMed: 30345100
DOI: 10.21037/jtd.2018.03.99 -
Translational Lung Cancer Research Jan 2021The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal... (Review)
Review
The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling. The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.
PubMed: 33569331
DOI: 10.21037/tlcr.2020.03.08 -
The Thoracic and Cardiovascular Surgeon Jan 2023The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that...
The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that has a minor impact on the patient's general status and allows for fast fluid evacuation and biopsy sampling if necessary. We present a subxiphoid mediastinoscopic autonomous (simultaneous noncommunicating) double fenestration approach for these patients with both diagnostic and therapeutic advantages in selected cases. Using the mediastinoscope alone through the subxiphoid incision can considerably reduce the duration of operation, allow for fluid evacuation, and significantly alleviate the patient's symptoms. This method enables the sampling of pleural and pericardial fluids and targeted tissue, if necessary.
Topics: Humans; Mediastinoscopes; Treatment Outcome; Pericardial Effusion; Mediastinoscopy; Biopsy
PubMed: 36216329
DOI: 10.1055/s-0042-1757177 -
Journal of Thoracic Oncology : Official... Apr 2007Pretherapeutic T4 staging of centrally located lung cancer is crucial for the treatment strategy, but non-invasive imaging techniques are of low accuracy. We have...
OBJECTIVES
Pretherapeutic T4 staging of centrally located lung cancer is crucial for the treatment strategy, but non-invasive imaging techniques are of low accuracy. We have developed the new imaging technique of intraoperative mediastinoscopic ultrasound (MUS) to predict technical resectability in tumors staged cT4 based on computed tomographic scanning.
METHODS
Intraoperatively, a sterilizable fingertip ultrasound probe is introduced and guided through the video mediastinoscope with a modified grasper during staging mediastinoscopy. The position of the probe in front of the tracheobronchial tree and in direct contact with the vena cava and pulmonary artery reduces air interference. We reviewed the results for 24 patients with tumors staged cT4 between July 2002 and January 2006. For 18, the prediction of MUS concerning resectability could be compared with intraoperative findings at the time of thoracotomy.
RESULTS
MUS visualizes all central vessels and their relation to the tumor with high accuracy. The pulmonary artery and pulmonary veins are displayed not only in their central parts but also in their interlobar branches. Of the 24 patients, 18 proceeded to thoracotomy after conclusive MUS and had tumors proved to be technically resectable in accordance with prediction by MUS. Comparison of cT (computed tomographic scan), cT (MUS) and pT revealed that T stages defined by MUS accurately predict pathologic T stages.
CONCLUSION
MUS allows investigators to assess infiltration of the great vessels and the mediastinum, especially in right-sided tumors. MUS will supplement endoscopic ultrasound-guided fine needle aspiration for the right upper mediastinum in staging of centrally located tumors.
Topics: Aged; Cohort Studies; Endosonography; Female; Humans; Lung Neoplasms; Lymph Nodes; Male; Mediastinoscopy; Middle Aged; Monitoring, Intraoperative; Neoplasm Invasiveness; Neoplasm Staging; Pneumonectomy; Predictive Value of Tests; Preoperative Care; Retrospective Studies; Sensitivity and Specificity
PubMed: 17409812
DOI: 10.1097/01.JTO.0000263723.99814.d4 -
Mediastinum (Hong Kong, China) 2019Mediastinal lymph node staging is crucial in deciding the treatment strategy for lung carcinoma. The diagnosis rate of computed tomography is not high; however, it is a... (Review)
Review
Mediastinal lymph node staging is crucial in deciding the treatment strategy for lung carcinoma. The diagnosis rate of computed tomography is not high; however, it is a standard examination. Although the contrast computed tomography is necessary for an accurate diagnosis, images from the positron emission tomography are excellent, and these two technologies are independent and complementary. Positron emission tomography has a disadvantage of false positives and false negatives, but it should also be used in cases where lymph node diameters are 1 cm or more. However, image-based diagnostic methods are not an alternative to histological examination. The results of a transbronchial needle biopsy are extremely dependent on the inspection method, the diagnostic ability of the physician, and the staging of the case. The transesophageal ultrasound endoscope is useful for reaching parts inaccessible by a mediastinoscope. Although its employment requires technical training, it is becoming popular as a minimally invasive method of obtaining cell and the tissue samples. A thoracoscopic biopsy is considered as a last resort for mediastinal lymph node diagnosis. Carefully-chosen invasive procedures are necessary to diagnose swollen lymph nodes. Although mediastinoscopy is still considered as the gold standard, most procedures will be replaced by a comparatively minimally invasive method in the future.
