The efficacy of cervical mediastinotomy in children

Jochen Hubertus; Wolfram Hirsch; Ulrich Burkhardt; Dieter Korholz; Carlos A Reck; Ralf-Bodo Trobs

doi:10.4103/0971-9261.34949

Journal of Indian Association of Pediatric Surgeons

Official journal of the Indian Association of Pediatric Surgeons

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ORIGINAL ARTICLE

Year : 2007 \| Volume : 12 \| Issue : 3 \| Page : 125-128

The efficacy of cervical mediastinotomy in children

Jochen Hubertus¹, Wolfram Hirsch², Ulrich Burkhardt³, Dieter Korholz⁴, Carlos A Reck⁵, Ralf-Bodo Trobs¹
¹ Department of Pediatric Surgery, University of Leipzig, Medical Center, Leipzig, Germany
² Department of Pediatric Radiology, University of Leipzig, Medical Center, Leipzig, Germany
³ Department of Anesthesiology, University of Leipzig, Medical Center, Leipzig, Germany
⁴ Department of Pediatric Hematology and Oncology, University of Leipzig, Medical Center, Leipzig, Germany
⁵ University San Francisco of Quito, Ecuador

Correspondence Address:
Jochen Hubertus
Department of Pediatric Surgery, University of Leipzig
Germany

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0971-9261.34949

Abstract

Objective: To report our experiences with surgical diagnostic procedures in patients with mediastinal pathologies. Materials and Methods: From 1995 to 2004, seven children with mediastinal pathology had seven surgical procedures for the purpose of histological tissue diagnosis. Of these seven patients, five were male and the average age was 11 years. Anterior mediastinotomy was performed in all patients. Results: Tissue diagnosis was achieved in all cases, enabling a specific diagnosis. The diagnoses were lymphoblastic lymphoma ( n = 1), Hodgkin disease ( n = 1) and thymus hyperplasia ( n = 5). There was no operation-related mortality although one patient required a postoperative blood transfusion. Conclusion: Anterior mediastinotomy is a safe surgical procedure, which can be performed quickly in children with a high diagnostic yield.

Keywords: Cervical anterior mediastinotomy, hyperplastic thymus, lymphoma, mediastinal mass

How to cite this article:
Hubertus J, Hirsch W, Burkhardt U, Korholz D, Reck CA, Trobs RB. The efficacy of cervical mediastinotomy in children. J Indian Assoc Pediatr Surg 2007;12:125-8

How to cite this URL:
Hubertus J, Hirsch W, Burkhardt U, Korholz D, Reck CA, Trobs RB. The efficacy of cervical mediastinotomy in children. J Indian Assoc Pediatr Surg [serial online] 2007 [cited 2023 Dec 10];12:125-8. Available from: https://www.jiaps.com/text.asp?2007/12/3/125/34949

Introduction

Anterior mediastinotomy has become widely used in adult patients to evaluate mediastinal masses, however, there is limited experience with this procedure in pediatric patients. Inspite of modern imaging techniques, the nature of mediastinal masses usually cannot be exactly determined. To get a definitive diagnosis, biopsy is essential. There are different surgical approaches to access mediastinal structures including video-assisted thoracic surgery, mediastinoscopy and sternotomy. We reviewed our experience and assessed the diagnostic efficacy as well as associated morbidity of cervical mediastinotomy.

Materials and Methods

Five pediatric patients with suspicious intrathoracic masses were referred for biopsy over a period of nine years (1995-2004). Two more pediatric patients with known hematologic neoplasias underwent collar mediastinotomy for tumor staging [Table - 1]. Five of these seven children were male; ages ranged between six months and 17 years (mean = 11 years). In five cases, the tumors were located in the anterior mediastinum while they affected the parahilar mediastinum in the remaining two cases. The most frequent symptoms were cough ( n = 3) and recurrent pulmonary infections ( n = 4). Other symptoms included weight loss ( n = 2), fever ( n = 2), dyspnea ( n = 1) and dysphagia ( n = 1) [Table - 2]. All patients were initially evaluated with standard laboratory tests, chest X-ray and computed tomography (CT) scan of the thorax. Bronchoscopy performed in two patients revealed thymus hyperplasia. Furthermore, the diagnostic work-up of patients with hematopoetic diseases included imaging of the abdomen and ultrasound of the neck.

