Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging

EBUS-TBNA in mediastinal staging of non-small cell lung cancer: comparison with pathological staging

OBJECTIVE

Although EBUS-TBNA combined with EUS-FNA or EUS-B-FNA stands as the primary approach for mediastinal staging in lung cancer, guidelines recommend mediastinoscopy confirmation if a lymph node identified on chest CT or showing increased PET scan uptake yields negativity on these techniques. This study aimed to assess the staging precision of EBUS/EUS.

METHODS

We conducted a retrospective study comparing the clinical staging of non-small cell lung cancer patients undergoing EBUS/EUS with their post-surgery pathological staging. We analyzed the influence of histology, location, tumor size, and the time lapse between EBUS and surgery. Patients with N0/N1 staging on EBUS/EUS, undergoing surgery, and with at least one station approached in both procedures were selected. Post-surgery, patients were categorized into N0/N1 and N2 groups.

RESULTS

Among the included patients (n = 47), pathological upstaging to N2 occurred in 6 (12.8%). Of these, 4 (66.7%) had a single N2 station, and 2 (33.3%) had multiple N2 stations. The adenopathy most frequently associated with upstaging was station 7. None of the analyzed variables demonstrated a statistically significant difference in the occurrence of upstaging. PET scan indicated increased uptake in only one of these adenopathies, and only one was visualized on chest CT.

CONCLUSIONS

Upstaging proved independent of the studied variables, and only 2 patients with negative EBUS/EUS would warrant referral for mediastinoscopy. Exploring other noninvasive methods with even greater sensitivity for detecting micrometastatic lymph node disease is crucial.

Comparative study of acute and chronic pain after inflatable videoasisted MediastinoscopicTranshiatal esophagectomy and minimally invasive McKeown Esophagectomy:A propensity score matching analysis

Objective

The short-term quality of life of patients can be enhanced by performing Inflatable Video-Assisted Mediastinoscopic Transhiatal Esophagectomy (IVMTE). Nevertheless, there is limited research on how it impacts postoperative acute and chronic pain in individuals diagnosed with esophageal cancer.Hence, this research aimed to examine the impact of IVMTE and minimally invasive Mckeown esophagectomy (MIME) on the occurrence of acute and chronic pain following surgery in individuals diagnosed with esophageal cancer.

Methods

A retrospective, propensity score matching analysis was adopted. In total, 133 patients with esophageal cancer who underwent IVMTE and MIME between January 2020 and December 2021 were part of the study. Among them, 38 patients underwent IVMTE and 95 patients underwent MIME. Following the propensity score matching analysis, 36 patients were included in each group. Patients' postoperative pain was evaluated using the numerical rating scale (NRS).

Results

The IVMTE group (Group A) had significantly reduced operation time and intraoperative blood loss compared to the MIME group (Group B) (P < 0.05). NRS scores on the 1st, 2nd, 3rd, and 7th days after surgery, as well as on the 3rd and 6th months post-surgery, were notably reduced in the IVMTE group (Group A) compared to the MIME group (Group B) (P < 0.05). Univariate and multivariate analysis showed that chronic pain occurred postoperative 3rd months was related to the operation methods (P < 0.05). Univariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation time, postoperative 14th days NRS scores and operation methods (P < 0.05). Multivariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation methods (P < 0.05).

Conclusion

The results showed that the operation methods were the main risk factors for postoperative chronic pain. The compared with MIME, IVMTE can further reduce the acute and chronic pain of patients with esophageal cancer.

Evaluation of mediastinoscopy for cranial mediastinal and tracheobronchial lymphadenectomy in canine cadavers

OBJECTIVE

To report technical feasibility and describe procedural details of a novel single incision minimally invasive approach to the mediastinum in cadaver dogs.

STUDY DESIGN

Cadaveric study.

ANIMALS

Large breed (25-40 kg) cadaver dogs (n = 10).

METHODS

Three of 10 cadavers were used for preliminary technique development without data recording. Cadaver specimens underwent pre- and postoperative thoracic computed tomographic scans. Seven dogs were placed in dorsal recumbency and mediastinoscopy was performed via a SILS port placed cranial to the thoracic inlet with CO2 insufflation of the mediastinum at 2-4 mmHg. Retrieval of all CT and visually identified mediastinal lymph nodes (LN) was attempted; endoscopic compartmental and individual LN dissection times and subjective operative challenges were recorded. Procedural success scores for visualization and dissection as well as NASA-task force index scores were recorded per lymph node, per cadaver.

RESULTS

Median time required for initial approach including SILS placement was 5 min (range 5-10 min). Individual LN retrieval times ranged from 2 to 32 min. Mediastinoscopic retrieval of LNs was most commonly successful for the left tracheobronchial LN (7/7), followed by the right tracheobronchial LN (4/7), the left and right sternal LNs (3/7 each), and the cranial mediastinal LNs (1/7). Post-procedure pleural gas was identified on CT in 4/7 cadavers.

