电视纵隔镜在纵隔肿物诊断和肺癌分期中的价值

目的探讨电视纵隔镜在纵隔肿物诊断和肺癌分期中的价值. 方法 2001年9月～2003年7月全麻下共行电视纵隔镜手术80例,其中颈部电视纵隔镜手术65例,胸骨旁电视纵隔镜手术11例,联合颈部与胸骨旁电视纵隔镜手术4例. 结果术前未获得明确病理诊断纵隔疑难疾病36例,除1例因术前放化疗未能明确诊断外,其余35例均获得明确诊断,确诊率97.2%(35/36).高度怀疑或病理已确诊为肺癌但CT提示伴纵隔淋巴结肿大(直径＞1.0 cm)44例,电视纵隔镜检查病理证实30例,阴性14例,阴性者行手术探查,切除标本未发现纵隔淋巴结转移.所有患者无术后并发症及手术死亡.结论电视纵隔镜手术视野好,清晰度高,操作灵活,安全可靠,可作为纵隔疑难疾病诊断和肺癌诊断、分期的常规方法.     

自行组配电视纵隔镜诊断纵隔疑难病灶的临床价值

目的 总结应用自行组配电视纵隔镜行纵隔镜检查诊断纵隔疑难病灶的临床经验,探讨其应用价值,为缺少纵隔镜设备情况下如何整合现有微创资源开展纵隔镜检查术提供借鉴.方法 回顾性分析2007年11月～ 2013年3月127例电视纵隔镜手术的临床资料.其中2011年10月前应用直达喉镜、活检钳和10 mm 0.胸腔镜自行组配电视纵隔镜完成69例（自组配组）,2011年11月后应用Storz电视纵隔镜完成58例（Storz组）.结果 全组无手术死亡.2组手术时间无明显差异（P＞0.05）.并发出血3例（填塞压迫止血1例,开胸止血2例）,喉返神经损伤2例,并发症发生率3.9％,两组间差异无显著性[4.3％ （3/69） vs.3.4％ （2/58）,Х^2=0.000,P=1.000].自组配组明确病理诊断率98.6％（68/69）,Storz组100％（58/58）,两组差异无显著性（P=1.000）.9例术前合并上腔静脉综合征,其中7例同期经股静脉置入上腔静脉支架（自组配组4例,Storz组3例）,临床症状明显缓解.71例纵隔镜检查术前拟诊为恶性肿瘤,术后病理确诊为恶性肿瘤50例,良性病变21例,术前临床诊断准确率为70.4％ （50/71）;56例拟诊为良性病变,术后病理诊断良性病变37例,恶性肿瘤19例,术前临床诊断准确率66.1％（37/56）.结论 电视纵隔镜手术微创、安全,是纵隔疑难疾病诊断的可靠方法,利用现有器械和设备自行组配的电视纵隔镜系统,可用于纵隔疑难疾病的诊断.     

纵隔镜检查在胸部疾病诊断及肺癌分期中的价值

目的　探讨纵隔镜手术在胸部疾病及肺癌分期中的应用价值。　方法　 71例患者行纵隔镜手术 ,其中颈部纵隔镜手术 5 5例 ,胸骨旁纵隔镜手术 12例 ,颈部加胸骨旁纵隔镜手术 4例。术前未获得明确病理诊断的纵隔疑难疾病 2 6例 ,高度怀疑或已明确诊断肺癌且影象学显示纵隔淋巴结肿大 (≥ 1.0 cm) 4 5例。　结果　 2 6例纵隔疑难疾病患者 ,经纵隔镜检查后 2 5例获得明确诊断 ,确诊率为 96 .2 % (2 5 / 2 6 )。高度怀疑或病理诊断已确诊为肺癌的 4 5例 ,纵隔镜检查阳性 2 9例 ,阴性 16例。阳性者放弃手术 ,予以化疗 ;阴性者中 8例经开胸探查证实为肺癌 ,手术切除标本未发现纵隔淋巴结转移 ,特异性、敏感性均为 10 0 %。纵隔镜手术后发生声音嘶哑 1例 ,气胸 1例。无围手术期死亡。结论　纵隔镜手术创伤小、安全、取材可靠 ,是诊断纵隔疾病和明确肺癌术前分期最重要的方法。     

