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Ann Thorac Surg 2003;76:208-212
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Video-assisted mediastinoscopy: experience from 240 consecutive cases

^a Service de Chirurgie Thoracique, Hôpital Pasteur, C.H.U. de Nice, Nice, France

Accepted for publication January 17, 2003.

^* Address reprint requests to Dr Mouroux, Service de Chirurgie Thoracique, Hôpital Pasteur, 30 Av. de la Voie Romaine, 06002 Nice Cedex 1, France.
e-mail: mouroux.j{at}chu-nice.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: We report our experience with video-assisted mediastinoscopy.

METHODS: We retrospectively reviewed clinical records of all patients who underwent video-assisted mediastinoscopy in a 26-month period. Video-assisted mediastinoscopy was performed in the presence of enlarged lymph nodes (short axis > 1 cm) found at computed tomography scan. Data about operative time, node stations sampled, number of biopsies, and operative complications were collected. Results of the pathologic examination were recorded, as well as (when different) the definitive diagnosis.

RESULTS: Video-assisted mediastinoscopy was performed in 240 consecutive patients. In 2 patients, the technique was employed for resection of a mesothelial cyst. In the other cases, it was used for diagnosis of enlarged nodes or staging of lung cancer. Mean number of biopsies was 6.0; mean number of sampled nodal stations was 2.3. Mean operative time was 36.6 minutes. Two operative complications occurred: a pneumothorax not requiring drainage and an injury to the innominate artery requiring manubrial split and suture. In 192 patients, the definitive diagnosis was lung cancer (18 small–cell lung cancers). In the remaining 46 patients, video-assisted mediastinoscopy allowed establishment of the diagnosis (sarcoidosis, n = 22; reactive hyperplastic lympho-adenitis, n = 13; tuberculosis, n = 4; involvement by malignancies other than lung cancer, n = 7). Among the 174 patients with non–small cell lung cancer, mediastinal nodal involvement was recognized in 107 cases (N3, n = 28; N2, n = 79). Sixty-seven patients were staged N less than 2; 47 underwent thoracotomy. Postthoracotomy staging agreed with video-assisted mediastinoscopy staging in 44 cases (93.6%).

CONCLUSIONS: Video-assisted mediastinoscopy proved to be safe and effective in nodal assessment of the mediastinum.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Standard cervical mediastinoscopy is widely employed for surgical exploration of superior retrovascular mediastinum. It allows biopsy of paratracheal and subcarinal lymph nodes as well as direct biopsy of retrovascular mediastinal tumors [1], thus representing an extremely useful tool for diagnosis of benign and malignant mediastinal disease. In the management of lung cancer patients, mediastinoscopy plays a fundamental role for both diagnosis and staging purposes [1].

Conventional equipment for cervical mediastinoscopy obliges surgeons to work in a relatively uncomfortable position; furthermore, only he or she can view through the instrument and only one-hand surgical maneuvers are possible through the tight operative channel of the instrument. To overcome such limitations, different forms of video-mediastinoscopes have been developed.

In 1994 Sortini and associates introduced the video-assisted mediastinoscopy (VAM) in a clinical setting [2]. We recently reported our initial experience with the use of VAM in the management of patients with lung cancer [3]. More recently, Hürtgen and associates showed the technical feasibility of a true lymph node dissection by VAM in 46 consecutive cases [4]. To our knowledge, no further series of VAM have been published in the English-language medical literature. In the present study, we evaluated retrospectively our experience with the use of VAM in 240 consecutive cases.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
We retrospectively reviewed clinical records of all patients who underwent VAM in our institution between October 1998 and December 2001. We have used VAM instead of standard mediastinoscopy since April 1998. Our initial experience (April 1998 to October 1998) with VAM has been previously published [3]. VAM was carried out in the presence of enlarged (short axis > 1 cm) retrovascular mediastinal lymph nodes at computed tomography (CT) scan. In patients with lung tumors in close contact with the trachea or tracheo-bronchial angle, the necessity of ruling out a direct tumoral involvement of these structures constituted an additional indication for VAM.

Data regarding operative time, node stations sampled, number of biopsies, and operative complications were collected. Results of pathologic examination of surgical specimens were recorded, as well as (when different) definitive diagnosis.

