Eur J Cardiothorac Surg 1998;13:491-493
© 1998 Elsevier Science NL
Diagnostic role of videothoracoscopy in mediastinal diseases1
Luciano Solaini,
Paolo Bagioni,
Andrea Campanini,
Basilio Domenico Poddie
Department of Surgery, S. Maria delle Croci Hospital, Viale Randi 5, 48100 Ravenna, Italy
Received 20 October 1997;
received in revised form 4 February 1998;
accepted 24 February 1998.
Corresponding author. Tel.: +39 544 409615; fax: +39 544 409722.
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Abstract
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Objective: In order to assess the role of videothoracoscopy in the diagnosis of mediastinal diseases, we report a retrospective analysis of 52 cases of mediastinal biopsy performed with this technique. Methods: Between January 1992 and December 1996 52 patients (39 men and 13 women, mean age 53±29 years) with mediastinal lesions were referred to our department for videothoracoscopic biopsy. There were eight lesions in the anterior mediastinum, while the remaining 44 were in the middle (25 right and 19 left). The adenopathies were solitary or located in positions not within reach of the mediastinoscope, or combined with pulmonary nodules or diffuse pulmonary diseases. Results: The procedure was performed from the right side in 30 cases and from the left side in 22. In nine cases the complete excision of the mass was achieved. In the eight patients with pulmonary disease a wedge resection was carried out at the same time. Diagnosis was achieved in all cases of mediastinal and lung disease (100%). No conversion to open thoracotomy and no intraoperative complications occurred. The mean hospital stay after surgery was 2.3±1.3 days in the 49 (94.2%) patients with no complications. The postoperative complications consisted of one case of fatal pulmonary embolism and two cases of prolonged air leak. Conclusion: This analysis shows that videothoracoscopy is an effective and reliable method of obtaining a diagnosis of solitary unilateral mediastinal lesions or of adenopathies not within reach of the mediastinoscope. In some cases it also allows the complete excision of the mass. If a procedure on the lung such as a wedge resection is needed, it can be performed at the same time. Since this is a strictly unilateral procedure, it cannot be used in routine preoperative lung cancer staging.
Key Words: Mediastinum • Thoracoscopy • Video-assisted thoracic surgery • Mediastinal disease • Mediastinal adenopathy • Mediastinal biopsy
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Introduction
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Video-assisted thoracic surgery (VATS) is a technique that came into operative use in 1991 and, with regard to the invasive diagnosis of the mediastinum, has expanded the possibilities previously given by the already well-known mediastinoscopy, anterior mediastinotomy, thoracotomy and sternotomy. For the moment, however, the potential and limits of this technique are still not well defined, and the indications for its use remain controversial. The purpose of the present report, based on an experience of 52 mediastinal biopsies by VATS, is to contribute to the clarification of the role that this technique should play among surgical methods of diagnosis of diseases of the mediastinum.
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Materials and methods
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Between January 1992 and December 1996 at the Surgical Unit of the Ospedale S. Maria delle Croci in Ravenna, Italy, 52 patients affected by diseases of the mediastinum underwent VATS for diagnostic purposes. Thirty-nine were male and 13 female, aged between 23 and 83 years (mean age 53 years). All patients had undergone chest roentgenography and computed tomography (CT) providing evidence of anterior mediastinal masses in eight cases, and an adenopathy or middle mediastinal mass in the other 44, associated in eight cases with ipsilateral pulmonary nodules; four patients with right-sided carcinoma of the lung were also included, with enlarged lymph nodes in the aorticopulmonary window and normal lymph nodes in the right mediastinum. In patients with an anterior mass and pulmonary nodules, a transcutaneous biopsy had been carried out, whereas in the others bronchoscopy with alveolar lavage had also been performed. In all cases these techniques had failed to provide a clear diagnosis.
The mass size, calculated from CT scans, ranged from 3 to 10 cm, whereas the lymph nodes were considered to be pathological when >1.5 cm in diameter. VATS was used for adenopathy only if the lymph node was solitary or located in positions that were inaccessible by medianoscopy: the aorticopulmonary window and subazygos nodal stations.
The techniques utilised were all video assisted, usually known as mini-invasive and by now well described
[1]
[2]
[3]
[4]. In particular, a zero-degree thoracoscope was used, with a 10-mm trocar and two or three 5-mm trocars used for the introduction of the endoscopic instruments and the extraction of bioptic specimens. In cases in which an atypical pulmonary resection had to be carried out, a 12-mm trocar was introduced instead of a 5-mm one for the insertion of the endostapler.
