Complete Medical “Mediastinoscopy” Under Conscious Sedation Using Combined Endoscopic Ultrasound and Endobronchial Ultrasound
Michael B. WallaceJorge M. PascualMassimo RaimondoTimothy A. WoodwardMargaret M. JohnsonAlan D. SavoyNoh KyungSurakit PungpapongMohammad Al‐HaddadJoy HardeeJohn A. Odell
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Keywords:
Endoscopic Ultrasound
Midazolam
The Mediastinum is one of the most important locations in the human body, though this is not widely recognized because of its miscellaneous nature. Mediastinoscopy is an endoscopy to the mediastinum. It is used to find the mediastinal metastasis of lung cancer. The mediastinoscopic findings can be applied to know the operability of lung cancer. Thoracoscopy is also used in diagnosing mediastinal disease. Endoscopic vision using a thoracoscope is better than mediastinoscopy. Thoracoscopy, therefore, is used in preference to mediastinoscopy to diagnose mediastinal lesions when both are possible. Endoscopic surgery is a better treatment than open thoracotomy, but we must not depend on it since it can lead to complication.
Thoracoscopy
Thoracotomy
Thoracoscope
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Parasternal line
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Imaging diagnostics often fail to provide enough certainly to make therapeutic decisions, since radiological images do not always correlate well with the pathological condition of the lesions. Surgical exploration of the mediastinum by mediastinoscopy allows to obtain very accurate information from inspection, palpation and biopsies of lymph nodes or tumors directly affecting the mediastinum. Mediastinoscopy assesses the upper mediastinum, including nodal stations 1, 2R, 2L, 3, 4L, 7, 10R and 10L. It can also assess direct invasion of the mediastinum from adjacent tumors. Parasternal mediastinoscopy is a complementary technique to reach nodal stations 5 and 6, which cannot be reached with standard cervical mediastinoscopy. Remediastinoscopy has been performed to restage tumors after delayed treatment and to stage second primary and recurrent tumors. It has proved useful, too, to restage N2 lung cancer after induction chemotherapy. In all these indications, remediastinoscopy was technically possible. All these techniques are associated with very few complications (around 3%) and a low mortality rate of less than 1%.
Parasternal line
Palpation
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Mediastinoscopy has been widely used by thoracic surgeons to evaluate the superior mediastinum since 1959. Large series of mediastinoscopy have been reported with very low morbidity and no mortality. Proper attention to surgical techniques and mediastinal anatomy are essential to maintain the safety of the procedure. Situs inversus totalis is exceedingly rare, but variations in mediastinal anatomy in this group of patients can render the procedure challenging for the thoracic surgeon. A case of mediastinoscopy in a situs inversus patient is presented with emphasis on anatomical variations of the mediastinum and technical pitfalls of the procedure in this rare group.
Anterior mediastinum
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In order to ascertain the diagnostic value of computed tomography (CT) of the thorax, the reports of the CT investigations of the thorax, carried out over a 2-year period, were compared with the actual final diagnosis. This study was narrowed down to those patients on whom a mediastinoscopy and/or an operation was performed. There appears to be a good correlation between the CT findings and the mediastinoscopy if no tumor or metastases are present in the mediastinum. This means that, where the CT scan shows a patient to have a normal mediastinum, it is not necessary to perform mediastinoscopy as a preoperative diagnostic aid.
Thorax (insect anatomy)
Torso
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In order to assess the potential of computed tomography (CT) of the mediastinum and mediastinoscopy in the staging of lung cancer, 125 patients were examined. Of these, 104 underwent thoracotomy, at which there was no evidence of mediastinal tumour involvement in 79 while 25 patients had signs of tumour spread. The sensitivity and specificity of CT were 87.0 per cent and 95.8 per cent, respectively, in the detection of direct tumour extension with a mediastinal mass. When lymph node enlargement was the sole finding, CT did not provide any differentiation between benign and malignant lymphadenopathy. The mediastinal involvement was inaccessible on mediastinoscopy in 18 cases (72%). Despite the surperior sensitivity of CT it was often difficult to determine whether direct tumour infiltration of mediastinal structures had occurred. It was concluded that CT is necessary for screening the entire mediastinum and, when it reveals no evidence of mediastinal tumour spread, mediastinoscopy will yield no further information. Mediastinoscopy will help to correctly identify accessible mediastinal lymph node involvement of the superior mediastinum and to define the mediastinal tumour invasion in doubtful cases.
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Thoracotomy
Mediastinal lymph node
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Parasternal line
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To investigate the value of mediastinoscopy in diagnosis of the thoracic diseases and the determination of the operative indication.From 1979 to 2000, 165 patients were given mediastinoscopy by local infiltration anesthesia (rare cases with additional vein bacic anesthesia). The exploration and biopsy were given to the neoplasms and lymph nodes around the trachea through the pretracheal interstice.The diagnosis of 125 patients by mediastinoscopy accorded with the pathological diagnosis and that of 21 patients was not accorded with the pathology. The rate of definitive diagnosis was 85.6% (125/146). The other 19 cases were not included into the ground because 11 cases were not given definitive diagnosis and 8 cases with lung cancer were not be performed operation although the results of mediastinoscopy were negative. Twenty patients with lung cancer which had metastasis in the mediastium and 7 patients with malignant lymphadenoma avoided exploratory thoracotomy.The mediastinoscopy is a effective examinative method to the disease involving the lymph nodes in the mediastinum and the thoracic disease closing on the mediastinum. The mediastinoscopy in appropriate especially to the simple enlargement of lymph node in the mediastinum that is not given definitive diagnosis. The cases with lung cancer accompanied enlargement of lymph node in the mediastinum and that with tumors in the mediastinum may choose the mediastinoscopy.
Thoracotomy
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A total of 299 patients is presented in them the mediastinoscopy has been performed from 1970 up to 1987. The indications and examination technique are also reported. Its significance is evaluated in recognizing the individual groups of diseases of lung and mediastinum. Comparing this method with other techniques, its advantages are referred to as for its precision a good tolerance by patients. The relatively small rate of complications is stated which represented 1.33 per cent in total proposed.
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