电视纵隔镜在胸部疾病诊断与治疗中的应用

目的探讨电视纵隔镜在胸部疾病诊断和治疗中的应用价值，总结其临床经验。方法对2006年3月至2007年5月开展的47例电视纵隔镜手术资料进行回顾性分析，其中经颈部纵隔镜手术38例，左胸纵隔镜手术8例，右胸纵隔镜手术1例。结果本组手术时间10～100min，平均44．2min；术中出血5～200ml，平均33．5ml。肺癌术前分期12例，纵隔淋巴结病理检查阴性4例，阳性8例，均与开胸手术后检查结果相符，其敏感性、特异性、准确性均为100％。纵隔疑难疾病诊断31例，经过纵隔镜手术后30例（96．8％）明确诊断，其中恶性肿瘤16例，分别为纵隔转移性肿瘤8例、纵隔淋巴瘤3例，恶性纤维组织细胞瘤、食管鳞状细胞癌、促纤维组织增生性小圆细胞肿瘤、胸腺类癌、淋巴上皮癌各1例；良性疾病14例，分别为结节病8例、慢性淋巴结炎4例、纵隔淋巴结结核2例。纵隔镜辅助纵隔或肺部病变切除4例，均顺利完成手术。本组手术无死亡及严重并发症发生，均治愈出院。结论电视纵隔镜手术安全、可靠，可作为纵隔疑难疾病诊断和鉴别诊断的有效方法以及肺癌术前分期的金标准。     

电视纵隔镜与传统纵隔镜在临床应用中的比较

目的　比较电视纵隔镜手术 (VM)与传统纵隔镜手术 (SM)在胸部疾病临床应用中的价值。方法　回顾性分析纵隔镜手术 10 0例 ,其中VM组 5 4例 ,SM组 46例。比较两组手术时间、术后并发症以及纵隔疑难疾病的诊断率和肺癌治疗前分期的准确性。两组中单纯接受纵隔镜检查的病人还进行了术后住院天数的比较。结果　VM组手术时间为 ( 5 3 9± 17 2 )min ,SM组为 ( 6 9 4± 2 4 7)min ,两组比较t=2 0 5 ,P <0 0 5。VM组术后并发症发生率 ( 0 )及术后住院天数 ( 2 5 8± 1 6 7)d均少于SM组 ,但两组差异无显著性 (P >0 0 5 )。两组在纵隔疑难疾病诊断率和肺癌治疗前分期准确性方面差异无显著性 (P >0 0 5 )。结论　与传统纵隔镜手术相比 ,电视纵隔镜手术视野更清晰 ,双手操作更加灵活、舒适 ,可作为诊断纵隔疑难疾病和明确肺癌术前分期的常规方法。     

电视纵隔镜临床应用的初步体会

目的：探讨电视纵隔镜手术在临床应用中的价值。方法：回顾性总结2001年9月－2002年9月54例经电视纵隔镜手术患者的临床资料,其中颈部纵隔镜手术44例,胸骨旁纵隔镜手术6例,颈部加胸骨旁纵隔手术4例。术前未获得明确病理诊断的纵隔疾病18例;高度怀疑或已明确诊断为肺癌且影像学显示纵隔淋巴结肿大（直径＞1．0cm）者36例。结果：术前未获病理诊断的18例患者,经电视纵隔镜检查后17例取得明确诊断,确诊率为94．4％（17／18）;高度怀疑或病理已确诊为肺癌的36例,电视纵隔镜检查证实肿瘤纵隔淋巴结转移（阳性）22例,未见纵隔淋巴结转移（阴性）14例。阳性者放弃手术,予以化疗。阴性者均中转开胸行肺叶切除或肺楔型切除加纵隔淋巴结清扫。术后病理证实肺癌11例（纵隔淋巴结未见转移,与纵隔镜检查结果相符）,肺结核球、炎性假瘤和错构瘤各1例。本组纵隔镜手术后患者并发症发生率及病死率均为0。结论：电视纵隔镜手术更安全、可靠,可作为纵隔疑难疾病诊断和明确肺癌术前分期的常规方法。     