Surgical technique

The anatomic basis for cervical mediastinotomy is the existence of a cervico-mediastinal fascial continuity. There are two clearly defined and mutually exclusive mediastinal planes distinct from each other but both accessible through the same suprasternal notch incision [Figure - 1]. The usual anatomic zone is the upper or superior part of the visceral mediastinal compartment. It is entered after carrying the cervical incision down to the anterior surface of the trachea after retracting the sternohyoid and sternothyroid muscles and dissecting the paratracheal layer of the deep fascia properly. This retrovascular plane is entered by finger dissection passing first behind the innominate artery and aortic arch, then down to below the level of the carina and along both sides of the trachea and main bronchi for about 2 cm.

Available for biopsy are lymph nodes as well as paratracheal tumors and cysts. Also accessible through the same cervical incision is the superior part of the mediastinal compartment. This more superficial prevascular plane is located anterior to the great vessels and behind the manubrium. Here, just below the strap muscles, one can find the cervical cornua of the thymus. By following the cornua down, hugging the undersurface of the manubrium, the digital dissection proceeds anterior to the left innominate vein and aortic arch. Available for biopsy here are the thymus gland and lymph nodes as well as other anterior mediastinal tumors and cysts [Figure - 2]. It is this exposure that allows for transcervical thymectomy.^[1]

Case Reports

Case 1

An 11 year-old girl was referred to our department with a mediastinal mass of unknown nature. Some weeks before, she had complained of dysphagia and associated pain. There was no previous history of illness or trauma. On admission, physical examination showed no significant findings. Standard laboratory tests, ultrasound of the neck and esophagogastroscopy did not show any pathological findings. CT scan of the neck and thorax revealed a mass of 5 x 6 cm size in the anterior upper mediastinum [Figure - 3].

Operation was performed for tissue biopsy. Intraoperatively, a persistent thymus with a hyperplastic left lobe was assumed and a partial resection of the hyperplastic, yellow-greyish tissue was realized without any surgical complications.

During the first postoperative day, slight dysphagia was present which resolved the next day. The patient recovered uneventfully. She was discharged home on the first postoperative day.

Histological examination revealed a persistent enlarged tissue of thymus of benign character.

Three years later, the patient was a healthy young girl without any persisting pathology.

Case 2

A 15 year-old boy consulted a general practitioner due to complaints of cough, pulmonary infection of three weeks' duration and weight loss of four kilograms in the last few months. There was no history of thoracic trauma and past medical history was unremarkable. Conservative therapy for an assumed upper airway infection was prescribed without results. Therefore, the patient was referred to the department of pediatrics.

X-ray of the thorax disclosed an upper left mediastinal mass, which was verified by a CT scan [Figure - 4],[Figure - 5]. Ultrasound of the neck and abdomen showed a tumour of 2 cm size within the spleen. Otorhinolaryngology (ORL) examination revealed a labyrinthine hypoacusia.

Suspected diagnosis was of Hodgkin's disease and mediastinotomy was performed for histological confirmation and tumor staging.

Biopsy of perihilar lymph nodes was performed without any side effects. The patient was discharged during the first postoperative day and referred to the pediatric oncologists. Histological examination confirmed the diagnosis of a T-cell-lymphoma, type IIIb.

Chemotherapy (Protocol GPOH-HD 2002) was initiated immediately followed by radiation. After complete remission, the patient suffered an early relapse necessitating high-dose chemotherapy with autologous stem cell transplantation. To date, he is in complete remission for 1.5 years.

Results

A clear diagnosis was achieved in all patients. Histology revealed Hodgkin's disease ( n = 1), T-cell-lymphoma ( n = 1) and thymus hyperplasia ( n = 5). All the procedures were performed as elective operations. The mean operation time calculated from skin incision to the end of suture, was 100 min with a range from 55 min to 165 min, independent from diagnosis or location. There was no operation-related mortality. However, there was one intraoperative, relevant blood loss requiring a blood transfusion after biopsy of a hyperplasic thymus. Wound drainage was applied in four cases and was removed on the first or second postoperative day.

