Video Mediastinoscopy Research Articles

Research Progress of the Diagnostic Value of Video Mediastinoscopy in the Staging of Lung Cancer

In the process of diagnosing patients with lung disease, traditional imaging diagnosis has certain limitations, which can easily lead to missed diagnosis and misdiagnosis. In recent years, with the advancement and development of imaging technology, video mediastinoscopy has gradually been promoted and applied in clinical practice, and has significant advantages in the identification of benign and malignant lung lesions, lung cancer staging, and efficacy evaluation. This study mainly discusses the specific application of video mediastinoscopy and its diagnostic value in staging of lung cancer.

Accuracy of positron emission tomography and computed tomography (PET/CT) in detecting nodal metastasis according to histology of non-small cell lung cancer.

Positron emission tomography and computed tomography (PET-CT) is the non-invasive gold standard method for determining the oncological stage of patient with diagnosis of lung cancer. A correct preoperative staging is significant because only patients who do not have a history of regional or distant disease are those who will benefit from a surgical treatment. However, due to the different values of the PET-CT in terms of sensitivity and specificity to evaluate the mediastinal lymph node involvement, it is often necessary to perform a surgical mediastinal sampling through a cervical video mediastinoscopy (VM). Patient's risk factors which could modify the results of the PET scan, performing differences between non-invasive staging and the lymph node sampling due to VM are not yet clearly established in the literature. This knowledge will allow to identify in whom a surgical staging by sampling the mediastinal lymph nodes is needed. We included 234 patients with diagnosis of lung cancer who underwent a mediastinal lymph node staging by PET-CT images and histopathological results of mediastinal sampling by VM, analyzing the sensitivity and specificity of this non-invasive imaging study. We also analyzed variables that could modify the results of PET-CT, such as tumor type, location of the tumor and patient's history. We showed that those PET-CT presented an overall sensitivity and specificity of 93.8 and 62.7%, respectively, with negative and positive predictive values of 95.05 and 57.1%, respectively. The false-positive rate was 25% (57 of 234 patients). Analyzing risk factors involved in this false-positive rate (n = 57), we found that the only statistically significant factor that could explain these results was the histology of squamous carcinoma (p < 0.03). In this group of patients, it is essential to perform a mediastinal lymph node biopsy to know the real state of lymph node involvement.

A pragmatic view of the usefulness of video-mediastinoscopy in the modern era

As a result of the introduction of new technologies, such as endoscopic (EUS) and endobronchial ultrasound (EBUS) guided aspiration, surgeons are moving away from routine mediastinoscopy prior to lung cancer resection. The scope of this article is two-fold: to describe in detail our technique of video-mediastinoscopy (VM), applied in more than 100 patients, and to clarify the current indications for its use. In the modern era, VM remains a fundamental technique in thoracic surgery as it is able to provide diagnosis for many thoracic conditions, overcoming some of the weaknesses associated with EBUS and EUS guided aspiration. VM is a valuable and irreplaceable tool in the mediastinal staging of patients affected by non-small cell lung cancer (NSCLC).

