Heterotopic mediastinal goitre

The unusual coexistence in a woman of 34 years of a cervical thyroid and a heterotopic mediastinal thyroid is recorded. Both thyroids had undergone non-toxic nodular enlargement. Recurrent enlargement was noted in the cervical gland 12 months after transpleural thoracic removal of the mediastinal goitre, whilst no corresponding change has so far been noted in the mediastinum. The literature on heterotopic thyroid is briefly reviewed and the diagnosis discussed.     

Endothoracic goitre: anatomoclinical and therapeutic considerations

Substernal goitre is a clinical condition in which the masin bulk of the enlarged gland is firmly located in the chest. The incidence of this pathology ranges in literature from 1.7% and 30%. This study examines 230 cases of substernal goitre out of a total 5.362 operations performed from 1965 to 2000, for thyroid gland pathologies (4.36%). According to their experience the Authors propose a classification based on the anatomical location of the goitre: right, left, anterior and posterior goitre are therefore identified. The surgical procedures performed include 136 subtotal thyroidectomies (59.1%), 59 emithyroidectomies (25.7%) and 23 total thyroidectomies (10%). In 12 cases the operation was confined to removal of the mediastinal mass (5.2%). The cervical approach was the only surgical access route used in all the patients, regardless of the different anatomical variants. Appreciable venous stasis, due to the mediastinal mechanical obstruction exerted by the goitre, was always evident at the operation. In order to limit the risk of bleeding during operation, careful hemostasis of the major vascular pedicles must be performed. Any attempt to legate the smallest vessel, should be avoided since it is a difficult, useless and time-consuming procedure. Minor bleeds promptly stop as soon as the pathological mass is removed. Ligation of the vascular pedicles can be easily achieved; in this way, the goitre is freed from its anatomical connections and the surgeon can safely manage the substernal portion of the mass. The mortality reported in this study was 0.43% (one patient died 30 days postoperatively due to respiratory complications), whereas the morbidity rate was 2.6%.     

Lymph flow and lymph node metastasis in esophageal cancer

This paper delineates which lymph nodes should be dissected due to the high frequency of metastasis associated with different types of primary lesions of the thoracic esophagus. In cancer involving the upper third of the esophagus (Iu), lymph flow was found to be primarily from the superior mediastinal area to the cervical area; in that involving the middle third (Im), it was broadly distributed from the superior, middle, and inferior mediastinal region to the cervical and abdominal regions; and in that involving the lower third (Ei), it tended to extend from the inferior mediastinal region to the abdominal region, with single primary metastatic nodes also being noted in this area. The significance of the top nodes, namely, the nodes located along the right recurrent laryngeal nerve in the upper portion of the thorax, was also investigated, and it was confirmed that the prognosis for patients with metastases to both the top nodes and other nodes was unfavorable. An immunohistochemical study on mediastinal lymph flow using the anti-Su-Ps antibody demonstrated interactions between top nodes and cervical and/or thoracic nodes.Part of this paper was presented at the UICC Kyoto International Symposium on Recent Advances in Management of Digestive Cancers held in Kyoto, Japan, in April 1993.     

A difficult case of mediastinal parathyroid adenoma: theoretical and clinical considerations

About one quarter of patients with primary hyperparathyroidism have ectopic parathyroid tissue. The majority of parathyroid glands can be reached through a cervical approach, but in about 2% of the cases the ectopic gland is in the mediastinum in a location that requires a thoracic approach. Failure to remove ectopic mediastinal parathyroid tissue results in persistent hyperparathyroidism. Reoperative exploration for persistent hyperparathyroidism is often difficult even in the hands of experienced surgeons. Recent advances in preoperative localization techniques and intraoperative parathyroid hormone measurement have improved the rates of successful resection. We present a difficult case of persistent hyperparathyroidism secondary to an ectopic middle mediastinal parathyroid adenoma, which was eventually successfully managed in a specialised unit.     

