Ann Thorac Surg 2004;77:1091-1093
© 2004 The Society of Thoracic Surgeons
Case report
Extrapleural thoracoscopic excision of a mediastinal bronchogenic cyst in a patient with dense pleural adhesions
Hiroki Sato, MD, PhDa*,
Atsushi Watanabe, MD, PhDb,
Tamotsu Yamaguchi, MD, PhDa,
Nobuhiro Harada, MDa,
Satomi Inoue, MD, PhDa,
Tomio Abe, MD, PhDb
a Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kitami Hospital, Kitami, Japan
b Second Department of Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication April 25, 2003.
* Address reprint requests to Dr Sato, Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kitami Hospital, 1-1-2 Koueinishimachi, Kitami, Hokkaido, 090-0058 Japan
e-mail: hiroki{at}sapmed.ac.jp
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Abstract
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We report the case of a 70-year-old man with dense pleural adhesions who underwent an excision of a mediastinal bronchogenic cyst by video-assisted thoracoscopic surgery (VATS) through an extrapleural approach. The VATS approach for the diagnostic and therapeutic excision of a mediastinal tumor is easier and safer than an intrapleural approach if a patient has dense pleural adhesions.
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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. Recently, the thoracoscopic excision of mediastinal bronchogenic cysts has been reported to have favorable results [2]. However, it is difficult to excise a mediastinal bronchogenic cyst by video-assisted thoracoscopic surgery (VATS) if there are dense pleural adhesions, and in such cases, VATS is often converted to a standard thoracotomy. An extrapleural approach is one option for such cases. However, such an approach may cause injuries to vessels or organs (e.g., the esophagus), so careful dissection is necessary. Extrapleural approaches for thoracic disease have been used in cases with dense pleural adhesions [3], invasions of the chest wall [4], and pleural tumors [5], as well as cases requiring the excision of lung tumors [6]. The use of an extrapleural approach for the excision of a mediastinal bronchogenic cyst by VATS is uncommon. We performed an excision of a mediastinal bronchogenic cyst by VATS by an extrapleural approach for a patient with dense pleural adhesions, and the result was very satisfactory.
A 70-year-old man was admitted to our hospital with a mediastinal mass found incidentally on chest radiography. He had a history of chronic bronchitis and atrial fibrillation. Magnetic resonance imaging showed a cystic lesion of 45 x 20 mm in size located in the middle mediastinum, close to both the superior vena cava and the lower trachea. T1-weighted images showed a mass lesion with high signal intensity, a thin wall, and parietal pleural thickness (Fig 1). Any other masses were detected on a whole-body computed tomographic (CT) scan or scintigram. The mediastinal and hilar lymph nodes were not swollen.
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Fig 1. Preoperative T1-weighted magnetic resonance image showing a mass lesion with high signal intensity and thin wall (thick arrow) and parietal pleural thickness (thin arrows).
