Posterior mediastinal extralobar pulmonary sequestration misdiagnosed as a neurogenic tumor:A case report

BACKGROUND Pulmonary sequestration-both intralobar and extralobar-is a rare congenital developmental malformation.Extralobar pulmonary sequestrations(EPS)have their own pleura but are separated from the bronchus and usually occur in the left lung.They are mainly found mainly between the lower lobe and the mediastinum.EPS is rarely found within the mediastinum itself,even rarer so in the posterior mediastinum.CASE SUMMARY We report the case of a 27-year-old man who was misdiagnosed with a neurogenic tumor based on preoperative contrast-enhanced computed tomography(CT)and magnetic resonance imaging findings.Contrast-enhanced chest CT revealed a posterior mediastinal mass measuring 1.2 cm×1.4 cm×3.3 cm,which consisted of some cystic areas and showed slight enhancement.The mass was in the 11th paravertebral region and attached to the 11th thoracic vertebra behind the descending aorta in the posterior mediastinum.An arteriole originating from the intercostal artery and a vein originating directly from the hemiazygos vein were found in the pedicle of the mass.The mass was resected in a uniport videoassisted thoracoscopic surgery.During the operation,the pyramid-shaped mass appeared well-encapsulated.Postoperative histopathology established a diagnosis of EPS.One month later,a follow-up CT of the thorax showed good recovery.CONCLUSION Although EPS rarely occurs in the posterior mediastinum,its diagnosis should be considered when posterior mediastinal tumors are suspected.

Comparison between different reconstruction routes in esophageal squamous cell carcinoma

AIM:To compare postoperative complications and prognosis of esophageal squamous cell carcinoma patients treated with different routes of reconstruction. METHODS:After obtaining approval from the Medical Ethics Committee of the Sun Yat-Sen University Cancer Center, we retrospectively reviewed data from 306 consecutive patients with histologically diagnosed esophageal squamous cell carcinoma who were treated between 2001 and 2011. All patients underwent radical McKeown-type esophagectomy with at least two-field lymphadenectomy. Regular follow-up was performed in our outpatient department. Postoperative complica-tions and long-term survival were analyzed by treatment modality, baseline patient characteristics, and operative procedure. Data from patients treated via the retrosternal and posterior mediastinal routes were compared. RESULTS:The posterior mediastinal and retrosternal reconstruction routes were employed in 120 and 186 patients, respectively. Pulmonary complications were the most common complications experienced during the postoperative period (46.1% of all patients; 141/306). Compared to the retrosternal route, the posterior mediastinal reconstruction route was associated with a lower incidence of anastomotic stricture (15.8% vs 27.4%, P = 0.018) and less surgical bleeding (242.8 ± 114.2 mL vs 308.2 ± 168.4 mL, P < 0.001). The median survival time was 26.8 mo (range:1.6-116.1 mo). Upon uni/multivariate analysis, a lower preoperative albumin level (P = 0.009) and a more advanced pathological stage (pT; P = 0.006; pN; P < 0.001) were identified as independent factors predicting poor prognosis. The reconstruction route did not influence prognosis (P = 0.477). CONCLUSION:The posterior mediastinal route of reconstruction reduces incidence of postoperative complications but does not affect survival. This route is recommended for resectable esophageal squamous cell carcinoma.

Distal gastric tube resection with vascular preservation for gastric tube cancer:A case report and review of literature

BACKGROUND Survival rates in patients with esophageal cancer undergoing esophagectomy have improved,but the prevalence of gastric tube cancer(GTC)has also increased.Total resection of the gastric tube with lymph node dissection is considered a radical treatment,but GTC surgery is more invasive and involves a higher risk of severe complications or death,particularly in elderly patients.CASE SUMMARY We report an elderly patient with early GTC that had invaded the duodenum who was successfully treated with resection of the distal gastric tube and Roux-en-Y(R-Y)reconstruction.The tumor was a type 0-IIc lesion with ulcer scars surrounding the pyloric ring.Endoscopic submucosal resection was not indicated because the primary lesion was submucosally invasive,was undifferentiated type,surrounded the pyloric ring,and had invaded the duodenum.Resection of distal gastric tube with R-Y reconstruction was safely performed,with preservation of the right gastroepiploic artery(RGEA)and right gastric artery(RGA).CONCLUSION Distal resection of the gastric tube with preservation of the RGEA and RGA is a good treatment option for elderly patients with cT1bN0 GTC in the lower part of the gastric tube.

Robotic Surgery of the Mediastinum: A Review

Background: The mediastinum is a complex anatomical region which contains many vital structures. Many aspects of mediastinal surgery, like that for other anatomic regions, have evolved from a maximally invasive approach involving a median sternotomy, anterior mediastinotomy, mediastinoscopy or thoracotomy, to a minimally invasive video-assisted approach. Robotic surgery is presently the most advanced form of minimally invasive surgery. Methods: We reviewed our experience with a robotic approach to mediastinal pathology. In addition, an extensive search was conducted using PubMed, in order to extract references for the application of robotics to surgical conditions of the mediastinum. Results: The first robotic procedure by our group was a mediastinal procedure in 2003. In the past eighteen years, 203 patients have undergone robotic surgery for mediastinal pathology. There were 119 procedures for the Anterior Mediastinum, 33 procedures for the Middle Mediastinum, and 51 procedures for the Posterior Mediastinum. 78 patients underwent robotic thymectomy using a left-sided approach. 43/78 (55%) patients underwent radical thymectomy for Myasthenia Gravis. Thymoma was histologically identified in 32% of patients with Myasthenia Gravis. In patients with thymoma, there was no tumor recurrence. In patients with Myasthenia Gravis, the overall improvement rate after robotic radical complete thymectomy was 91% (39/43). Following robotic surgery for the mediastinal disease, the median hospitalization was 3 days, major complications occurred in 0.9% of patients and there was no mortality. Conclusion: With the advent of robotic surgery, many of the current surgical approaches to diseases of the mediastinum will likely be replaced over time by robotic surgery. When applied to the mediastinum, robotics has a number of benefits when compared to conventional Video-Assisted Thoracic Surgery (VATS) including three-dimensional visualization, magnification of the operative field, precise instrument movement, and improved dexterity. Much of the mediastinal disease encountered in an adult is benign, making it especially suited to a minimally invasive approach. With the use of the robot, a complete anatomical and oncological procedure can be performed through a number of small incisions or ports, while at the same time providing the patient with minimally invasive benefits including shorter hospitalizations, quicker returns to preoperative activity, less pain, less inflammatory response and better cosmesis. The excellent range of motion of the robotic instruments makes them particularly suitable to maneuver around the vital structures and the rigid axial skeleton encountered in various compartments of the mediastinum, and for reaching those “distant” areas of the mediastinum that are difficult to explore and dissect with conventional Video-Assisted Thoracic Surgery (VATS).

Treatment of thoracic hemorrhage due to rupture of traumatic mediastinal hematoma

Patients in traffic accidents are usually presented with pain and bleeding due to fractures or soft tissue injury. On some occasions, more severe complications may be triggered by the trauma. A review of the published English language literature reveals no survival case once the traumatic mediastinal hematoma is ruptured. In our case, a 54-year-old man suffering motorcycle accident was admitted to emergency department. Computed tomography scan revealed subdural hematoma combined with posterior medi- astinal hematoma. The patient was saved and discharged with a satisfactory outcome, Here we hope to share our treatment experience in dealing with the patient with severe multiple trauma.