Embolic brain infarction: a rare complication of thoracic outlet syndrome. A report of two cases

The thoracic outlet syndrome is known to cause brachial neuropathy. Pressure on the subclavian artery causing post-stenotic dilatation with intraluminal thrombosis is not a common complication. This may lead to antegrade embolisation and ischemic changes in the upper limb. In right sided thoracic outlet syndrome the thrombus may extend retrogradely. From this an embolus may detach to the right hemisphere of the brain resulting in left sided hemiplegia. This is a rare but serious complication from a neglected, relatively benign, curable condition. This report describes two cases of a right sided thoracic outlet syndrome due to cervical rib compression with retrograde embolisation.     

Thoracoscopic resection of ectopic parathyroid glands

BACKGROUND: The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach. METHODS: We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure. RESULTS: All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication. CONCLUSIONS: Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.     

Association of the Primary Tumor Location with the Site of Tumor Recurrence after Curative Resection of Thoracic Esophageal Carcinoma

The site of surgical failure in cases of thoracic esophageal cancer (TEC) may be affected by the vertical location of the cancer in this longitudinal organ, suggesting the need to select the mode of adjuvant therapy based on location. We classified 501 TECs (92% squamous cell carcinomas) that underwent curative surgery without preoperative treatment as 13% upper thoracic (Ut), 51% middle thoracic (Mt), and 36% lower thoracic (Lt) lesions. Recurrent disease was discovered in 180 (36%) of the patients during a postoperative survey, most frequently in the cervical nodes (19%), liver (18%), abdominal paraaortic nodes (17%), and upper mediastinal nodes (17%). Although postoperative survival rates were similar (5-year survival: Ut 51%, Mt 55%, Lt 54%), the tumor recurrence site was significantly affected by the TEC vertical location, with recurrence in the cervical and upper mediastinal nodes being most frequent for Ut and Mt cases and in the liver and abdominal paraaortic nodes for Lt cases. Insufficient surgical lymph node clearance could be assessed by the recurrence index (RI), defined as the frequency of metastasis at recurrence divided by that at surgery. The RI was significantly lower for the upper abdominal nodes (4%, 8/184) than the lower mediastinal nodes (15%, 19/123) or the upper mediastinal nodes (19%, 30/154). These findings indicated that regional tumor recurrence, corresponding to the surgical field, was more frequent in the Ut and Mt cases (53% and 51%) than the Lt cases (18%); and distant recurrence was more frequent in the Lt cases (62%) than in Ut or Mt cases (25% and 36%). Thus the vertical location of the thoracic esophageal cancer can be said to affected strongly the site of tumor recurrence after curative surgery. Regional radiotherapy might be expected to have an adjuvant effect on Ut/Mt tumors and systemic chemotherapy on Lt tumors.     

选择性颈胸腹三野淋巴结清扫治疗胸段食管鳞癌

目的 研究胸段食管鳞癌的淋巴结转移规律，探讨合适的淋巴结清扫范围。方法 87例接受食管次全切除术的胸段食管鳞癌患者，根据术前食管腔内超声和颈部超声检查结果，选择性进行胸腹二野或颈胸腹三野淋巴结清扫。结果 超声发现颈部淋巴结肿大并行三野清扫35例（40．2％，三野清扫组），其中原发肿瘤位于胸上段食管者的比例（16／24例，66．7％）显著高于中、下段肿瘤者（19／63例，30．2％）（P=0．002）。三野清扫术扫除淋巴结13．7组／例，显著多于二野清扫组（52例，59．8％）的10．5组／例（P〈0．001）。术后病理检测三野清扫组转移淋巴结1．5组／例，也显著多于二野清扫组的0．8组／例（P〈0．01）。颈淋巴结转移（pM1-LN）17例（占全组19．5％，占三野清扫组48．6％），有区域淋巴结转移者的颈淋巴结转移比例（15／48例，31．3％）显著高于无区域淋巴结转移者（2／39例，5．1％）（P〈0．01）。上、中、下纵隔及上腹部的淋巴结转移率分别为25．3％、23．O％、5．7％和24．1％，颈淋巴结转移与上纵隔（P〈0．01）及中纵隔（P〈0．01）淋巴结转移显著相关，但与下纵隔及上腹部淋巴结转移无关。三野清扫组术后并发症发生率（60．0％）显著高于二野清扫组（34．6％，P=0．020）。喉返神经损伤发生率两组差异无统计学意义（P〉0．05）；但喉返神经损伤者吻合口瘘发生率（7／13例，53．8％）显著高于无喉返神经损伤者（10／74例，13．5％，P=0．001）。术后死亡率两组差异无统计学意义（P〉0．05）。结论 应对肿瘤位于胸上段食管、或上纵隔及中纵隔淋巴结已发生转移的食管癌患者在超声指导下进行选择性颈胸腹三野淋巴结清扫术，以降低手术风险、提高手术根治效果。     