CONCLUSIONS

Mediastinoscopy as reported was feasible in large breed canine cadavers and retrieval or cup biopsy of a variety of lymph nodes is possible from the described approach. Application in living animals and its associated challenges should be further investigated.

CLINICAL SIGNIFICANCE

Mediastinoscopy may provide a novel minimally invasive approach to the evaluation and oncologic staging of the cranial mediastinum in dogs.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA): Mature results for staging non-small cell lung cancer with normal mediastinum

OBJECTIVES

The aim of this study is to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the unsuspected (u) N2/3 rates in patients with non-small cell lung cancer (NSCLC) and normal mediastinum by integrated positron emission tomography-computed tomography.

METHODS

Prospective observational single-center study of 603 consecutive VAMLAs from 2010 to 2022.

EXCLUSION CRITERIA

other indications (n = 32), tumors different from NSCLC (n = 91), and clinical (c) N2/3 tumors by positron emission tomography-computed tomography (n = 46). Systematic nodal dissection was the gold standard to validate negative VAMLAs. Those patients with negative VAMLA and missing reference standard test were excluded. uN2/3 rates were analyzed in the global series and in the subgroups of tumors according to their clinical nodal and tumor categories. Pathologic findings were reviewed, and staging values were calculated.

RESULTS

Three hundred eighty-three patients with cN0/1 NSCLC underwent VAMLA. Staging values of VAMLA were: sensitivity, 0.98 (95% CI, 0.92-0.99); negative predictive value, 0.99 (95% CI, 0.98-1); and diagnostic accuracy, 0.99 (95% CI, 0.98-1). The uN2/3 rate for the whole series (N = 383) was 18.8%. The uN2/3 rates according to presurgical nodal and tumor categories determined by positron emission tomography computed tomography were: 3.6% (4 out of 111) in cT1N0; 16.3% (18 out of 110) in cT2N0; 10.25% (4 out of 39) in cT3N0; and 32% (7 out of 22) in cT4N0. Forty-two percent (39 out of 93) in cN1; complication rate was 7%.

CONCLUSIONS

This series of NSCLC with normal mediastinum staged by VAMLA demonstrates a high accuracy of this technique and a high rate of uN2/3 disease (specially in cN1 and cT4N0). VAMLA could be considered the reference staging procedure for staging cN0/1 NSCLC.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer

BACKGROUND

Mediastinoscopy was originally applied for lymph node biopsy and mediastinal tumor resection. Improved video imaging with spreadable working channels enabled mediastinoscopy for inspection and tissue biopsy in the superior mediastinum but it is rarely used in minimally invasive esophageal cancer surgery. In this prospective trial, the practicability and security of spreadable video-assisted mediastinoscopic combined with laparoscopic transhiatal esophagectomy (VAME) with video-assisted thoracoscopic esophagectomy (VATE) were compared.

METHODS

A total of 200 eligible patients with esophageal squamous cell carcinoma were randomly divided into VAME or VATE groups. Early postoperative outcomes and lymph node dissection between the two groups were compared.

RESULTS

The operation time was significantly shorter (164.3 ± 47.0 min vs. 265.4 ± 47.2 min, P < 0.001), the number of dissected lymph nodes was less (15.8 ± 4.5 vs. 20.3 ± 6.5, P < 0.001), and the intraoperative blood loss was also significantly reduced (94.7 ± 56.7 mL vs. 184.4 ± 65.2 mL, P < 0.001) in the VAME compared to the VATE group, respectively. The incidence of pneumonia was lower (7% vs. 29%; P < 0.001) and the length of hospital stay was shorter in the VAME group compared to the VATE group (18.0 ± 7.6 days vs. 23.2 ± 7.2, P < 0.001, respectively). The chyle leak incidence appeared to be lower in the VAME group but statistical significance was not reached (1% vs. 4%; P = 0.369). There were no differences in the incidence of anastomotic leakages and recurrent laryngeal nerve paralysis between the groups. No 30-day mortality occurred in any of the cases.

CONCLUSION

VAME appears to be a practicable and secure method for esophagectomy but needs further proof of concept. Clinical registration number: Registered at Chinese Clinical Trial Registry, ChiCTR1900022797.

Surgical mediastinal lymph node staging for non-small-cell lung carcinoma

Background

The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.

Methods

A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.

Results

Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).

Conclusions

We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.

Video mediastinoscopy-assisted superior mediastinal dissection in the treatment of thyroid carcinoma with mediastinal lymphadenopathy: preliminary results

Background

Mediastinal lymph node metastases (MLNM) are not rare in thyroid cancer, but their treatment has not been extensively studied. This study aimed to explore the preliminary application of video mediastinoscopy-assisted superior mediastinal dissection in the diagnosis and treatment of thyroid carcinoma with mediastinal lymphadenopathy.