Sensitivity, specificity, and accuracy of VAM were calculated according to standard methods. In patients with benign disease, subsequent follow-up, positive response to specific treatment, or results of other diagnostic investigations constituted the "gold diagnostic standard."

Technique
Video-assisted mediastinoscopy (VAM) was carried out according to a standard technique [3]. General anesthesia and tracheal intubation with an armed single-lumen tube was employed. Patients were positioned in the dorsal decubitus with a roll under the shoulders to provide extension of the cervical area. The Dahan/Linder video mediastinoscope (model 8783.401; Richard Wolf, Knittlingen, Germany) was employed. It was fitted to a mono-CCD video camera (model INH 002756; Karl Storz-Endoskope, Tuttlingen, Germany), thereby allowing all members of the surgical team to view. This video mediastinoscope may be considered as a two-bladed speculum. The inferior valve may be opened widely, thus allowing optimal exposure of mediastinal structures and creation of an operative field for bimanual surgery.

Surgical technique up to the introduction of the scope is the same as that used for standard mediastinsocopy. After the para-tracheal fascia opening and finger blunt dissection along the trachea, the video mediastinoscope was inserted. The inferior valve was opened and blocked. The video mediastinoscope was then handled by the assistant, allowing the surgeon to continue dissection under direct visual control and with bimanual maneuvers. The metal blunt-tipped suction-coagulation device and endoscopic swabs or graspers were used simultaneously for dissection of mediastinal structures. Endoscopic dissectors and scissors, as well as clip appliers, were also used when indicated. Trachea, carinal region with the origin of two main bronchi, vena cava, azygos vein (Fig 1), right main pulmonary artery, and left recurrent nerve (Fig 2) were easily identified. Lymph nodes of levels 2, 4, and 7 were easily accessible for dissection and biopsy. Lymph nodes could be entirely enucleated in several instances. If a neoplastic infiltration of the outer surface of trachea or main bronchi was suspected, a biopsy at this level was carried out. Needle puncture was performed before biopsy if doubts existed about the possible vascular nature of a structure. Specimens were sent to the laboratory for frozen sections. Minor hemorrhage was controlled by coagulation or compression with gauze. In some instances, clips were employed to control minor bleeding or lymphatic leakage. The mediastinal bed was not drained routinely; if judged necessary, a 9-Ch (3-mm) drainage was used.

View larger version (78K): [in this window] [in a new window]   Fig 1. Trachea, azygos vein, and right main bronchus.

View larger version (88K): [in this window] [in a new window]   Fig 2. Trachea and left recurrent nerve.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Video-assisted mediastinoscopy (VAM) was carried out in 240 consecutive patients. There were 186 men and 54 women; mean age was 59.4 years (range, 23 to 77 years). In two patients,the technique was employed for exeresis of a mesothelial cyst (8 and 6 cm in diameter, respectively). In both cases, complete resection vas achieved with no operative complication.

In the other cases, VAM was used for etiological diagnosis of enlarged mediastinal nodes or staging of lung cancer. Mean number of biopsies was 6.0 (range, 1 to 20); it is noteworthy that in most instances, excisional biopsy of entire nodes was carried out. Mean number of sampled nodal levels was 2.3 (range, 1 to 4). Mean operative time (excluding the time for associated procedures) was 36.6 minutes (range, 15 to 75 minutes).

In 39 patients, a diagnosis of benign disease was established at VAM. The diagnosis was confirmed in all the cases on the basis of subsequent follow-up, positive response to specific treatment, or results of other diagnostic investigations. Diagnosis of benign disease included sarcoidosis (n = 22), tuberculous lympadenitis (n = 4), and reactive hyperplastic lymphadenitis (n = 13).

In 7 patients, the nodal involvement by a malignancy other than lung cancer was recognized at VAM (prostate, breast, kidney, non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, leiomyosarcoma, and colon cancer, one each). In 18 patients, diagnosis of small cell lung cancer could be established.