SC01.05 Video-Thoracoscopy for Staging of N2 NSCLC During Induction Therapy

The optimal strategy for patients with stage III non-small cell lung cancer (NSCLC) is not well-established and significant variation in practice exists across the United States and Europe. In the U.S., the majority of National Comprehensive Cancer Network (NCCN) member institutions consider surgery to be indicated in stage IIIA patients with involvement of a single N2 lymph node station smaller than 3 cm who have undergone induction chemotherapy. However, there is no agreement among institutions regarding treatment for other manifestations of stage IIIA-N2 involvement (e.g., multi-station or bulky disease) and both NCCN and European Society of Medical Oncology (ESMO) guidelines recommend that the role of surgery be discussed in a multidisciplinary tumor board setting. The use of induction chemotherapy vs induction chemoradiotherapy is currently of great interest worldwide, and the use of the latter is still common despite the results of numerous clinical trials and meta-analysis. The lack of consensus regarding treatment strategies for stage III NSCLC is in part due to the relatively low number of randomized studies available to guide decision-making, as well as institutional biases despite evidence. One important issue is the role and methods of restaging after induction therapy for patients with potentially resectable Stage IIIA (N2) disease. While all would agree that pathologic confirmation of N2 disease prior to induction chemotherapy is mandatory, using EBUS or mediastinoscopy, not all surgeons believe that restaging after induction therapy to confirm response to chemotherapy is necessary, despite evidence that the overall and cancer-specific survival of non-responders is quite low. There are 2 dominant strategies for staging and restaging patients with N2 disease: EBUS prior to induction therapy and restaging with video mediastinoscopy or mediastinoscopy prior to induction therapy and restaging with thoracoscopy or repeat mediastinoscopy. There may be a role for each strategy depending on individual patient characteristics. Advantages of thoracoscopic restaging after induction therapy include the ability to resect all ipsilateral nodes to most accurately assess response and the resection of nodal tissue at thoracoscopy is the first step in thoracoscopic resection and thus greatly facilitates the procedure. The role of thoracoscopic restaging after induction therapy will be reviewed, and the technical aspects for successful restaging and thoracoscopic lobectomy after induction therapy are demonstrated in videos. 1. Martins RG, D'Amico TA, Loo BW, Jr., et al. The management of patients with stage IIIA non-small cell lung cancer with N2 mediastinal node involvement. Journal of the National Comprehensive Cancer Network : JNCCN. 2012;10(5):599-613. 2. Vansteenkiste J, De Ruysscher, D, Eberhardt WEE, Lim E, Senan S, Felip E, Peters s. Early-Stage and Locally Advanced (non-metastatic) Non-Small-Cell Lung Cancer: ESMO Clinical Practice Guidelines. Annals of Oncology. 2013;24((suppl 6)):vi 89-98. 3. Ettinger DS, Wood DE, Akerley W, et al. Non-small cell lung cancer, version 6.2015. Journal of the National Comprehensive Cancer Network : JNCCN. 2015;13(5):515-524. 4. Weeks JC, Uno H, Taback N, et al. Interinstitutional variation in management decisions for treatment of 4 common types of cancer: A multi-institutional cohort study. Annals of internal medicine. 2014;161(1):20-30. 5. Pless M, Stupp R, Ris HB, et al. Induction chemoradiation in stage IIIA/N2 non-small-cell lung cancer: a phase 3 randomized trial. Lancet. 2015;386(9998):1049-1056. 6. Katakami N, Tada H, Mitsudomi T, et al. A phase 3 study of induction treatment with concurrent chemoradiotherapy versus chemotherapy before surgery in patients with pathologically confirmed N2 stage IIIA nonsmall cell lung cancer (WJTOG9903). Cancer. 2012;118(24):6126-6135. 7. Girard N, Mornex F, Douillard JY, et al. Is neoadjuvant chemoradiotherapy a feasible strategy for stage IIIA-N2 non-small cell lung cancer? Mature results of the randomized IFCT-0101 phase II trial. Lung Cancer. 2010;69(1):86-93. 8 Jaklitsch MT, Gu L, Harpole DH, D'Amico TA, et al. Prospective phase II trial of pre-resection thoracoscopic restaging following neoadjuvant therapy for IIIA(N2) non-small cell lung cancer: Results of CALGB 39803. J Thorac Cardiovasc Surg 2013;146:9-16 9. Yang CF, Gulack BC, Gu L, et al. Adding radiation to induction chemotherapy does not improve survival of patients with operable clinical N2 non-small cell lung cancer. The Journal of thoracic and cardiovascular surgery. 2015;150(6):1484-1492; discussion 1492-1483. 10. Shah AA, Berry MF, Tzao C, et al. Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Ann Thorac Surg. 2012;93(6):1807-1812. lung cancer surgery, minimally invasive surgery, stage IIIA

Does videomediastinoscopy with frozen sections improve mediastinal staging during video-assisted thoracic surgery pulmonary resections?