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Results
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The procedure was completed by thoracoscopy in all cases, enabling us to obtain a diagnosis (Table 1). In 22 cases left-sided and in 30 cases right-sided thoracoscopy was used. In seven cases pleural adhesions were present, that were sectioned before proceeding to the planned endoscopic manoeuvres. In three cases it was necessary to divide the azygos vein. No intraoperative incidents or complications arose. The operative time was 35 min, ranging from a minimum of 20 min to a maximum of 210 min in a case with numerous pleural adhesions. It must also be noted that at the beginning of this experience operative times were longer, reflecting a lack of familiarity with the procedure.
The mean postoperative hospital stay was 2.3±1.3 days in the 49 patients (94.2%) with no complications. There was one case of mortality the day after operation due to massive pulmonary embolism (diagnosis confirmed at autopsy), and in two patients there was an air leak that continued until the eleventh and twelfth day associated with an extensive adhesional lysis.
In nine patients the lesion was entirely excised since it was possible to separate it from the surrounding tissue: this was the case for two pleuropericardial cysts, one enterogenous cyst, one benign thymoma, one parathyroid adenoma, two thymic hyperplasias following chemotherapy carried out for a germ cell tumour, one solitary breast cancer metastasis and one metastasis from a carcinoma of the liver. These masses, with a maximum diameter of 4 cm, were first inserted into a plastic bag through a trocar opening that had been specially widened, and then extracted. In the eight patients in which an atypical pulmonary resection had been carried out, two cases of small cell lung cancer were found associated with a massive lymph node invasion, one pulmonary amartoma with non-Hodgkin's lymphoma, two cases of obliterating bronchiolitis with concomitant hyperplastic adenopathy and three cases of sarcoidosis. In four cases of right-sided pulmonary carcinoma, lymph node sampling revealed the presence of hyperplastic adenopathy so that the patients were subsequently treated by surgery for the primary tumour.
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Discussion
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VATS has been utilised in thoracic surgery since 1991, but the indications for its use have not yet been well-defined. In the field of mediastinal biopsies whether to use VATS, mediastinoscopy or anterior mediastinotomy is not always clearly indicated. However, there is no doubt about the value of transcutaneous biopsy in the diagnosis of mediastinal masses, since it is a far less invasive technique and must in any case precede the use of VATS
[4].
As reported by Landreneau and co-workers
[2] and also observed in this study, thoracoscopic nodal sampling was 100% sensitive and 100% specific in diagnosing mediastinal adenopathy. Moreover, in agreement with the results of other authors
[2]
[5]
[6], VATS biopsies may be taken from lymph nodes that are not within reach of the mediastinoscope such as in the eighth and ninth nodal stations and the lower part of the subcarinal station, whereas on the left side the fifth and the sixth may also be reached. The left side nodes were usually biopsied by means of anterior mediastinotomy, which is preferable when local anestesia can be used, otherwise, in agreement with Rendina and co-workers
[6] we believe VATS to be more reliable.
In cases in which there is a single lesion, well encapsulated and of modest size, no larger than 4 cm, it is possible to carry out a complete excision with the video-assisted technique and this is obviously not possible with the mediastinoscope. Roviaro and co-workers
[7] report 20 mediastinal masses successfully operated on with VATS and stress the use of this minimally invasive approach for this type of pathology. Also in the present experience, in nine cases, in the presence of a solitary mediastinal lesion preference was given to VATS as it was considered possible to excise the mass completely.
With VATS it is also possible to carry out an atypical pulmonary resection, or other ipsilateral intrathoracic procedures when necessary, as also reported by Mouroux and co-workers
[8]; we therefore believe that in these cases the endoscopic technique is preferable to mediastinoscopy.
The disadvantages of VATS consist mainly of the need to carry out selective intubation for pulmonary collapse, and the need to enter the pleural cavity, with the consequent need for pleural drainage resulting in an increase in the length of hospital stay. Although in the experience reported no such incidents arose, it is necessary to consider the risk of having to convert to thoracotomy in the case of anesthesia's inability to correctly achieve adequate one-lung ventilation, or tenacious pleural adhesions, or haemorrhage that cannot otherwise be brought under control. Finally, it must be stressed that VATS is a strictly monolateral technique, so if a bilateral paratracheal lymph node biopsy is needed, as in the staging of pulmonary carcinoma, it cannot be used.
In conclusion, we consider that VATS can play an important role in the diagnosis of diseases of the mediastinum: it makes it possible to obtain biopsies in areas not within reach of the mediastinoscope, to remove the lesion when it is single, easy to separate from the surrounding tissue and small in size, and in other cases to proceed with pulmonary and pleural biopsies. It presents the disadvantage of requiring selective intubation and pleural drainage, as well as the risk of having to convert the procedure to thoracotomy.
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Footnotes
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Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997. 
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References
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Abstract
Introduction
