Ann Thorac Surg 2000;69:1525-1528
© 2000 The Society of Thoracic Surgeons
Original articles: General thoracic
Thoracoscopic excision of mediastinal bronchogenic cysts: results in 20 cases
Emmanuel Martinod, MDa,
François Pons, MDb,
Jacques Azorin, MDa,
Jérome Mouroux, MDc,
Marcel Dahan, MDd,e,f,
Jean-Marie Faillon, MDa,b,c,d,e,f,g,
Antoine Dujon, MDa,b,c,d,e,f,g,
Paul S. Lajos, MDa,
Marc Riquet, MDg,
René Jancovici, MDb
a Department of Thoracic and Vascular Surgery, Avicenne Hospital, Bobigny, Paris, France
b Department of General and Thoracic Surgery, Military Percy Hospital, Clamart, France
c Department of General and Thoracic Surgery, Archet Hospital, Nice, France
d Department of Thoracic Surgery, Purpan Hospital, Toulouse, France
e Department of Thoracic Surgery, Clinique du Bois, Lille, France
f Department of Thoracic Surgery, CMC du Cèdre, Bois-Guillaume, France
g Department of Thoracic Surgery, Laënnec Hospital, Paris, France
Address reprint requests to Dr Martinod, Service de Chirurgie Thoracique et Vasculaire, Hôpital Avicenne, 125 route de Stalingrad, 93000 Bobigny, France
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Abstract
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Background. We present our experience with thoracoscopic resection of mediastinal bronchogenic cysts in adults.
Methods. From November 1990 to September 1993, 20 patients with mediastinal bronchogenic cysts were operated on by thoracoscopy. The average cyst size was 4.9 cm, and the largest diameter was 10 cm. Ten cysts were located in the middle mediastinum and 10 in the posterior mediastinum. Two cysts were complicated.
Results. Thirteen bronchogenic cysts were resected completely by thoracoscopy. We had to convert thoracoscopy into thoracotomy because of bleeding in two cases and because of major adhesions to vital structures in five cases. There were no operative deaths and no postoperative complications. Mean hospital stay was significantly less in the completely thoracoscopically treated group. Long-term follow-up (range, 4.5 to 7.5 years) showed no late complications and no recurrence.
Conclusions. Preoperative complications, intraoperative injuries, and major adhesions to vital structures seem to be the only unfavorable conditions to thoracoscopic treatment of bronchogenic cysts. This study found encouraging results for thoracoscopic excision of mediastinal bronchogenic cysts in selected patients.
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Introduction
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Bronchogenic cysts of the mediastinum are rare and represent 18% of all primary mediastinal tumors [1]. Standard surgical therapy for mediastinal bronchogenic cysts consists of excision by thoracotomy. Since 1991, use of thoracoscopy to remove mediastinal bronchogenic cysts has been published in numerous reports or letters [2, 3] and in rare series [4]. We present on our experience including long-term follow-up with the thoracoscopic resection of 20 mediastinal bronchogenic cysts in adults.
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Material and methods
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From November 1990 to September 1993, 20 patients with mediastinal bronchogenic cysts were treated by the thoracoscopic approach by 12 thoracic surgeons from different general thoracic surgery centers in France. All were members of the Thorax Group created in September 1990. All surgeons had similar or equivalent endoscopic equipment, similar surgical backgrounds, and frequent training updates. There were 12 male and 8 female adult patients. Age range was 22 to 73 years with a mean age of 41.9 years. Symptoms were present in 7 patients, including pain (n = 4), dysphagia (n = 2), and cough (n = 1). Two cysts were complicated, one by rupture in the right pleural space (Fig 1) and one by bronchopulmonary infection. Twelve cysts were asymptomatic and suspected by chest radiograph (Fig 2). Bronchoscopy was done in all cases. Preoperative assessment was done by chest computed tomographic scan or magnetic resonance imaging. The cysts averaged 4.9 cm (range, 2.5 to 10 cm) in their greatest diameter. Ten cysts were located in the middle mediastinum (right hilar, 1; subcarinal, 4; paratracheal, 5) and 10 in the posterior mediastinum (paraesophageal).
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Fig 1. Chest computed tomographic scan showing a bronchogenic cyst of the mediastinum (star) which was complicated by rupture in the right pleural space (asterisk) and treated by thoracoscopy converted into thoracotomy.
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Fig 2. Chest radiograph showing an asymptomatic cyst of the mediastinum (asterisk) that was completely treated by thoracoscopy.
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All patients were positioned in lateral thoracotomy position after selective endotracheal intubation. The lung was collapsed by selective clamping. Three or four trocars were required. The first trocar was placed in the seventh or eight intercostal space. Remaining trocars were placed after visualization of the cyst. Complete exploration of the cavity preceded resection. Slight aspiration of the cyst under direct thoracoscopic view made grasping and manipulation easier. Gram staining and cultures were done on the fluid. Cysts were excised with sharp and blunt dissection using endoscopic scissors and dissecting tools. In cases where the cyst was adherent to vital structures, a portion of the cyst wall was left in place and the mucosa was obliterated by electrocautery to prevent recurrence. The wall of the cyst was completely removed by the trocars. Before lung reexpansion, one or two chest tubes were placed under direct vision. Histologic examinations were done in all cases. Follow-up was obtained by patient contact, and chest X-rays were done to detect recurrences.
