Mediastinoscopy

Complications of mediastinoscopy

From 1968 to 1987, mediastinoscopy was performed on 2021 consecutive patients. The procedure was carried out in 35.7 per cent on patients with a pulmonary infiltrate and in 28.8 per cent with bronchogenic carcinoma. Mediastinoscopy was positive in 54 per cent of the cases. The total number of complications was 2.3 per cent (47/2021). There were four cases with major haemorrhage, three tracheal ruptures and three wound infections. Recurrent nerve paralysis was verified in three patients and pericardial rupture in two patients. The total of major complications was 0.5 per cent (10/2021). There was no deaths in this series. In the authors' opinion, mediastinoscopy can be regarded as an effective and safe procedure in the hands of an experienced surgeon.

Transbronchial lung biopsy through fibreoptic bronchoscope in diagnosis of sarcoidosis

Sarcoidosis was ultimately diagnosed in a consecutive series of 79 patients, of whom 24 presented with unusual features. Histological support for this diagnosis was obtained in 37 out of 42 patients who underwent transbronchial biopsy; epithelioid and giant-cell granulomas were also found on biopsy of the bronchial mucosa in 17 out of 22 patients. Kveim tests were completed in 44 patients: results were positive in 19, equivocal in 11, and negative in 14. In 16 patients histological support was obtained on biopsy of various other tissues. The clinical presentation of the disease and the degree of histological support provided by the various procedures used in reaching a diagnosis of sarcoidosis varied considerably. Transbronchial biopsy of the lung is a useful advance in diagnosing sarcoidosis and provided a higher diagnostic yield than any other method.

Experience with mediastinoscopy

Six hundred and eighty diagnostic mediastinoscopies are presented. Of these, 552 were classical, 114 anterior mediastinal, 12 posterior mediastinal, and 2 from below the sternum. In addition, 20 therapeutic mediastinoscopies were performed for the insertion of a pacemaker electrode or evacuation of a mediastinal cyst.

Of 125 mediastinoscopies performed on patients with an initial diagnosis of sarcoidosis, in most the diagnosis was confirmed, the rate of false negative results being 2·4%.

Extremely encouraging were the results in patients with an initial diagnosis of Hodgkin's disease. Out of 60 patients, a different diagnosis was established in 30 and further follow-up proved this to be correct. In mediastinal tumours the results were discouraging, the rate of false results being as high as 43%.

Four hundred and ten patients were mediastinoscoped for lung cancer. In 52, mediastinoscopy was the first successful biopsy. Metastases to lymph nodes were found in 139 (33·9%). The percentage of exploratory thoracotomies following the introduction of mediastinoscopy fell from 22% to 14%.

Mediastinoscopy was also used to investigate the spread of oesophageal cancer and enabled us to exclude patients who were obviously inoperable.

Mediastinoscopy: a diagnostic procedure in hilar and paratracheal lymphadenopathy

Mediastinoscopy, in the skilled hands of a thoracic surgeon, is a safe, cosmetically accepted procedure with negligible complications, less than that reported in many series of scalene node biopsies.

It has the advantage of yielding a much higher rate of diagnostic tissue, in all instances over 90%. In the cases of tuberculosis it enabled an organism to be isolated and sensitivities obtained.

It has also revealed a group of cases with findings, a further study of which may increase our understanding, assessment and management of patients presenting with hilar and/or paratracheal lymphadenopathy.

Problems in histological interpretation in sarcoidosis

The sarcoid granuloma has a histological structure that is similar to that seen in many other diseases. Some of its diagnostic features are negative, but an accurate diagnosis can be made from biopsy tissues if numerous, monotonously uniform granulomata are present. Histological confidence is often proportional to the number of granulomata seen in the specimen.

Mediastinal lymph nodes taken at mediastinoscopy have been positive in 90% of seventy-four patients with sarcoidosis.

Problems in the histological interpretation of Kveim biopsies may be due to failure to include the injection site in the biopsy, to inadequate sectioning of the specimen and to equivocal cellular reactions. Despite these difficulties, dual blind reading of sections of mediastinal lymph nodes and Kveim reaction biopsies from patients with sarcoidosis has shown that the observer variation that is likely to be of clinical significance is approximately 5% in each group.