Procedimientos quirúrgicos diagnósticos en el síndrome de vena cava superior

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.

[Superior vena cava syndrome caused by multinodular goiter]

Currently, the vena cava superior syndrome (VCSS) is mainly of oncologic origin. We report here four cases of this syndrome caused by intrathoracic multinodular goiter. All patients had compressive symptoms, particularly of the oesophagus and trachea. Axial CT was the imaging technique that delineated the intrathoracic multinodular goiter compressing brachiocephalic vessels. Surgery (total thyroidectomy) was used and all compressive symptoms resolved.

Mediastinoscopy in superior vena cava obstruction: analysis of 80 consecutive patients

BACKGROUND

Prejudices against mediastinoscopy in superior vena cava obstruction still remain. Hereby we analyze risk/benefit balance in a large series of patients.

METHODS

Eighty consecutive patients underwent cervical mediastinoscopy for caval obstruction, 51 after uncertain diagnosis obtained by lesser techniques, 17 after ineffective chemotherapy (n = 9) or radiotherapy (n = 8). In 12 patients we immediately performed mediastinoscopy as an urgent procedure. In addition the examination was combined with left anterior mediastinotomy (n = 7) for staging purposes.

RESULTS

No perioperative mortality was recorded. Five patients had significant bleeding, but only one required sternotomy. Definitive diagnosis was obtained in all patients: 50 lung cancer, 17 lymphoma, 7 invasive thymoma, 3 postradiation fibrosis, 2 metastatic lymph nodes from renal carcinoma, and 1 fibrosing mediastinitis. Specific therapy had excellent effects in 71 patients, negligible in 7, and adverse in 2. Postmediastinoscopy brachial venous pressure had a mean significant decrease (p < 0.0001). Lung cancer was the sole variable significantly associated with unfavorable outcome (p < 0.0004).

CONCLUSIONS

Mediastinoscopy should be routinely included after less invasive procedures in the diagnostic program because it is simple, low risk, and effective.

[Descriptive study of complications caused by mediastinoscopy]

To analyze the surgical and non surgical complications of mediastinoscopy in a series of 200 consecutive patients. Retrospective study of all surgical patients between 1 January 1994 and 1 May 1997. Any complication presenting between time of surgery and patient release is analyzed. Complications were seen in 8 out of 200 cases (4%). In three cases, there were lesions in neighboring structures (recurrent nerve, bronchial artery and innominate artery). The rest were non surgical complications (3 cases of arrhythmia, 2 of prolonged mechanical ventilation). One male patient (0.5%) died from cerebral infarction, probably as a result of arterial occlusion needed to suture damage to the innominate artery. Superior win cava syndrome affected 20% (1 in 5) and morbidity was 60% (3 in 5). Morbidity involving both medical and surgical complications in this series is higher than that reported elsewhere in the literature, in series for which non surgical complications go unreported.