The surgical approach for cervicothoracic masses in children

BackgroundThe surgical approach to masses located in the cervicothoracic juncton represents a challenge for surgeons. Many techniques have been described with good results.MethodsWe analyzed and compared the results obtained in 2 Italian pediatric surgery centers using 2 different techniques in patients with tumors of the thoracic inlet: center 1, using anterior cervical transsternal approach on 7 patients, and center 2, applying “trap-door” technique on 5 patients.ResultsExcision was incomplete in 5 patients and complete in 7 patients. Histologic examination revealed 5 patients with neuroblastoma; 3, ganglioneuroblastoma; 1, mixoid liposarcoma; 1, desmoid fibromatosis; 1, Castleman disease; and 1, Schwann cell tumor. The median duration of the procedure was 345 minutes in center 1 and 245 minutes in center 2. The median blood loss was 200 mL in both centers. The median hospital stay was 11 days in center 1 and 9 days in center 2. Globally, 5 patients developed postoperative complications. No significant differences were encountered comparing the main surgical outcome parameters between the 2 approaches.ConclusionsBoth techniques resulted in valid options to achieve a safe excision of thoracic inlet masses with a manageable complication rate and acceptable hospital stay. Surgical risk factors should be carefully investigated preoperatively. Postoperative pain control is important to guarantee early recovery.     

Cervicothoracic neuroblastoma arising from the stellate ganglion in children: the use of muscle and bone sparing transmanubrial transcostal approach

Cervicothoracic neuroblastoma arising from the stellate ganglion in children has always been a challenge to the pediatric surgeon. Localized thoracic neuroblastoma in children has a very good prognosis if excised completely even without adjuvant therapy. Several approaches have been described to resect cervicothoracic neuroblastoma arising from the stellate ganglion with limited success. The muscle and bone sparing transmanubrial transcostal approach which spares the clavicle and the sternomastoid muscle provides excellent exposure for the complete excision of the tumor and excellent functional outcome. We report a 2-year-old girl with cervicothoracic neuroblastoma who had an excellent outcome with this approach.     

Aortopulmonary window: a new operative approach

A new method for surgical closure of an aortopulmonary window is presented.     

Mini-open anterior approach to the cervicothoracic junction: a cadaveric study

Purpose

To investigate the feasibility of mini-open anterior approach to the cervicothoracic junction (CTJ) in cadaveric specimens.

Methods

Four adult fresh-frozen cadaveric specimens were used for this study. On the cadaveric specimen, an osteotomy window was made in manubrium sterni to remove the bony obstacle. To bypass the vital vascular and neural structures over the operative field, we used the surgical corridor which was located medially by the brachiocephalic artery and laterally by the right brachiocephalic vein, or in combination with another surgical corridor between the ascending aorta and the superior vena cava. And we used a special self-retaining retractor system and an endoscope to facilitate the procedures.

Results

Surgical procedures performed on the four fresh-frozen cadaveric specimens to expose the CTJ through mini-open anterior approach were successful. The anterior surface of C6–T5 could be exposed, allowing complete decompression and application of locking plate and screws. The most caudal accessible vertebral body was T5 vertebral body in our study.

Conclusion

It is feasible to expose the CTJ through this mini-open anterior approach.     

A surgical approach to the cervicothoracic spine

We describe a method for approaching the lower cervical and upper thoracic spine, the brachial plexus and related vessels. The method involves the elevation of the medial corner of the manubrium, the sternoclavicular joint, and the medial half of the clavicle on a pedicle of the sternomastoid muscle. We have used this exposure in 17 cases with few complications and good results. Its successful performance requires high standards of anaesthesia, surgical technique and postoperative care.     

Optimal exposure of thoracic inlet vascular structures: transmanubrial approach

Exposure of the neurovascular structures of the thoracic inlet is limited by the bony thorax and clavicle. A cervicothoracic approach with resection of the medial one third of the clavicle or total claviculectomy provide excellent exposure but may render the patient with a significant cosmetic and functional defect. We describe a transmanubrial approach that preserves rigid fixation of the shoulder girdle and allows full access to the thoracic inlet. This technique is straightforward and may be easily modified to fit the particular needs of the patient, including access to the proximal brachiocephalic vessels, the hilum of the lung and the vertebral bodies of the lower cervical and upper thoracic spine.     

Anatomic considerations of a modified anterior approach to the cervicothoracic junction

The results of a study on 30 adult human cadavers showed that the anterior aspect of T-3 can be easily exposed through a modified anterior approach to the cervicothoracic spinal junction. Anterior exposure of T-4 caused significant tension on the brachiocephalic vein in 57%; in 7% the vein actually tore. The location of the vital structures is as follows: the left brachiocephalic vein is at T-1 and T-2 in 80%; the aortic arch is at T-2 and T-3 in 90%; the right recurrent laryngeal nerve reaches the tracheoesophageal groove at the level of C-6 in 50%; the thoracic duct empties into the systemic venous system from C-7 to T-2. Adequate exposure of the low cervical to the upper thoracic spine can be obtained with this approach. Preoperative computed tomographic evaluation of the location of the left brachiocephalic vein with respect to the vertebral levels is recommended.     