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Suspecting a bronchogenic cyst, we conducted VATS for a definitive diagnosis. General anesthesia with endotracheal intubation using a double-lumen tube was performed to enable selective contralateral lung ventilation. The patient was positioned in a lateral thoracotomy position. An incision 15 mm in length was made in the sixth intercostal space on a middle axillary line. Dense pleural adhesions were observed beneath the wound, and a thoracoscope could not be placed in the pleural space. A minithoracotomy 50 mm in length was made in the third intercostal space on an anterior axillary line as an access port. The same dense pleural adhesions were observed beneath the minithoracotomy. It was suggested that there were dense pleural adhesions throughout the right lung due to old pleuritis. Therefore, an extrapleural approach was chosen to prevent lung injury caused by the dissection of the dense pleural adhesions. Blunt dissection was performed in a small area to secure a space in which the thoracoscope could be used. Then, with the aid of a video-assisted thoracoscope, the extrapleural space was entered on the anterior and half-cranial side between the parietal pleura and suprapleural sheath. The manipulation of the cyst was carried out through the minithoracotomy, and the cyst's location was determined (Fig 2). At first, the azygos vein was exposed and divided to prevent laceration and to obtain a clear operative field. Fortunately, there were no severe adhesions with the lower trachea and superior vena cava. The cyst was excised with sharp and blunt dissection using endoscopic scissors and dissecting tools. Neither a fistula nor a stalk was found around the cyst. The cyst was completely removed together with the wall by minithoracotomy. It contained a yellowish, viscous fluid. A cytologic examination of the fluid showed benign class 2 findings. A bacteriologic examination showed no organisms. At the end of the procedure, a chest tube 8 mm in diameter was placed in the middle mediastinal space through the incision, and the incisions were closed in layers. The operation time was 120 minutes. At the end of the procedure, we found good pulmonary reexpansion through the thoracoscope. Also, a postoperative chest roentgenogram showed full pulmonary expansion. The chest tube was removed on postoperative day 3. The patient had an uneventful postoperative course and was discharged on postoperative day 4. Pathologic examination showed that the cyst wall was lined by a ciliated, stratified columnar epithelium with scattered bronchial glands. No malignant cells were observed in the cyst wall. The patient is now doing well, without showing any sign of recurrence on a CT scan.
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Fig 2. Intraoperative view through a thoracoscope. (A) Extrapleural view. (B) Cyst exposure. (CW = chest wall; EPS = extrapleural space; MP = mediastinal pleura; PP = parietal pleura; SVC = superior vena cava.)
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Comment
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We report the case of a 70-year-old man with dense pleural adhesions who underwent the excision of a mediastinal bronchogenic cyst by VATS using an extrapleural approach. Extrapleural dissection has risks for potential injuries to vessels or organs, and it may cause major bleeding from the extrapleural space. To prevent these complications, we carefully observed the operative field through the thoracoscope and minithoracotomy. Also, sharp and blunt dissection using endoscopic scissors and dissecting tools enabled us to prevent unnecessary bleeding. In our case, the azygos vein was ligated and divided. This procedure helped us obtain a clear operative view and a direct view of the cyst and also enabled us to prevent bleeding due to the laceration of great vessels.
Standard surgical therapy for mediastinal bronchogenic cysts consists of excision by thoracotomy. Recently, the thoracoscopic excision of mediastinal bronchogenic cysts has been reported to have favorable results. The treatment of asymptomatic mediastinal bronchogenic cysts remains controversial. Some authors have recommended surgical excision when symptoms exist or when a malignant cyst is suspected. Others have advocated resection in all cases to confirm the diagnosis and prevent complications. The excision of a cyst by VATS is safer and less invasive to a patient than excision by thoracotomy. We recommend this procedure when a cyst is found.
The use of VATS to perform the diagnostic and therapeutic excision of a mediastinal tumor has gradually become accepted. We also have experienced the excision of a mediastinal tumor by VATS. Since 1991, thoracoscopy has been proposed as an alternative method for resecting mediastinal bronchogenic cysts. Martinod and colleagues [2] performed 20 thoracoscopic excisions of mediastinal bronchogenic cysts. In their series, 7 of 20 (35%) procedures were converted to thoracotomies from thoracoscopic procedures because of the laceration of vessels (2 cases) and major adhesions to vital organs (5 cases). In some cases of dense pleural adhesions, VATS is converted to standard open thoracotomy. Even using standard open thoracotomy in such cases, dissection between the parietal and visceral pleura usually causes lung injury with pulmonary bleeding and air leakage, the repair of which is costly in terms of both time and materials. In cases in which patients have dense pleural adhesions, an extrapleural approach to mediastinal tumors such as bronchogenic cysts is a good method to prevent lung injury and unnecessary bleeding. This approach may also be available to patients who have peel formations of the parietal pleura.
We conclude that an extrapleural approach for the diagnostic and therapeutic excision of a mediastinal bronchogenic cyst by VATS is easier and safer than an intrapleural approach if a patient has dense pleural adhesions.
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References
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Abstract
Introduction