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Results
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Twenty patients with bronchogenic cysts of the mediastinum were included for thoracoscopic treatment. Thirteen bronchogenic cysts were completely resected by the thoracoscopic approach (Table 1). In this first (completely thoracoscopically treated) group of 13 patients, seven cysts were located in the posterior mediastinum and six in the middle mediastinum. In four cases, complete removal of the cyst was not easy because of adhesions. In one case, there was a small laceration to the membranous trachea, which was sutured thoracoscopically, and the postoperative course was uneventful. In another case, resection was incomplete because of direct adherence to the left atrium. In 7 patients, we had to convert thoracoscopy into thoracotomy (Table 2). Two patients were opened because of significant bleeding (more than 500 mL) resulting from a laceration of the azygos vein and a laceration of the left inferior pulmonary vein extending to the left atrium. Five patients were opened for major adhesions to vital structures. In the converted thoracotomy group, four cysts were located in the middle mediastinum and three in the posterior mediastinum. Resection was complete in three cases, but a portion of the cyst wall was left in place because of adhesions in four cases. Mean size of bronchogenic cysts was higher in the converted thoracotomy group (6.1 cm) than in the completely thoracoscopically treated group (4.3 cm), but difference observed was not significant (p = 0.0763, unpaired t-test). The average operating time was 2 hours but ranged from 1 to 5 hours at the beginning of our experience. There were no operative deaths and no postoperative complications for all patients. Chest tubes were left in place for an average of 1.9 days with no significant difference between the two groups. Median hospital stay was significantly shorter (p = 0.0112, unpaired t test) in the thoracoscopically resected group (5.2 days) than in the converted thoracotomy group (8.5 days). Pathologic evaluation confirmed the diagnosis of bronchogenic cyst in all cases. All lesions were benign. Two patients were lost to follow-up (numbers 9 and 10 in Table 1). There were no late complications and no recurrence of the cyst for the 18 other patients. The follow-up period ranged from 4.5 to 7.5 years.
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Comment
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None of the 20 adult patients included in this study of thoracoscopic treatment of bronchogenic cysts were selected on the basis of location, size, and complications. Indeed, two cysts were complicated (by rupture and pulmonary infection), and size was larger than 5 cm in six cases. Only 13 cysts (65%) were removed completely by the thoracoscopic approach. However, we would like to emphasize that patients were operated on at the beginning of the surgical experience with thoracoscopy. Furthermore, 11 difficult cases that had major adhesions to vital structures were included in the study. For the 7 patients who were converted to thoracotomy, major adhesions were found in all cases and two had intraoperative vascular injuries. However, major adhesions were observed in only four cases in the completely thoracoscopically treated group. Even if there was a difference in mean size of bronchogenic cysts between the two groups of our study, we cannot confirm that it represents a predictive factor for conversion into thoracotomy. We think that difference might become significant in a larger series. Similarly, location of the cyst in the middle or posterior mediastinum did not predispose to intraoperative difficulties. Conversion to thoracotomy was necessary in the two complicated cases. Finally, removal of the cysts was incomplete in one case (7.7%) in the completely thoracoscopically treated group and in four cases (57.1%) in the converted thoracotomy group. In this study, preoperative complications, intraoperative injuries, and major adhesions to vital structures were the only unfavorable conditions to thoracoscopic treatment of bronchogenic cysts. However, minor intraoperative wounds, such as tracheal injury observed in one case, could be repaired safely using thoracoscopy; postoperative course was uneventful in that case. In our opinion, conversion into thoracotomy is strongly advised in cases where excision is difficult because of adhesions and vascular complications. All instruments for thoracotomy should be available in the operating room. Operating time progressively decreased in the learning period for all thoracic surgeons who participated in the study. Thoracoscopy significantly reduced median hospital stay. Results obtained concerning mortality, morbidity, and long-term follow-up were identical in comparison with studies evaluating standard thoracotomy treatment for bronchogenic cysts in adults [5].
Treatment of mediastinal bronchogenic cysts, particularly for asymptomatic patients, remains controversial. Some authors recommend surgical resection when symptoms exist or when a malignant cyst is suspected [6]. For others, excision is advocated in all cases to confirm the diagnosis and prevent complications [7, 8]. Standard surgical treatment consists of excision by thoracotomy [9]. Percutaneous [10] or transbronchial [11] aspirations, injection of sclerosing agents, and excision via mediastinoscopy have also been reported [12]. Since 1991, thoracoscopy has been proposed as an alternative method for resecting mediastinal bronchogenic cysts. Although some reports have been published [2, 3], series of thoracoscopic treatment of bronchogenic cysts are rare. Hazelrigg and associates [4] safely demonstrated good results with this new approach in a series of seven bronchogenic cysts. Removal of the cysts was incomplete in only one case and there were no conversions into thoracotomy, no intraoperative or postoperative complications, and no recurrence of the cysts after a mean follow-up of 6 months. Their results are similar to those we obtained for cysts that were completely resected by thoracoscopy. We chose to present all nonselected cases proposed for thoracoscopic treatment, emphasizing difficulties encountered with complicated and very adherent cysts. Even if conversion to thoracotomy was done in a high percentage of cases, this study was safe, and encouraging results for thoracoscopic excision of mediastinal bronchogenic cysts with a long-term follow-up were obtained. Finally, preoperative evaluation including computed tomographic scan is important in predicting potential complications and proximity to vital structures, which might in some instances be approached better with standard thoracotomy.
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Accepted for publication August 13, 1999.
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Top
Abstract
Introduction