To assess if video-mediastinoscopy (VM) with frozen sections (FS) combined with a video-assisted thoracic surgery major pulmonary resection (VMPRS) is able to improve VATS mediastinal intraoperative staging. From June 2012 to March 2015 a total of 146 patients underwent VMPRS lymphadenectomy. NCCN guidelines were followed for pre-operative staging, including VM with FS in 27 patients (19%). Procedural time, dissected nodal stations, complications related to VM and VATS lymphadenectomy and definitive histology, were evaluated. Operative time for VATS resection with VM (group 1) and VATS pulmonary resection alone (group 2) was 198±64 vs. 167±43 min (P=0.003). Mean/median numbers of dissected nodal stations were 4.93±1.1/5 (range, 4-8) in group 1 and 3.25±0.5/5 (range, 3-8) in group 2 (P<0.001). Group 1 vs. group 2 right-sided lymphadenectomy (n=86) was performed at station 2R/4R in 18 (90%) and 46 (69.7%); at station 3a/3p in 14 (51.8%) and 22 (31%); at station 7 in 18 (90%) and 44 (66.7%); at station 8/9 in 11 (55%) and 24 (36.4%) respectively. On the left side (n=60) group 1 vs. group 2 lymphadenectomy resulted at station 4 in 6 (85.7%) and 38 (71.7%); at station 5/6 in 6 (85.7%) and 26 (49%); at station 7 in 6 (85.7%) and 33 (62.3%), and at station 8/9 in 1 (14.3%) and 18 (34%). There were no early deaths and recurrent laryngeal nerve palsy occurred in 1 (0.8%) in group 2. Pathological upstaging (pN1; pN2) was found in 5 patients (17%) in group 1, and 13 (11%) in group 2 (P=0.23). About FS (n=29), formal paraffin histology resulted in 0% of both, false negative and false positive results. Based on our experience, the combination "VM with FS followed by VMPRS in sequence", seems to be effective and offers an alternative approach to improve intraoperative mediastinal staging.

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

Mediastinal lymph node involvement is an important prognostic factor in patients with non-small cell lung cancer (NSCLC). The American and European guidelines for preoperative mediastinal lymph node staging agree in which situations a pre-surgical exploration of the mediastinum is required in order to avoid futile pulmonary resections (1,2). Invasive mediastinal staging with cyto-histological confirmation is indicated when computed tomography (CT) shows enlarged mediastinal or hilar lymph nodes, when positron emission tomography (PET) shows an increase uptake in the mediastinum or hilum, when the tumour is centrally located and when the tumour size is more than 3 cm, especially in adenocarcinoma with high 18F-Fluorodeoxyglucose (FDG) uptake. In general, a minimally invasive technique (endobronchial or endoesophageal ultrasound fine needle aspiration) is indicated of first choice, but when negative, a surgical exploration of the mediastinum (mainly a video mediastinoscopy) is required. In some particular situation, like clinical (c) staged N1 tumours, with normal mediastinum on imaging techniques, it was suggested to proceed directly to surgical resection when preoperative endosonography was negative. However, this issue has been analyzed, concluding that in cN1 NSCLC, endosonography alone has an unsatisfactory sensitivity to detect mediastinal involvement and, therefore, a confirmatory video mediastinoscopy is mandatory when endoscopic techniques show a negative result (3). Although stage cIA NSCLC is the main situation in which invasive mediastinal staging might be omitted, this paper will analyze the established indications and other particular situations in which performing a pre-surgical mediastinal staging in this group of patients can add a benefit in terms of accurate staging.

The Safety and Efficacy of Mediastinoscopy When Performed by General Thoracic Surgeons

Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons. A retrospective cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only. Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard. In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.