PubMed: 35118261
DOI: 10.21037/med.2019.07.04 -
Journal of Visualized Surgery 2016Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is a minimally invasive option for thoracic esophageal cancer with the potential benefit of decreasing...
BACKGROUND
Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is a minimally invasive option for thoracic esophageal cancer with the potential benefit of decreasing pulmonary complications by avoiding one-lung ventilation or a transthoracic procedure. However, the conventional MATHE procedure is less radical than transthoracic esophagectomy due to operative view limitations and insufficient mediastinal lymphadenectomy. In upper mediastinal dissection, the conventional MATHE procedure only provides esophageal mobilization with or without lymph node sampling. We developed a novel MATHE procedure with en bloc mediastinal lymphadenectomy by introducing a single-port laparoscopic technique.
METHODS
The patient was placed in a supine position with bilateral lung ventilation. The upper mediastinal dissection, using a left cervical approach, was performed with a single-port mediastinoscopic technique. A laparoscope was used as a 'mediastinoscope'. The lymph nodes along the right recurrent laryngeal nerve (RLN) were dissected under direct vision using a right cervical approach. Bilateral cervical approaches were followed by hand-assisted laparoscopic transhiatal esophagectomy.
RESULTS
A single-port technique provides a favorable expansion of the mediastinal space by carbon dioxide insufflation, and improves the visibility and handling in the deep mediastinum around the aortic arch, allowing for en bloc lymphadenectomy in the upper mediastinum including the subaortic arch lymph nodes. In addition, a hand-assisted laparoscopic transhiatal procedure allows for en bloc lymphadenectomy in the middle and lower mediastinum including the subcarinal and bilateral main bronchial lymph nodes. Cervical and transhiatal procedures were performed safely and carefully under video-assisted magnified vision according to the standardized procedure with an appropriate operative field expansion using retractors.
CONCLUSIONS
Single-port MATHE is feasible as a novel minimally invasive surgery for esophageal squamous cell carcinoma (ESCC) or thoracic esophageal cancer.
PubMed: 29078513
DOI: 10.21037/jovs.2016.07.08 -
Mediastinum (Hong Kong, China) 2019The staging of mediastinal lymph nodes is essential for planning the most adequate treatment for patients with non-small cell lung cancer (NSCLC). For this reason, the... (Review)
Review
The staging of mediastinal lymph nodes is essential for planning the most adequate treatment for patients with non-small cell lung cancer (NSCLC). For this reason, the current American and European guidelines recommend obtaining tissue confirmation of any mediastinal abnormality seen on chest computed tomography (CT) and positron emission tomography (PET). This can be done by endoscopic techniques, such as endobronchial ultrasonographic fine-needle aspiration (EBUS-FNA), esophageal ultrasonographic FNA (EUS-FNA), or a combination of the two (CUS). Traditionally, surgical methods have been reserved to validate the negative results of minimally invasive endoscopic techniques. However, based on the latest evidence, cervical mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy (VAMLA) have demonstrated their superiority over minimally invasive methods in terms of performance for those tumors with normal mediastinum [clinical (c) N0-1 by CT and PET]. Therefore, cervical mediastinoscopy and VAMLA should be considered in the staging algorithms of this particular subset of NSCLC, and in the other well-established indications.
PubMed: 35118259
DOI: 10.21037/med.2019.07.01 -
Mediastinum (Hong Kong, China) 2020Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme... (Review)
Review
Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.
PubMed: 35118271
DOI: 10.21037/med.2019.09.06