Echo-enhanced ultrasound voiding cystography in children: a new approach

The development of echo-enhancing agents has significantly improved the detection of the movement of fluid within the urinary tract by ultrasonography (US). The purpose of our study was to compare ultrasound voiding cystography (USVC) for the detection of vesicoureteric reflux (VUR) in children with direct radionuclide voiding cystography (DRVC). Ninety-nine children, aged 1.1–12.3 years, with 198 potentially refluxing units, were investigated simultaneously by DRVC and USVC. The indications for cystography were urinary tract infection, follow-up of a previously detected VUR, and screening of siblings of children with VUR. During the investigation an echo-enhancing agent (Levovist) was administered intravesically through a catheter already in place for the DRVC. The movement of both agents, radiotracer and Levovist, was registered simultaneously by a computerized gamma camera and US, respectively. The results were analyzed with DRVC representing the reference diagnostic test. The overall sensitivity and specificity of USVC for the detection of VUR were 79% and 92%, respectively. USVC may represent a reliable diagnostic tool for the detection and follow-up of VUR in children. Received: 13 January 1999 / Revised: 28 June 1999 / Accepted: 30 June 1999     

Holocord astrocytoma: a two-staged operative approach

Biopsy or subtotal resection followed by radiation for intramedullary astrocytomas of the spinal cord offer palliation but not cure. A treatment modality using an ultrasonic suction device has revolutionized the treatment of these tumors and has been extended to include the treatment of intramedullary tumors involving the entire length of the spinal cord (holocord tumors) with evident success. An alternative to this technique, a two-staged microsurgical approach, allows complete excision of the tumor and thus offers a chance for cure. Two patients have been treated in this manner, and more than 3 years after the operations, both patients were still improving neurologically without any evidence of tumor recurrence.     

Lateral-trigonal intraventricular tumors. A new operative approach

Summary With the introduction of additional diagnostic methods, computerized axial tomography, interventricular tumors are discovered at a time when these lesions are still small and may have presented very insignificant or no clinical symptoms. If the lesion is a benign tumor as a meningioma and within the lateral ventricle of the dominant hemisphere a very difficult problem presents itself to the patient and surgeon. Shall they wait until the tumor reaches such a size to make more permanent symptoms to justify entering the ventricle by the conventional approach through the middle temporal gyrus and leaving the patient at least with a visual field defect? Or should surgery be postponed until the ventricle especially the temporal home is enlarged due to blockage by the tumor, making the operative procedure technically easier? The authors present a method used in three atrial trigonal meningiomas of the dominant hemisphere which did not result in any neurological deficit which was not present before surgery and which abolished paroxysmal attacks of hemianopsia and severe headaches in one patient. The latter patient was believed to have suffered from migraine for 2 1/2 years.     

Double transmanubrial approach and sternotomy for resection of a giant thymic carcinoid tumor

The transmanubrial approach allows excellent unilateral exposure of the thoracic outlet. However, selected patients may require a bilateral cervicomediastinal exposure to completely resect the neoplasm. We report the use of a "double" transmanubrial approach for the resection of a giant mediastinal mass requiring bilateral vascular dissection and superior vena cava system resection and replacement.     

Transclavicular approach for a large dumbbell tumor in the cervicothoracic junction

Neurogenic dumbbell tumors occur more frequently in the cervical than in the thoracic or lumbar spine. Cervical paravertebral masses usually do not become exceptionally large because they are superficial and are palpated easily. Thoracic tumors can become large before they are detected. The authors describe a large intrathoracic dumbbell tumor arising from the C8 nerve root. The intraspinal tumor was resected through a posterior approach. In the second stage, dividing the clavicle, the intrathoracic component was resected by separating it from the lung. Two years after treatment, the preoperative neurologic deficit had improved except for weakness of muscles innervated by the C8 nerve root. Radiographs showed no residual or recurrent mass at the apex of the lung. Sometimes a retroclavicular location may conceal a large paravertebral mass, such as Pancoast tumors. As described here, the transclavicular approach gave adequate access to the cervicothoracic junction.     

Combined cervicothoracic approach in thymectomy for myasthenia gravis

Thymectomy was performed for myasthenia gravis on 30 patients, using a new approach with a collar incision which gave full exposure of the retrothyroid space and was directly connected to a median sternotomy. The thymus was removed en bloc without pleural incision. There was no perioperative mortality and the only complications were transient respiratory insufficiency in two cases. The postoperative hospital stay was 3-9 (mean 5.8) days. The effect of thymectomy was evaluated after 2-8 years at the Department of Neurology, when changes in symptoms (stages I-IV) or medication (need for cholinesterase inhibitors) were registered. The total clinical improvement rate was 97%, with 3% of the patients improved three stages, 33% two stages and 60% one stage compared with the preoperative classification. Twenty patients (67%) were asymptomatic at follow-up and six (20%) also required no medication. The medication need was reduced in 70% of cases (mean reduction 42%). Our cervicothoracic approach resulted in the same rate of improvement as in studies using more extensive transsternal procedures, but the morbidity was lower, with no complications requiring prolonged hospital stay. The morbidity was also less than after only transcervical procedures aiming to perform total thymectomy--a prerequisite for maximal and lasting benefit from surgery. Moreover, as this cervicothoracic approach is simple and safe, it can be recommended as an option in the surgical management of myasthenia gravis.