Surgical treatment of non-malignant laryngotracheal stenosis

The objectives of this study were the following: (1) to analyze the results of surgical treatment of non-malignant subglottic laryngeal and tracheal stenosis, (2) to evaluate the feasibility and technical aspects of the video mediastinoscopy for the mobilization of the mediastinal trachea, (3) to evaluate the influence of the early internal condition of the anastomosis on the development of restenosis. From 1996 up to 2013, 75 patients aged 11-78 years underwent surgery for post-intubation/tracheostomy (71 patients), post-traumatic (3 patients), and idiopathic (1 patient) subglottic laryngeal and tracheal stenosis. Twenty-three (30.7 %) patients with subglottic laryngeal and upper tracheal stenosis underwent cricotracheal resection and thyrotracheal anastomosis (group A), while 52 (69.3 %) patients with tracheal stenosis underwent tracheal resection and cricotracheal or tracheotracheal anastomosis (group B). The length of the resected segment in patients of groups A and B was 28-55 (42 ± 11) mm and 18-65 (36 ± 14) mm, respectively, (p = 0.22). Perioperative complications within 30 days occurred in eight (34.8 %) patients of group A, and in six (11.5 %) patients of group B (p = 0.04). There was one intraoperative and one postoperative death on the third day due to heart failure. The excellent results were achieved in 63 (86.3 %), satisfactory in 8 (11.0 %), and unsatisfactory in 2 (2.7 %) patients. The incidence rate of perioperative complications is related to the location of the stenosis and the type of the resection and anastomosis. Video mediastinoscopy simplifies the mobilization of the mediastinal trachea, which allows for carrying out the anastomosis with minimal tension. Early internal abnormalities of the anastomosis predict its restenosis.

Video mediastinoscopy; university first experience,

video mediastinoscopy; university first experience,

Combination of tissue biopsy and fine needle aspiration cytology reduces false negativity of mediastinoscopy for non-small cell lung cancer

Background: This study aims to compare tissue biopsy with fine needle aspiration (FNA) and investigate whether the combination reduces false negativity of mediastinoscopy. Methods: Between January 2004 and October 2005, 92 patients with non-small cell lung cancer (NSCLC) who underwent cervical video mediastinoscopy were included in this prospective study. Tissue biopsy samples and FNAs were obtained from the same lymph node and were sent for a pathologic examination. Tissue samples and FNAs were stained with Hematoxilene-Eosine. All specimens were evaluated by two histopathologists. Results: Using tissue biopsy samples, no metastasis was found in 54 patients, while 38 patients were metastatic. Forty-eight patients had no metastasis, while 44 patients were metastatic using FNA samples. The difference was statistically non-significant (p>0.05). The false negativity of the FNA and tissue biopsy were 5.4% and 12%, respectively. Subsequently, 43 patients with negative FNA and tissue biopsy underwent lung resection with thoracotomy and sistematic lymph node dissection. Following lymph node dissection, lymph node metastases were found in two cases (4.6%). As a result, false negativity of mediastinoscopy was reduced to 4.6% when two techniques were combined. There was no complication related to the technique. Conclusion: The FNA of mediastinal lymph nodes is a safe and effective method, compared to tissue biopsy and reduces the false negativity of mediastinoscopy when combined with tissue biopsy.

Troublesome bleeding at mediastinoscopy.

We present in this video a case of troublesome bleeding at mediastinoscopy. Video Mediastinoscopy is a vital part of the pre-operative evaluation of patients prior to lung resection. A full staging mediastinoscopy with lymph node sampling from stations 2L, 2R, 4L, 4R, and 7 are key to competent staging and for the avoidance of lobectomy or pneumonectomy in patients with N2 disease for which there is little or no benefit with surgery alone (1,2). The case presented in the video is just such a case (Video 1), with a 67 years old patient who has a right upper lobe T2aN0M0 adenocarcinoma. The PET scan was negative in the mediastinum but we embarked on a staging mediastinoscopy for the reasons highlighted above. Video 1 Troublesome bleeding at mediastinoscopy Surgeons will often be most concerned about accidental biopsy of the major vessels including the innominate artery anteriorly, superior vena cava on the right, the left and right pulmonary artery distally, or the aorta to the left, but often the most troublesome bleeding does not come from these major structures. For example, bleeding may occur an exception to that comes when a malignant lymph node has eroded through a major structure and thus pulling on the node disrupts the structure behind which there is an already weakened vessel wall. Thus extra caution should be taken when the mediastinoscopy is performed to confirm already suspected established or extensive N2 disease rather than to look for micrometastases. One additional caution is paid to the azygous vein. This vessel joins the SVC from posteriorly and it lies close to the 4R lymph nodes. In this video, all these structures were easily identified and avoided. However, a very large bronchial artery was encountered, which in our experience causes troublesome bleeding much more often than the major structures. We note that with some additional aforementioned equipment available and some experience, these can often be successfully addressed without resorting to sternotomy. In our case, early efforts were made to avoid the bronchial artery but as we were reaching over this artery to reach station 7 it started to bleed, perhaps at the site of a side branch to it. We used the suction diathermy to control it initially and then placed and adrenaline soaked swab over it to attempt to vasoconstrict the vessel. While waiting for the adrenaline soaked swab to work, we continued the mediastinoscopy, taking samples from 4R and 4L. On removal of the swab, the vessel was still bleeding significantly. But during that time we had brought into theatre a 5 mm endoscopic clip applicator which fits easily down the mediastinoscope. Then, using the suction diathermy to control the bleeding, we eventually managed to achieve hemostasis with a 5 mm clip. We continued with the procedure and took samples from station 7 before exiting the mediastinum, leaving behind a surgicel haemostat for further haemostasis.