Materials and methods

We retrospectively reviewed the clinical pathologic data and short-term outcomes of thyroid cancer patients with suspicious MLNM treated with video mediastinoscopy-assisted mediastinal dissection at our institution from 2017 to 2020.

Results

Nineteen patients were included: 14 with medullary thyroid carcinoma and five with papillary thyroid carcinoma. Superior mediastinal nodes were positive in nine (64.3%) patients with medullary thyroid carcinoma and in four (80.0%) patients with papillary carcinoma. No fatal bleeding occurred. There were three cases of temporary recurrent laryngeal nerve (RLN) palsy postoperatively, one of which was bilateral. Four patients had temporary hypocalcemia requiring supplementation, one had a chyle fistula, and one developed wound infection after the procedure. Postoperative serum molecular markers decreased in all patients. One patient died of cancer while the other 18 patients remained disease-free, with a median follow-up of 33 months.

Conclusion

Video mediastinoscopy-assisted superior mediastinal dissection can be performed relatively safely in patients with suspicious MLNM. This diagnostic and therapeutic approach may help control locoregional recurrences.

The learning curve of video-assisted mediastinoscopic lymphadenectomy for staging of non-small-cell lung carcinoma

OBJECTIVES

The objective of this study was to define the learning process of video-assisted mediastinoscopic lymphadenectomy (VAMLA) by the assessment of consecutive procedural metrics.

METHODS

We conducted a single-centre retrospective observational study of all consecutive VAMLAs performed between 2011 and 2018 for the staging of non-small-cell lung carcinoma. Learning curves were assessed using non-risk adjusted cumulative observed minus expected (CUSUM) failure charts of complications. Boundary lines were defined by the acceptable and unacceptable complication rates of 4.5% and 15.0%. The Kruskal-Wallis test with post hoc analysis was used to assess trends in operation time and blood loss.

RESULTS

Two-hundred-thirty-six unique VAMLAs by 4 surgeons performing their first procedures were evaluated. CUSUM charts of surgeons A and B showed a typical learning curve with an initial incline, followed by a turning point towards lower complications rates after 16-17 cases, whereas surgeons C and D showed an average performance. The median time between consecutive VAMLAs was shorter for surgeons A and B (13.0 vs 28.5-38.0 days for surgeons C and D). Overcoming the learning curve, complication rates of surgeons A and B decreased from 19% to 3% and from 18% to 5%, respectively. Operation time and blood loss showed a significant improvement after, respectively, 81-100 and 61-80 procedures compared to the first 20 procedures.

CONCLUSIONS

VAMLA is a safe procedure to adopt and perform with acceptable complication rates from the first operation onward, regardless of the caseload. To overcome its learning curve, 16-17 cases are required, preferably at least 1 per 2 weeks.

Mediastinal staging for non-small cell lung cancer

The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling. The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.

Preoperative staging of the mediastinum is an essential and multidisciplinary task

Mediastinal staging is a crucial step in the management of patients with NSCLC. With the recent development of novel techniques, mediastinal staging has evolved from an activity of interest mainly for thoracic surgeons to a joint effort carried out by many specialists. In this regard, the debate of cases in MDT sessions is crucial for optimal management of patients. Current evidence-based clinical guidelines for preoperative NSCLC staging recommend that mediastinal staging should be performed with increasing invasiveness. Image-based techniques are the first approach, although they have limited accuracy and findings must be confirmed by pathology in almost all cases. In this setting, the advent of radiomics is promising. Invasive staging depends on procedural factors rather than diagnostic performance. The choice between endoscopy-based or surgical procedures should depend on the local expertise of each centre. As the extension of mediastinal disease in terms of number of involved lymph nodes and nodal stations affects prognosis and the choice of treatment, systematic samplings are preferred over random targeted samplings. Following this approach, a diagnosis of single mediastinal nodal involvement can be unreliable if all reachable mediastinal nodal stations have not been assessed. The performance of confirmatory mediastinoscopy after a negative endoscopy-based procedure is controversial but currently recommended. Current indications of invasive staging in patients with radiologically normal mediastinum have to be re-evaluated, especially for central tumour location.