Thoracic outlet syndrome in whiplash injury.

Thirty-five cases of thoracic outlet syndrome complicating whiplash or cervical strain injury were studied. Thirty cases had confirmation by the demonstration of slowed ulnar nerve conduction velocity (UNCV) through the thoracic outlet. Two distinct groups of patients were found. An acute group, seen an average of 3 1/2 months post injury, had severe neck pain with often mild or incidental thoracic outlet syndrome. A chronic group, with symptoms persisting more than 2 years after cervical injury, often had thoracic outlet symptoms as the predominant complaint. This study suggests that the arm aches and parethesias seen in association with both acute and chronic cervical strain injury are most often secondary to thoracic outlet syndrome.     

胸段食管癌颈部及上纵隔淋巴结转移

探讨胸段食管癌颈部及上纵隔淋结转移规律。方法采用颈,胸,腹三切口施行胸段食管癌手术６１６例,同时施行三区域淋巴洁清扫。结果：中及上纵隔淋巴结转移率和转移度分别为５７．１％和２１．５％。结论胸段食管癌必须重颈部及上纵隔淋巴结清扫。     

Mediastinal goitres: when the transthoracic approach?

The correct surgical approach to mediastinal goitre is not always well defined. We reviewed why and when our patients required a transthoracic approach. From 1979 to 1998, on 7.480 patients who underwent thyroid surgery in our hospital, 374 (5%) had a goitre whose greater bulk was inferior to the thoracic inlet; 43 patients of these last ones (11%) required a transthoracic approach. General anaesthesia was performed in all patients and orotracheal intubation was selective in 11 cases (double lumen tube of Carlens). In 34 cases, the first approach was a cervicotomy, followed by sternotomy in 23 cases or right posterolateral thoracotomy in 11 cases. Three patients underwent a sternotomy and 6 a thoracotomy only. We had neither perioperative mortality nor major complications. The mean hospital stay was 5 days. Mean goitre weight was 430 g and on average the greater diameter was 13 centimetres. The removal of a substernal goitre can be difficult and risky via the cervicotomy only. A transthoracic approach is often required in the case of greater secondary, primary and recurrent mediastinal goitres.     

Collateral Artery Aneurysm: A Unique Presentation of Thoracic Outlet Syndrome

Aneurysms of collateral arteries are unusual. A case of transverse cervical artery aneurysm as the sole presentation of vascular thoracic outlet syndrome is presented and the relevant literature reviewed.     

Thoracoscopic partial thymectomy for untraceable mediastinal parathyroid adenomas

Despite accurate preoperative imaging, ectopic mediastinal parathyroid adenomas can be difficult to find via a thoracic approach. Considering that - in most cases - these adenomas are intrathymic, it can be advisable to directly perform a partial thymectomy. We present the cases of three patients who were successfully cured using a thoracoscopic partial thymectomy.     

Cervicotomy using a hemi-clamshell approach for a rare enlarged substernal goitre

The substernal goitre is defined as a goitre for which >50% of the mass is located below the superior orifice of the thorax, surgical resection remains the reference treatment, the approach used is the cervicotomy, which often allows to extract the mediastinal portion of the plunging goitre, and we report a rare case of a huge cancerous plunging goitre whose complete resection required the enlargement of the cervicotomy in right hemi-clamshell, for the carcinological, vascular and recurrent control.     