The remaining 174 patients had non–small cell lung cancer. This diagnosis was known before VAM in 71 cases, and VAM was carried out for staging purposes. In the other 103 patients, there was no histologic diagnosis of lung cancer before VAM, and VAM was performed for both diagnosis and staging purposes. Histopathologic diagnosis was obtained in 84 cases. In the remaining 19 cases, diagnosis was obtained at thoracotomy. In all these cases, the absence of mediastinal nodal involvement was confirmed.

Of all the 174 patients with a definitive diagnosis of non–small cell lung cancer, a mediastinal nodal involvement was found in 107 cases; in 28 of them, an N3 disease was found, whereas a N2 disease was found in 79 patients. Sixty-seven patients were staged N less than 2; 47 of them underwent thoracotomy with lung resection and nodal dissection. Postthoracotomy staging agreed with VAM staging in 44 of 47 cases (93.6%). In two of the remaining cases, a "minimal" N2 disease was found at thoracotomy: a single micrometastasis in a subcarinal node (1 patient) and a partial metastatic involvement of two lower paratracheal nodes out of all nodes obtained at full nodal dissection. A third patient staged N less than 2 at mediastinoscopy was found to have "bulky" N2 disease at a thoracotomy performed 1 month later. One month after thoracotomy, he presented two large muscular metastasis (not present when thoracotomy was performed) and died soon after.

In 4 patients, VAM was performed also to rule out a tumoral infiltration of the trachea or main bronchi suspected at CT scan. At VAM, it was confirmed in three cases. In one case, it was ruled out. The absence of tracheal infiltration was confirmed in the patient who underwent subsequent thoracotomy.

Overall sensitivity, specificity, and accuracy were 98.3%, 100%, and 98.6%, respectively (Table 1).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
In the present study, we evaluated our experience with the use of VAM in 240 consecutive patients. The video-assisted technology proved fully satisfactory in terms of visualization and facility of dissection.

The video mediastinoscope we employed in the present series has the advantage of opening, thus providing an operative field for bimanual dissection. It is slightly larger as compared with the standard material, but we never experienced difficulties in its introduction and handling. It is noteworthy that a veritable lymphadenectomy is possible by VAM [4]. Though we did not attempt to perform a lymphadenectomy, in our experience, nodes were easily dissected and in most cases completely enucleated. The possibility of exicising whole nodes is particularly advantageous while dealing with suspected lymphomas or small cell lung cancer because of the improved tissue diagnosis and characterization.

Dissection of the normal and pathologic mediastinal structures is particularly easy, and in two cases, a complete exeresis of a mesothelial cyst could be achieved. In the other cases, VAM proved to be particularly satisfactory for surgical exploration of retrovascular mediastinum. In 39 patients, a definitive diagnosis of nodal disease other than metastatic lung cancer could be established at VAM and subsequently confirmed. Thus, a 100% diagnostic accuracy in this subgroup of patients was achieved. This percentage compares favorably with that (93.6%) reported in a recent large study evaluating standard mediastinoscopy [6], thus suggesting that VAM could probably further improve the high diagnostic accuracy of standard mediastinoscopy in these patients.

One hundred seventy-four patients had non–small cell lung cancer. In 107 of them (61.5%), mediastinal retrovascular nodes were found to contain tumor at VAM. This high incidence of mediastinal nodal disease among patients undergoing mediastinal exploration is probably due to the indications for VAM in our institution. In fact, as suggested also by others for standard mediastinoscopy [7, 8], we employed VAM in the presence of enlarged nodes at CT scan, whereas other authors suggest routine mediastinoscopy for prethoracotomy staging of lung cancer [6, 9–11]. For comparison Luke and associates [9] found metastatic nodes in 30% of all patients with a lung cancer who underwent mediastinoscopy. More recently, Hammoud and associates [6] found nodal involvement in 24% of patients. These authors suggest prethoracotomy routine mediastinoscopy because of the supposed lack of diagnostic accuracy of noninvasive staging tools. The recent introduction of positron emission tomography with fluorodeoxyglucose has probably improved the presurgical staging of lung cancer [12, 13]. However, the accuracy of staging protocols including positron emission tomography is not optimal, and it has been suggested that surgical staging can not be replaced [13]. In our and others’ opinion [14, 15], in patients with clinical N0 disease, the prethoracotomy knowledge of a possible "minimal" N2 disease (which could be detected at mediastinoscopy) is not crucial; as in the few patients undergoing immediate thoracotomy and understaged at clinical workup, surgery would not be inappropriate. Survival rates are relatively satisfactory, and the possible role of induction treatments in this particular setting is difficult to establish [16]. Furthermore, the low cut-off chosen in our institution to consider nodes as pathologic (short axis > 10 mm) allows a good sensitivity of CT scan, thus providing a good selection criterion for VAM. All the 107 patients with histologically proven mediastinal nodal disease were enrolled in chemotherapy/radiotherapy protocols for exclusive or neo-adjuvant treatment; thus, in all these cases, VAM provided to be useful for clinical decision-making.