Minimizing residual occult nodal metastasis in NSCLC: recent advances, current status and controversies

Introduction: Nodal involvement in lung cancer is a significant determinant of prognosis and treatment management. New evidence exists regarding the management of occult lymph node metastasis and residual disease in the fields of imaging, mediastinal staging, and operative management.Areas covered: This review summarizes the latest body of knowledge on the identification and management of occult lymph node metastasis in NSCLC. We focus on tumor-specific characteristics; imaging modalities; invasive mediastinal staging; and operative management including, technique, degree of resection, and lymph node examination.Expert opinion: Newly identified risk-factors associated with nodal metastasis including tumor histology, location, radiologic features, and metabolic activity are not included in professional societal guidelines due to the heterogeneity of their reporting and uncertainty on how to adopt them into practice. Imaging as a sole diagnostic method is limited. We recommend confirmation with invasive mediastinal staging. EBUS-FNA is the best initial method, but adoption has not been uniform. The diagnostic algorithm is less certain for re-staging of mediastinal nodes after neoadjuvant therapy. Mediastinal node sampling during lobectomy remains the gold-standard, but evidence supports the use of minimally invasive techniques. More study is warranted regarding sublobar resection. No consensus exists regarding lymph node examination, but new evidence supports reexamination of current quality metrics.

Mediastinal staging: when and how?

Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.

Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer

Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.

Present indications of surgical exploration of the mediastinum

Preoperative mediastinal staging is crucial in the management of patients with non-small cell lung cancer (NSCLC), especially to define prognosis and the most proper treatment. To obtain the highest certainty level before lung resection, the current American and European guidelines for preoperative mediastinal nodal staging for NSCLC recommend getting tissue confirmation of regional nodal spread in all cases except in patients with small (≤3 cm) peripheral carcinomas with no evidence of nodal involvement on computed tomography (CT) and positron emission tomography (PET). We have a wide variety of surgical methods for mediastinal staging that are well integrated in the current preoperative algorithms. Their main indication is the validation of negative results obtained by minimally invasive endoscopic techniques. However, recent studies have reported the superiority of mediastinoscopy over endosonography methods in terms of accuracy for those tumours classified as clinical (c) N0-1 by CT and PET or with intermediate risk of N2 disease (cN1 and central tumours). Apart from the exploration of the mediastinum, other surgical procedures [parasternal mediastinotomy, extended cervical mediastinoscopy (ECM) and video-assisted thoracoscopic surgery (VATS)] allow the completion of the staging process with the assessment of the primary tumour and metastasis, exploring the lung, pleural cavity, and pericardium when it is required. Transcervical lymphadenectomies represent the evolution of mediastinoscopy and they are already considered the most reliable method for mediastinal staging, mainly in the subgroup of patients in whom endosonography methods have a low sensitivity: tumours with normal mediastinum by CT and PET. In addition to their indication for staging, these procedures have also demonstrated to be feasible as preresectional lymphadenectomy in VATS lobectomy, improving the radicality of the number of lymph nodes and lymph node stations explored, mostly for left-sided tumours for which a complete mediastinal nodal dissection is not always possible by VATS approach.

Lung cancer staging: a concise update

Diagnosis and clinical staging of lung cancer are fundamental to planning therapy. The techniques for clinical staging, i.e anatomic and metabolic imaging, endoscopies and minimally invasive surgical procedures, should be performed sequentially and with an increasing degree of invasiveness. Intraoperative staging, assessing the magnitude of the primary tumour, the involved structures, and the loco-regional lymphatic spread by means of systematic nodal dissection, is essential in order to achieve a complete resection. In resected tumours, pathological staging, with the systematic study of the resected specimens, is the strongest prognostic indicator and is essential to make further decisions on therapy. In the present decade, the guidelines on lung cancer staging of the American College of Chest Physicians and the European Society of Thoracic Surgeons are based on the best available evidence and are widely followed. Recent advances in the classification of the adenocarcinoma of the lung, with the definition of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma, and the publication of the eighth edition of the tumour, node and metastasis classification of lung cancer, have to be integrated into the staging process. The present review complements the latest guidelines on lung cancer staging by providing an update of all these issues.

Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions

Lung cancer is one of the most frequent neoplastic diseases. To date, most lung cancer is diagnosed at an advanced stage, making it difficult to choose the diagnostic and therapeutic strategy. Surgical resection represents the best therapeutic solution. However, the best results are obtained only in the early stages of the disease. Lymph node involvement conditions the treatment (surgical or non-surgical approach). Mediastinoscopy is an effective and widely used method for mediastinal staging but does not allow us to reach many mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration (EBUS-TBNA) allows us to reach more lymph nodes and is referred to as a first-choice exam for mediastinal staging.

Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment

Background

This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach.

Methods

From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared.

Results

There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05).

Conclusion

Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.

Left minimally invasive esophagectomy in a patient with synchronous esophageal and lung cancers: Case report

RATIONALE

Minimally invasive esophagectomy (MIE) have been increasingly used and are regarded as suitable alternatives to open esophagectomy. However, few previous reports described minimally invasive esophagectomy using a left-sided approach.

PATIENT CONCERNS AND DIAGNOSES

A 71-year-old man was admitted to our hospital because of progressive dysphagia. Synchronous double primary thoracic esophageal and left lung cancers were considered before the operation.