Superiority of Video-Assisted to Standard Mediastinoscopy in Non-Small-Cell Lung Cancer Staging

We compared the efficiency of videomediastinoscopy (VM) and standard mediastinoscopy (SM) in detecting mediastinal lymph node (MLN) metastasis in non-small-cell lung cancer (NSCLC) patients. By SM method a surgeon sampled bilateral paratracheal and subcarinal lymph node stations and then by VM method, another surgeon resampled all lymph node stations once more through the same incision in the same operative setting. Results of the pathologic examinations of two methods were compared. Twenty-seven consecutive mediastinoscopies were included. The numbers of nodal stations biopsied in SM and VM were 97 and 103, respectively. Lymph node metastasis was found in six patients with SM and nine patients with VM. Lymph node dissection by thoracotomy revealed metastases, which were not found by mediastinoscopy, in two patients. Our study showed an accuracy of 92.3% for VM versus 80.7% for SM and corresponding negative predictive values of 88.2% and 75%, respectively (p = 0.002; Fig. 1). This study showed that VM is superior to SM in detecting MLN metastasis in patients with NSCLC.

Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted mediastinoscopy (VAM) is a more effective procedure than conventional mediastinoscopy (CM). A total of 108 papers were identified using the search as discussed below. Of which, eight papers presented the best evidence to answer the clinical question as they included a sufficient number of patients to reach conclusions regarding the issues of interest for this review. Complications, complication rates, number of lymph nodes biopsies, number of stations sampled and training opportunities were included in the assessment. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Literature search revealed that CM is a safe procedure associated with low mortality (0-0.05%) and morbidity (0-5.3%). CM has high levels of accuracy (83.8-97.2%) and negative predictive value (81-95.7%). Training in CM can be difficult as the limited vision means that the trainer cannot monitor directly the dissection and the areas biopsied by the trainee as one operator and effectively see at any time. VAM is also a safe procedure with comparable results to that of CM in term of mortality (0%), morbidity (0.83-2.9%), accuracy (87.9-98.9%) and negative predictive values (83-98.6%). The main advantage is higher number of biospsies taken (VAM, 6-8.5; CM, 5-7.13) and number of mediastinal lymph node stations sampled (VAM, 1.9-3.6; CM, 2.6-2.98). VAM can be associated with more aggressive dissecting and that can lead to more complications. The use of VAM can provide a better and safer training opportunity since both trainer and trainee can share the magnified image on the monitor. All studies available are comparing heterogeneous groups of non-matched group of patients which can bias the outcomes reported. There is a lack of comprehensive randomized studies to compare both procedures and to support any preference towards VAM over CM. We conclude that there is actually very little objective evidence of VAM superiority over CM.

Combining Endobronchial Ultrasound and Videomediastinoscopy in the Diagnosis and Staging of Patients With Mediastinal Adenopathy or Lung Cance

PURPOSE: Endobronchial Ultrasound (EBUS) and videomediastinoscopy (VM) have important roles in the diagnosis of mediastinal adenopathy, particularly in the staging of patients with lung cancer. Our goal to use the least invasive modality possible and obtain definitive results while minimizing delay, led us to develop a hybrid operating room mediastinal staging technique (ORMST). ORMST begins with EBUS, utilizing rapid on-site cytologic analysis, either establishing a diagnosis, thereby terminating the case, or confirming the need to progress to the more invasive VM.