胸廓出口综合征的诊疗体会

目的探讨胸廓出口综合征(TOS)的诊断和手术治疗。方法我院自1997-2003年诊断和手术治疗胸廓出口综合征23例24侧，诊断为臂丛上千型TOS2例，下千型17例18侧，全臂丛型1例，血管型2例，混合型1例。手术切除颈肋及过长的横突，同时作臂丛神经外膜松解术。术中发现23例有纤维束带压迫臂丛神经，均切断前斜角肌，松解臂丛神经及受压的锁骨下血管，如果发现中、小斜角肌压迫臂丛神经血管，则予切断。术后当天行颈肩部活动。结果按Ross的疗效评定标准评定疗效，本组优10例11例，良9例，可2例，差2例，优良率83.33％。结论胸廓出口综合征应早期手术探查，彻底松解臂丛神经血管。     

切断前中小斜角肌治疗胸廓出口综合征的远期疗效

目的 远期随访切断前中斜角肌治疗胸廓出口综合征（thoracic outlet syndrome，TOS）的疗效。方法对31例32侧胸廓出口综合征患者术后的疗效作远期随访。其中上干型4例，下干型26例27侧，全臂丛型1例。X线片示颈肋1例。第七颈椎横突过长2例。均行手术治疗。术中发现31例均有纤维束带压迫臂丛神经，作前、中、小前斜角肌切断术；3例骨异常者同时切除增长的骨组织和颈肋。术后随访4年8个月-8年3个月．平均为5年4个月。以症状、体征有无复发以及是否恢复原工作为随访主要观察项目。疗效按胸廓出口综合征评定标准评定。结果 术后症状明显改善15例16侧，部分改善6例，无效10例。优良率为68．7％。结论 该组病例远期疗效的优良率为68．7％，因此，胸廓出口综合征的治疗方法仍是个有待于进一步研究的临床课题。     

Robotic thoracoscopic mediastinal parathyroidectomy for persistent hyperparathyroidism: case report and review of the literature

Recurrent and persistent primary hyperparathyroidism remains a significant surgical challenge. Abnormal, hypersecreting parathyroid glands are found in ectopic locations in up to 15% to 20% of patients. A small portion of these ectopic glands will be found in the mediastinum at a location that precludes removal through the traditional cervical incision. Minimally invasive approaches to these glands are desirable because of the significant morbidity, pain, and hospital stay associated with sternotomy or thoracotomy. Recently, robotic approaches have been described for mediastinal parathyroids. We report a case of young woman with persistent primary hyperparathyroidism who was cured after undergoing robotic thoracoscopic mediastinal parathyroidectomy using radiooperative and intraoperative parathyroid hormone guidance.     

Efficacy of extended radical operation based on preoperative staging

From 1985 to 1988, we have resected 203 cases of the thoracic esophageal cancer with right thoracotomy. Those 203 cases were classified as R3 (bilateral cervical, thoracic and abdominal node dissection), R2 + alpha (left cervical, thoracic and abdominal nodes dissection) and R2 (thoracic and abdominal node dissection) based on preoperative staging. The background of R3 mainly contained Iu cases, advanced cases, positive cases of upper mediastinal metastasis, and that of R2 mostly contained high aged and risk cases, though this group showed low LN metastasis. The incidence of postoperative complications were higher R3 greater than R2 greater than R2 + alpha in order. Pneumonia had no relationship to neck dissection. Recurrent nerve palsy was recognized in R3 group about 16%. Operative mortality mostly belong to high aged group over 70 y.or., noncurative cases and R3 group. The survival rate of C greater than 0 resected cases with right thoracotomy after 1985 showed some improvement compared with the cases of standard R2 dissection by right thoracotomy from 1980-1984. It showed no difference of the curative survival curve among R3, R2 + alpha and R2 groups. Thus, it is effective to improve the survival rate of resected esophageal cancer with our indication based on preoperative staging.     

Mediastinalemphysem als Folge einer einfachen Mittelgesichtsfraktur

Mediastinal emphysema is usually seen in cases of blunt thoracic trauma or cervical injury accompanied by tracheobronchial or esophageal perforation. Characteristic of this injury is severe retrosternal pain. We present the case of a man with extensive mediastinal and cervical emphysema caused by a simple midfacial fracture and accompanied by no symptoms.