INTERVENTIONS AND OUTCOMES

A lobectomy and MIE, via a left video-assisted thoracoscopic approach, was performed. Preparation of a gastric conduit and an intra-abdominal lymphadenectomy were completed by laparoscopy and a cervical anastomosis was made. In addition, a cervical mediastinoscopy was performed to dissect the lymph nodes along the bilateral recurrent laryngeal nerves. No postoperative complications were observed. The patient achieved a favorable short-term outcome.

LESSONS

This is the first report of a patient with synchronous esophageal and left lung cancers treated with minimally invasive resection via left thoracoscopy, laparoscopy, and cervical mediastinoscopy. Our results showed that the left MIE approach in combination with cervical mediastinoscopy is potentially most appropriate for some esophageal cancer patients, when the right MIE approach is not applicable in certain conditions.

Clinical staging of NSCLC: current evidence and implications for adjuvant chemotherapy

Survival of all non-small cell lung cancer (NSCLC) patients is disappointing, with a 5-year survival of 18%. Staging NSCLC patients is crucial because it determines the choice of treatment and prognosis. Clinical staging is a complex process that comes with many challenges and with low accuracy between the clinical and pathological stage. Treatment modalities for stage I-III NSCLC consist of surgical resection, radiotherapy and chemotherapy. This review describes the current evidence on staging and the implications on adjuvant chemotherapy. For stage I disease, staging is most accurate. Primary treatment consists of surgery or stereotactic ablative radiotherapy. When a patient has stage II disease, staging is less accurate because more diagnostic modalities are necessary to stage the mediastinal lymph nodes. Surgery remains the primary treatment modality and platinum-based adjuvant chemotherapy gives a 4% 5-year survival benefit. Staging patients with stage III disease is difficult because of the heterogeneity of the patients. It should be decided if a patient has potentially resectable disease with or without risk of incomplete resection. Induction therapy with chemo(radio)therapy followed by surgical resection or definitive chemoradiotherapy are the treatments of choice. The 5-year survival can reach 44% in selected patients. Decisions in staging and treating patients with NSCLC should be made by a multidisciplinary team with sufficient expertise in all aspects of staging and treatment.

Minimally-invasive complete resection of intrathoracic mediastinal lesions with a Linder-Dahan spreadable-blade video mediastinoscope system: A report of two cases

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Schwannoma/parathyroid cyst was resected using Linder-Dahan video mediastinoscope.

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Resection with video, spreadable blades, and a scope-holding device was excellent.

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Linder-Dahan video mediastinoscopy improves safety, preciseness, and operability.

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Linder-Dahan video mediastinoscopy has similar invasiveness as standard procedures.

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Procedural simulation with 3-D PET/CT virtual mediastinoscopy is useful.

Introduction

Cervical mediastinoscopy can provide a minimally invasive access to the paratracheobronchial mediastinum within its reachable range, but its operability is substantially limited because of its small operative field, poor visualisation, and one-handed operation.

Presentation of cases

Patient 1, a 56-year-old woman, presented with a 22 × 17 mm, non-symptomatic, ¹⁸F-fluorodeoxy glucose (FDG)-avid, solid schwannoma originating from the vagus nerve trunk in the right upper paratracheal space. Patient 2, a 55-year-old man, presented with a 55 × 41 mm cystic mass in the left upper paratracheal space that extensively compressed and dislocated the trachea toward the right, which caused dyspnoea and cervicothoracic pain. The masses in both cases were completely resected using a Linder-Dahan spreadable-blade video mediastinoscope.

Discussion

The addition of the video system and spreadable blades to the conventional scope combined with a scope-holding device has enabled effective bi-manual preparation and more precise and safer mediastinoscopic procedures than those performed using the conventional one-handed mediastinoscope. Owing to the improved operability, more complex or extended procedures could be performed in wider and more stable operative spaces with better visualisation, although the system has the same minimal invasiveness as that of the conventional mediastinoscope.

Conclusion

We describe two patients with mediastinal lesions that were effectively resected by using this sophisticated video mediastinoscope system.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging

Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010. Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively. Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Current methods of staging and restaging of the mediastinal nodes in non-small-cell lung cancer

To analyze the current methods of primary staging and repeated staging (restaging) of the mediastinal nodes in non-small-cell lung cancer (NSCLC), all methods currently used for staging of NSCLC are analyzed. These methods include imaging techniques [computer tomography (CT), positron emission tomography (PET) combined with CT (PET/CT)], endoscopic/ultrasound techniques (endobronchial ultrasound/transbronchial needle aspiration) and endoscopic ultrasound/fine needle aspiration and surgical techniques [standard cervical mediastinoscopy, video-assisted mediastinoscopy, extended mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy, transcervical extended mediastinal lymphadenectomy, anterior mediastinotomy (Chamberlain procedure) and video-assisted thoracic surgery]. The diagnostic yield of Chest CT is regarded insufficient for both, primary staging and restaging. The PET/CT became a standard imaging technique preceding curative surgery of radical chemo-radiotherapy. The issue of intraoperative staging is also described. Finally, the author’s proposed algorithm of staging, both for primary staging and restaging after neoadjuvant therapy is presented. Detailed staging of NSCLC enables selection of patients with early stage disease for curative surgical/multimodality treatment and helps to avoid unnecessary surgery in advanced disease.

Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. Over the last years more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of CT-enlarged or PET-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography (EBUS/EUS) with fine needle aspiration is the first choice (when available) since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred over mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumors ≤3 cm located in the outer third of the lung. In central tumors or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and fine needle aspiration or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumors larger than 3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high SUV uptake.

Utility of mediastinoscopy in clinical stage I lung cancers at risk for occult mediastinal nodal metastases

OBJECTIVE

The prevalence of mediastinal lymph node metastases is unknown for patients with clinical N0 lung cancer who are thought to be at high risk for occult nodal metastases. Further, the utility of mediastinoscopy in these patients is unknown. We performed a prospective trial to evaluate the utility of routine cervical mediastinoscopy for patients who may be at high risk of occult nodal metastases.

METHODS

From January 1, 2008, July 31, 2013, 90 patients with lung cancer with clinical stage T2N0 or T1N0 with standardized uptake value greater than 10 by positron emission tomography/computed tomography underwent routine cervical mediastinoscopy before lung resection. Biopsy of a minimum of 3 nodal stations at mediastinoscopy and a minimum of 4 nodal stations with lung resection was advised. The prevalence of nodal metastases at mediastinoscopy and lung resection was recorded.

RESULTS

Some 64% of patients with lung cancer were male with a mean age of 67.3 years. A total of 81 patients had clinical T2N0 and 9 patients had T1N0 with standardized uptake value greater than 10. Mean tumor size was 4.3 ± 1.7 cm, and mean standardized uptake value was 13.5 ± 6.8. One patient (1.1%) had occult metastases detected at mediastinoscopy. A total of 86 patients underwent surgical resection; 4 patients (4.6%) were upstaged to pN2, and 18 patients (21%) were upstaged to pN1. Of 90 patients with clinically staged N0 lung cancer by positron emission tomography/computed tomography, 5.6% (5) were upstaged to pN2 and 20% (18) were upstaged to pN1 (total nodal upstaging = 25.6%).

CONCLUSIONS

Mediastinoscopy seems to have limited utility in these patients with T1 and T2 clinically staged N0 by positron emission tomography/computed tomography. Selective use of mediastinoscopy is recommended, along with thorough mediastinal lymph node evaluation in all patients at the time of lung cancer resection.

Save or sacrifice the internal mammary pedicle during anterior mediastinotomy?

Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.

Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.

Invasive and noninvasive advances in the staging of lung cancer

Accurate staging of lung cancer is crucial to ensure the validity of lung cancer clinical research efforts and constitutes the cornerstone of the management of affected patients. The last decade has witnessed unprecedented technological advances allowing for more accurate and less invasive staging. In general, these techniques should be viewed as complementary rather than competitive, and indications, contraindications, and limitations of all staging techniques should be fully understood by providers involved with lung cancer patients. Noninvasive imaging techniques include chest computed tomography (CT) and positron emission tomography (PET). Invasive techniques can be nonsurgical such as needle-based techniques (endobronchial or endoscopic ultrasound) or surgical (mediastinoscopy and variants). The necessary multidisciplinary approach to lung cancer patients dictates that all stakeholders be familiar with the benefits and limitations of these newer techniques.

Cotton-Derived Oxidized Cellulose in Minimally Invasive Thoracic Surgery

Objective

The aim of this study was to identify resorption, clinical performance, and safety of cotton-derived oxidized cellulose gauze applied as a hemostat in minimally invasive oncologic thoracic surgery.

Methods

This is a pilot prospective noncomparative observational human in vivo study. A piece of cotton-derived oxidized cellulose gauze measuring 5 × 20 cm was inserted into the subcarinal space of patients with potentially resectable lung carcinoma at the time of video-assisted mediastinoscopic lymphadenectomy and reexamined several days later for macroscopic and histologic evaluation at the time of subsequent lung resection. The primary endpoint was the local situation at the implantation site described by cellulose remnants, fluid collections, and adhesions. The secondary endpoint was safety, described by the number of adverse events and surgical reinterventions.

Results

Twenty-five consecutive eligible patients with potentially resectable lung carcinoma were included. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At re-exploration 10.5 (5–28) days later, the cellulose gauze was found to lose its solid structure from the fifth day on. Remnants were last detected 14 days after insertion. The implantation site exhibited no inflammatory changes and a remarkable small amount of fluid collections and adhesions.