Invited Commentary

Invited Commentary

Neoadjuvant Chemoradiation With Paclitaxel/Carboplatin for Selected Stage III Non–Small-Cell Lung Cancer: Long-Term Results of a Trimodality Phase II Protocol

To evaluate, in a Phase II trial conducted August 1998 through January 2001, the efficacy of neoadjuvant chemotherapy followed by chemoradiotherapy and definitive surgery in patients with locally advanced non-small-cell lung cancer (LA-NSCLC), Stages IIIA bulky and selected Stage IIIB. Staging of LA-NSCLC included computed tomography of cranium, thorax, and abdomen, whole-body positron emission tomography, and video mediastinoscopy. Induction chemotherapy with weekly paclitaxel and carboplatin was followed by hyperfractionated accelerated thoracic radiotherapy (45 Gy) with simultaneous weekly paclitaxel and carboplatin. Four to six weeks after completion of induction therapy, restaging and resection of primary tumor and lymph nodes was intended. A total of 59 consecutive patients were enrolled, 25% with Stage IIIA bulky disease, 65% with Stage IIIB, and 10% with Stage IV (excluded from further analysis). Forty-one patients completed induction therapy; in 52.4% a functional (positron emission tomography) downstaging was proven. Thirty-two patients (59.3%) underwent complete tumor resection, and 5 patients had an exploratory thoracotomy only. Histopathologic downstaging was proven in 59.4% and complete response in 21.9%. Hospital mortality was 5.4%. Median duration of follow-up for living patients was 62.1 months. Overall median survival was 22.6 months, 58.2 months for completely resected patients. During induction chemotherapy, Grade 3/4 granulocytopenia occurred in 8% of patients; the most common Grade 3/4 toxicity of chemoradiation was esophagitis, in 26.4% of patients. Induction paclitaxel/carboplatin with hyperfractionated accelerated chemoradiotherapy followed by complete tumor resection demonstrates high efficacy in LA-NSCLC and offers a promising chance of long-term survival.

The Clinical Application of Video Mediastinoscopy and CT in the N Staging of Preoperative Lung Cancer.

Preoperative lung cancer with mediastinal lymph nodes metastasis can be diagnosed by vedio mediastinoscopy (VM) and CT. This study was to explore the value of VM and CT in the diagnosis of N staging of preoperative lung cancer, and to discuss the difference between the two methods. Forty-eight cases diagnosed of lung cancer by CT or PET-CT were examined by VM. The sensitivity, specificity, validity, positive predictive value and negative predictive value of VM and CT were speculated according to the postoperative pathological reports, and the difference between VM and CT in the diagnosis of lung cancer with mediastinal lymph nodes metastasis was discussed. (1)Under the examination of VM, 31 patients with the negative outcome received the direct operation; 14 patients with N2 received 2 courses of neoadjuvant chemotherapy before operation; 3 patients with N3 received chemotherapy and/or radiotherapy. (2)Forty-one cases with final diagnosis of lung cancer were used as samples to speculate the sensitivity, specificity, validity, positive predictive value and negative predictive value of VM. They were 93.3%, 100%, 97.6%, 100%, 96.3%, which of CT were 66.7%, 53.8%, 58.5%, 45.5%, 73.7% (Chi-square=4.083, P=0.039), the difference between VM and CT was statistically significant. (3)In this group, the complications of VM incidence rate was 2.08% (1/48), and the case was pneumothorax. VM is superior to CT in the diagnosis of N staging of preoperative lung cancer; Due to its safety and effectiveness, VM will be wildly used in the field of thoracic surgery.