Discussion

Since the introduction of collar mediastinoscopy in the year 1959 by Carlens,^[2] this procedure was established as a diagnostic and therapeutically tool for lung carcinoma. Specialized centers achieve more than 100 interventions per year.^[3],[4],[5] In addition to lung carcinoma considered to be the most important entity in older patients, lymphomas dominate in younger people.^[5] Other neoplasias such as teratomas, yolk sac tumors, thymomas, neuroblastomas and metastases together with infectious causes such as tuberculosis should be considered in the differential diagnosis. Mediastinal disease is rare in childhood and is usually benign. Thymus hyperplasia is the most common entity found especially during the first few years of life.^[6] There have been some more recent studies on mediastinal tumors, performed on 100 pediatric patients. The periods of patient recruitments range from 15 to 30 years in selected individual institutions.^[7],[8] These are somewhat higher case numbers than the ones encountered in our Department of Pediatric Surgery. At our institution, seven patients underwent an anterior medistinotomy in nine years. Anterior mediastinotomy is characterized by a high diagnostic accuracy with a definite histological diagnosis being established in all cases. Results of studies in adult surgical populations as well as those of the pediatric surgery group achieved a high accuracy ranging from 98 to 100% with a small complication rate. Of the seven patients examined, only one child had to receive a blood transfusion because of intraoperative bleeding. Complications such as pneumothorax, mediastinitis, injuries of large vessels, trachea or esophagus were not observed in our patients. A substantial difference in comparison to adult surgery is shown in the duration of the surgical procedure. Whereas the average operation time in this study was 100 min, this intervention takes approximately 40 min in adults.^[3] A substantial factor for this difference is considered to be due to the larger number of cases with associated higher grade of routine.Two other procedures are available for invasive diagnosis of mediastinal pathologies.^[9] Parasternal mediastinotomy and the more commonly performed video-assisted thoracic surgery. Whereas the results of large studies related to the efficacy, morbidity and operation time of the procedures do not aid much in differentiation, the substantial desicion criteria for the several interventions is the localization of the desired structures.^[3] Thus, anterior mediastinotomy worked for the clarification of upper retrosternal structures. Parasternal mediastinotomy gives favorable results in case of paratracheal and infracarinal localizations as well. Pathologies in the posterior, posterior infracarinal and in the aorto-pulmonary windows were well attainable with video-assisted thoracic surgery. These individual procedures are to be regarded not as competing but complementary alternatives. Histological diagnosis in mediastinal masses should only be sought if diagnosis cannot be made using less invasive measurements. The findings of this study confirm that anterior mediastinotomy is an effective and safe procedure of high efficiency and low morbidity in infants also.

References

1.	Shields TW, Locicero J 3^rd . Cervical substernal "extended" medistinoscopy. General thoracic surgery. 6^th ed. Lipp Will Wilk 2004;2:2445-8.
2.	Carlens E. Mediastinoscopy: A method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959;36:343-7. [PUBMED] [FULLTEXT]
3.	Furrer M, Striffeler H, Ris HB. Invasive diagnosis of mediastinal space-occupying lesions. On differential indications between cervical mediastinoscopy, parasternal mediastinotomy and video thoracoscopy. Chirurg 1995;66:1203-9.
4.	Kim K, Rice TW, Murthy SC, DeCamp MM, Pierce CD, Karchmer DP, et al . Combined bronchoscopy, mediastinoscopy and thoracotomy for lung cancer: Who benefits? J Thorac Cardiovasc Surg 2004;127:850-6. [PUBMED] [FULLTEXT]
5.	Watanabe M, Takagi K, Aoki T, Ozeki Y, Tanaka S, Kobayashi H, et al . A comparison of biopsy through a parasternal anterior mediastinotomy under local anesthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors. Surg Today 1998;28:1022-6. [PUBMED] [FULLTEXT]
6.	Schück R, Galewski D. Operative Eingriffe am Thymus bei Kindern und Jugendlichen Z Kinderchir 1988;43:239-42.
7.	Kuleva SA, Kolygin BA. Malignant mediastinal neoplasms in children. Vestn Khir Im II Grek 2003;162:46-8.
8.	Sawicz-Birkowska K, Czernik J, Chrzan R, Kolodziej J. Mediastinal tumors in children. Pol Merkur Lekarski 2002;13:305-7.
9.	Rendina EA, Venuta F, De Giacomo T, Ciriaco PP, Pescarmona EO, Francioni F, et al . Comparative merits of thoracoscopy, mediastinoscopy and mediastionotomy for mediastinal biopsy. Ann Thorac Surg 1994;57:992-5. [PUBMED]