Conclusions

Mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 × 20 cm seems to be absorbed completely within 15 days, thus precluding any interference with oncologic restaging and follow-up. The absence of relevant adhesions facilitates further surgical procedures. Larger comparative confirmatory studies are required. For large-scale resorption studies, our clinical model should be translated into a porcine model.

Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer

OBJECTIVES

We aimed to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) as a tool for preoperative staging and the impact of the technique on survival in patients with non-small cell lung cancer (NSCLC) undergoing pulmonary resection.

METHODS

Between May 2006 and December 2010, 433 patients underwent pulmonary resection for NSCLC, 89 (21%) had VAMLA before resection and 344 (79%) had standard mediastinoscopy. The patients who had negative VAMLA/mediastinoscopy results underwent anatomic pulmonary resection and systematic lymph node dissection.

RESULTS

The median and mean numbers of resected lymph node stations were 5 and 4.9 in the VAMLA group and 4 and 4.2 in the mediastinoscopy group (P = .9). The mean number of lymph nodes per biopsy specimen using standard mediastinoscopy was 10.1, whereas it was 30.4 using VAMLA (P < .001). VAMLA unveiled N2 or N3 disease in 30 (33.7%) and in 6 (6.7%) of patients, respectively. The negative predictive value, sensitivity, false-negative value, and accuracy of VAMLA were statistically higher in the VAMLA groups compared with those of standard mediastinoscopy. The 5-year survival was 90% for VAMLA patients and 66% for mediastinoscopy patients (P = .01). By multivariable analysis, VAMLA was associated with better survival (odds ratio, 1.34; 95% confidence interval, 1.1-3.2; P = .02).

CONCLUSIONS

VAMLA was associated with improved survival in NSCLC patients who had resectional surgery.

Video-assisted mediastinoscopic lymphadenectomy and transcervical extended mediastinal lymphadenectomy

This article describes in detail the operative technique of the new surgical methods, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA). Both techniques enable the removal of the mediastinal nodes with the surrounding fatty tissue. VAMLA and TEMLA have very high diagnostic yield and can be combined with minimally invasive video-assisted lobectomy.

Video-assisted mediastinoscopy in superior vena cava obstruction: to fear or not to fear?

INTRODUCTION

We investigate the safety and efficacy of video-assisted mediastinoscopy (VAM) used for diagnosis of the superior vena cava syndrome.

METHODS

In a 7-year period, we have done 447 VAM for malignant causes. We have compared, in a retrospective study from a prospectively maintained database, the differences between the groups with (first group) or without (second group) superior vena cava syndrome in terms of operative time, preoperative and postoperative complications, and results of pathologic examination. Statistical differences between the groups were calculated by χ2 test.

RESULTS

Mean operative time for first (31 patients) and second (416 patients) groups was 18 and 34 minutes, respectively (p < 0.00). Mean hospital stay was 1.2 days in both the groups. Mortality rates for the first and second groups were 0 and 0.5% (p = 0.31); major morbidity rates were 0 and 0.7% (p = 0.50); and minor morbidity rates were 6.4 and 1.7% (p = 0.27), respectively. In the superior vena cava syndrome group, most of the lymph nodes biopsied were in paratracheal superior sites (81%); histology showed small cell lung cancer in 51.6%, non-small cell lung cancer in 25.8%, and lymphoma in 22.6%.

CONCLUSIONS

VAM represents an important diagnostic tool in superior vena cava syndrome. Once decided to be used, we think that video technique is a good option with high rate of efficacy and low rates of mortality and morbidity.

A comparative analysis of video-assisted mediastinoscopy and conventional mediastinoscopy

BACKGROUND

The objective of this study was to compare outcomes of video-assisted mediastinoscopic lymph node biopsy in patients with non-small cell lung cancer (NSCLC) with outcomes of conventional mediastinoscopic lymph node biopsy in this same patient population.

METHODS

All mediastinoscopies at one medical center from January 2008 to December 2009 were analyzed. Numbers of lymph nodes dissected, stations biopsied, remnant lymph nodes when major lung resection was performed after mediastinoscopic lymph node biopsy, and complications were recorded.

RESULTS

Of 521 mediastinoscopies, 222 were in the conventional mediastinoscopic lymph node biopsy group (CM group) and 299 were in the video-assisted mediastinoscopic lymph node biopsy group (VAM group). Eleven complications (2.11%) occurred, with more occurring in the CM group (3.6%) than in the VAM group (1.6%; p=0.030). The total number of dissected nodes was higher in the VAM group (mean, 8.53±5.8) than in the CM group (mean, 7.13±4.9; p=0.004), and there was no statistically significant difference between the average number of stations sampled in the CM group (2.98±0.7) and in the VAM group (3.06±0.75; p=not significant). The number of remnant lymph nodes when major lung surgery was performed after mediastinoscopy was lower in the VAM group (mean, 5.05±4.5) than in the CM group (mean, 7.67±6.5; p<0.001).