Primary Repair of an Iatrogenic Bronchial Rupture Under Video Mediastinoscopy

Complications after performing mediastinoscopy are uncommon, but they may occur even for an experienced surgeon. The major complications have the potential to be life-threatening injuries, such as major vascular or airway injury. A 51-year-old man presented to our hospital due to mediastinal node enlargement on follow-up after he had undergone gastric cancer surgery 2 years previously. An iatrogenic bronchial rupture occurred while performing mediastinoscopic biopsy, and this injury was primarily repaired with multiple direct interrupted sutures, along with the aid of a homemade knot pusher under video mediastinoscopy, and we did not have to convert to an open thoracotomy.

Does video-mediastinoscopy improve the results of conventional mediastinoscopy?☆

Despite new technologies, mediastinoscopy remains the gold standard for mediastinal staging of lung cancer even though the procedure is not standardised. Introduction of video-mediastinoscopy (VM) may help to overcome this problem as it better visualises the anatomy and allows a more uniform dissection than conventional mediastinoscopy (CM). Does the use of VM result in more lymph node tissue, higher accuracy and lower complication rates as compared to CM? All mediastinoscopies from June 2003 to December 2005 were analysed. In a protocol surgeons documented location of lymph node stations, number of lymph nodes resected or biopsied and technique (VM or CM). Two groups were created for analysis: group 1 (n=366) consisting of all mediastinoscopies was reviewed for complication rates; group 2 included all patients with lung cancer who had a pN0 status by mediastinoscopy and underwent subsequent thoracotomy (n=171). This group was studied for the number of lymph nodes resected or biopsied according to the technique (VM or CM), on accuracy and negative predictive value. Of 366 mediastinoscopies, 132 were CM (36.1%) and 234 VM (63.9%). Complications occurred in 17 patients (4.6%): 9 recurrent laryngeal nerve palsies (VM 2.1%, CM 3.0%), 5 mediastinal enlargement on routine chest radiography interpreted as postoperative bleeding (VM 0.9%, CM 2.3%), pneumonia (1), intraoperative laceration of the pleura (1) and main bronchus (1), both corrected during the procedure (all VM 1.3%). No intraoperative haemorrhage or death occurred. VM resected more lymph nodes (mean 8.1, range 3-25) then CM (mean 6.0, range 3-11), for all mediastinoscopies the mean lymph node yield was 7.6 (range 3-25). Comparison of lymphadenectomy via thoracotomy in patients classified pN0 by mediastinoscopy (n=171) showed an accuracy of 87.9% for VM versus 83.8% for CM (85.8% for all mediastinoscopies) with a negative predictive value of 0.83 for VM and 0.81 for CM (0.82 for all mediastinoscopies). This study demonstrates that in comparison with CM, VM routinely yields more lymph nodes with fewer complications with a tendency towards better accuracy and negative predictive value. For these reasons, we believe that VM should replace CM as the method of choice. Furthermore VM would allow standardisation, thereby having an advantage in comparison to the less invasive newer staging techniques. This way mediastinoscopy could remain the gold standard despite its invasiveness.

Intercostal video-mediastinoscopy: a report of 701 cases

To summarize the experience of intercostal video-mediastinoscopy (VMS) in treatment for mediastinal masses, malignant pleural effusion and palmar hyperhidrosis. The clinical data of 701 patients received intercostal VMS from November 2001 to June 2007 were summarized retrospectively. Forty-eight patients with mediastinal masses and 46 patients with suspected malignant pleural effusion underwent intercostal VMS pleural biopsy (39 cases with talc pleurodesis) and 607 patients with palmar hyperhidrosis underwent bilateral intercostals VMS thoracic sympathectomy. No mortality and morbidity were reported in this group. Definitive pathologic diagnosis had been made through VMS mediastinal masses biopsy in mediastinal masses and pleural biopsy in pleura effusion. The efficiency of talc pleurodesis was 100% for 39 cases. The symptoms of sweating of hands in 607 patients with palmar hyperhidrosis disappeared completely, all patients' hands became dry with a 1.5 degrees C to 3.0 degrees C increase of the skin temperature immediately after operation. No recurrence occurred during the follow-up. VMS is a simple, convenient and alternative procedure for the treatment of mediastinal masses, malignant pleural effusion and palmar hyperhidrosis.