Sixty-seven patients with lung cancer where staged N less than 2 at VAM; 47 of them underwent thoracotomy. Postthoracotomy staging agreed with VAM staging in 44 cases (93.6%).

However, it must be considered that among the three false-negative cases, there were two "minimal" N2 with only one or two nodes found to have metastatic disease among all the nodes dissected at thoracotomy. Thus, it is reasonable to state that immediate thoracotomy was not inappropriate [14–16]. The third patient was found to have "bulky" N2 disease at thoracotomy performed 1 month later. Subsequent clinical course in this patient permits the hypothesis that disease progression probably occurred between mediastinoscopy and thoracotomy.

In our series, the false-negative rate was 6.5%. This figure is slightly lower as compared with that reported in two others large series of routine conventional mediastinoscopy [6, 9], but remarkably lower then reported by the others [7, 8, 17]. Though results of different series are difficult to compare because of different indication criteria for mediastinoscopy, our data seem to prove a very satisfactory diagnostic accuracy of VAM. It should be remembered that prevascular mediastinal nodes (ie, subaortic and para-aortic nodes on the left side and precaval nodes on the right side) are not accessible at mediastinoscopy, and the involvement of these nodes was responsible for some false-negative results of mediastinal exploration in others’ experience [6, 9]. To overcome such limitations of mediastinoscopy, other techniques are employed, such as anterior mediastinotomy and "extended" mediastinoscopy [1]. We have recently described the combined VAM and video-assisted thoracoscopy [5], and suggested that this technique allows a unique mini-invasive staging, especially in patients with left lung cancer. In the present series, combined VAM and video-assisted thoracoscopy was used in 26 patients, and in all the case, it was extremely useful for clinical decision making.

No mortality occurred and only two complications were recorded: a partial pneumothorax not necessitating drainage and a tear of the innominate artery. In this case, there was no significant blood loss, but a manubrial split was necessary for suture of the tear. Thus, the complication rate was 0.83%. In the series by Luke and associates [11], dealing with 1,000 patients, in patients with lung cancer who had received a standard medistinoscopy, the complication rate was 2.3%; hemorrhage, tracheal injury, and pneumothorax occurred but never resulted in death. On the other hand, in the recent series by Hammoud and associates [6], dealing with 2,137 patients who underwent standard medistinoscopy in an 11-year period, a single procedure-related death occurred. Therefore, VAM would seem at least as safe as standard mediastinoscopy, but prospective studies are required to draw a definitive conclusion.

There is a slight increase in the costs of performing VAM as compared with standard mediastinoscopy. The material is more expensive (the camera equipment is the same as usually available in operative theaters for the other video-assisted procedures) and running costs are also slightly higher, but we believe that such cost increases are largely counterbalanced by the advantages of the video-assisted method. Standard mediastinoscopy is a procedure difficult to learn, and undoubtedly, VAM will be very helpful in teaching and training due to its characteristics of improved visualization and easier dissection. Furthermore, we believe that it would be advantageous for those who occasionally perform the procedure.

In conclusion, VAM appears to be an extremely satisfactory tool for mini-invasive exploration of retrovascular mediastinum. It seems particularly useful in diagnosis and staging of lung cancer.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jèrôme Mouroux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Venissac, N. Articles by Mouroux, J. Search for Related Content PubMed PubMed Citation Articles by Venissac, N. Articles by Mouroux, J. Related Collections Mediastinum