CONCLUSIONS

This study found that video-assisted mediastinoscopic lymph node biopsy had fewer complications than did the conventional method. More lymph nodes were examined and fewer lymph nodes remained after mediastinoscopy by video-assisted mediastinoscopy (VAM) than by conventional mediastinoscopy.

Current evidence on transcervical mediastinal lymph nodes dissection

In the last decade, we witnessed the development of two new, fascinating techniques of mediastinal exploration: the video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the transcervical extended mediastinal lymphadenectomy (TEMLA). During this time, several articles were published, providing a substantial body of evidence regarding different aspects of these techniques. Based on this evidence, we discuss the operative technique, its applications and results as well as questions to be answered and possible future development. The aim of this review is to provide the readers who have no personal experience with these techniques, with the key information regarding the usefulness, advantages and drawbacks of VAMLA and TEMLA.

Development of a new trans-oral endoscopic approach for mediastinal surgery based on 'natural orifice surgery': preclinical studies on surgical technique, feasibility, and safety

OBJECTIVE

In recent years, several surgical disciplines adopted endoscopic techniques. Presently, natural orifice approaches are under exploration to reduce surgical access trauma. We have developed a trans-oral endoscopic approach for endoscopic mediastinal surgery and have tested this new technique in preclinical studies for feasibility and safety.

METHODS

We conducted an experimental anatomical study in fresh-frozen cadavers. By a midline, sublingual incision, we placed an optical scissor through a 6.0-mm trocar in the pretracheal region and created a working space; two additional trocars were placed by bi-vestibular incisions in the oral cavity. We visualized and followed the trachea down to the main bronchi. Paratracheal and subcarinal lymph nodes were resected bilaterally; the specimen could be removed through the midline channel. In an additional animal study in pigs, we tested the feasibility and safety for this surgical approach. Anatomical dissection allowed an estimate of collateral damage.

RESULTS

In all cases, we could reach the target region endoscopically, and no conversion was necessary. Landmarks (the brachiocervical trunk, the azygos vein, and the pulmonary artery) were visualized easily and kept intact. A working space in the mediastinum could be established by the insufflation of air at 6-8mmHg. It was possible to harvest the specimen through the midline channel. Anatomical dissection of the cervical access route as well as of the mediastinal region showed no collateral damage. In the animal study, we encountered seroma of the surgical field due to the conditions of the animal model. The other outcomes with respect to pain and food intake were normal until the third postoperative day. No local infections occurred. Intraoperative gas exchange was normal and was not influenced by CO(2) insufflation with respect to blood gas analysis.

CONCLUSION

These preclinical studies showed that the mediastinum could be reached by a trans-oral endoscopic approach, based on natural orifice surgery. Complete compartment resection of the paratracheal and subcarinal lymph node stations was possible in a well-defined and clearly visible working space. This approach may enhance the extent of mediastinal resections in oncologic surgery.

Video-assisted mediastinoscopy compared with conventional mediastinoscopy: are we doing better?

BACKGROUND

Conventional mediastinoscopy (CM) is recently being replaced by video-assisted mediastinoscopy (VAM), with potentially better yield and better safety profile for VAM.

METHODS

All 645 mediastinoscopies (505 CM, 140 VAM) performed between May 2004 and May 2008 were reviewed. Numbers of stations biopsied, total number of lymph nodes dissected, pathology results, and complications were recorded. Patients were divided into two groups: staging for lung cancer group (n = 500) and diagnostic group (n = 145). The staging group was further analyzed, using 304 patients who eventually underwent thoracotomy to evaluate accuracy and negative predictive value of mediastinoscopy, comparing between the two methods (233 CM, 71 VAM).

RESULTS

Average age was 65 years (range, 26 to 91), and 382 were male. There was no mortality. Eight complications (1.2%) occurred, more in the VAM group (3.8%) than in the CM group (0.8%; p = 0.04). The total number of dissected nodes was higher in the VAM group than in the CM group (7.0 +/- 3.2 versus 5.0 +/- 2.8, p < 0.001), and so was the number of stations sampled (3.6 versus 2.6, p < 0.01). Sensitivity was higher for VAM (95% versus 92.2%, p = not significant), and so was the negative predictive value (98.6% versus 95.7%, p = not significant). Most false negative biopsies (8 of 11, 73 %) occurred in station 7.

CONCLUSIONS

Both methods are safe. More lymph nodes and stations were evaluated by VAM, with trend toward higher negative predictive value. The higher rate of minor complications seen with VAM might be related to a more aggressive and thorough dissection.