纵隔镜诊断成人单纯纵隔淋巴结病变

目的探讨纵隔镜检查在诊断成人单纯纵隔淋巴结病变中的作用。方法对120例纵隔淋巴结肿大患者采用标准颈部纵隔镜检查术或胸骨旁纵隔镜检查术获取可疑组织标本行病理学检查。结果通过纵隔镜检查本组120例患者中有113例获得明确的病理诊断,总确诊率为94.2%(113/120);成人单纯纵隔淋巴结病变以结节病(59.2%)、淋巴滤泡增生(16.7%)、淋巴结结核(11.7%)最为多见。手术时间64.2±21.5min,失血量45.6±26.8ml;穿破左侧胸膜1例,术后死亡1例,死因为药物性血管内溶血。结论纵隔镜检查术是诊断成人单纯纵隔淋巴结病变的一种高效、安全的检查方法。     

电视纵隔镜手术诊治胸部疾病36例

目的探讨电视纵隔镜检查术（video-mediastinoscopy,VM）在肺癌术前分期、纵隔疾病诊断中的价值。方法自2006年2月至2007年4月,我们采用电视纵隔镜对36例拟诊为肺癌、纵隔肿物患者进行检查,33例经颈部行纵隔镜术,采用全身麻醉单腔气管内插管;3例经肋间行纵隔镜术,采用全身麻醉双腔气管内插管。结果除术前纤维支气管镜检查确诊4例外,余30例均经电视纵隔镜术检查后确诊;2例诊断不明或可能误诊,其中1例转院失访,另1例经开胸活检证实为肺大B细胞淋巴瘤。平均手术时间55min,平均出血量40ml,术后无死亡患者,无切口感染;发生并发症2例,1例出血,经止血纱布填压止血;1例喉返神经麻痹,经中医针灸治疗后好转。结论电视纵隔镜术是肺癌术前病理分期、纵隔疾病的重要检查方法,具有诊断准确率高、安全可靠等优点。     

纵隔肿瘤、囊肿的诊断及手术治疗

目的:探讨纵隔肿瘤、囊肿的诊断、鉴别诊断及手术治疗。方法:对68例经手术及术后病理证实的纵隔肿瘤及囊肿进行回顾性总结。结果:本组病例中畸胎瘤16例(23.5％),胸腺肿瘤39例(57.4％),神经源肿瘤7例(10.3％),良性囊肿5例(7.4％)。纵隔肿瘤、囊肿的手术切除率为97.1％(66/68),手术探查率为2.9％(2/68),手术死亡率为1.5％(1/68)。结论:纵隔肿瘤及囊肿一经确诊,均应手术治疗。     

经颈部纵隔镜检查在胸部疾病诊断中的价值

目的探讨经颈部纵隔镜检查术在胸部疾病诊断中的价值。方法回顾性分析1990年1月-2008年9月施行281例经颈部纵隔镜检查术的临床资料。采用局部浸润麻醉或全身麻醉,经气管前间隙向下方探查气管周围肿物和淋巴结,并进行活检。结果268例获得明确病理诊断,确诊率95.4%（268/281）。术前诊断不明23例全部获得明确病理诊断,恶性肿瘤术前诊断病理符合率56.9%（41/72）,良性病变术前诊断病理符合率87.4%（104/119）。结论经颈部纵隔镜检查术对单独或伴有纵隔内肿块的胸部疾病是一种有效的检查方法,对于诊断不明的单纯纵隔淋巴结肿大者尤其适合,对肺癌伴有纵隔淋巴结肿大或纵隔肿瘤者可选择应用。     

Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung

Between 1979 and 1984, mediastinoscopy was performed on 1,000 of the 1,500 patients admitted to the Thoracic Surgical Service of the Toronto General Hospital with the diagnosis of carcinoma of the lung. In 144 cases, concomitant anterior mediastinoscopy was also performed. Abnormal mediastinal nodes were found in 296 (29.6%). The overall complication rate was 2.3%, with no deaths. Mediastinoscopy revealed diseased nodes in 24% of patients with squamous cell carcinoma, 29% with adenocarcinoma, 54% with small cell undifferentiated carcinoma, 31% with large cell undifferentiated carcinoma, and 12% with bronchoalveolar carcinoma. Abnormal mediastinal nodes were found with equal frequency in right- and left-sided tumors and occurred in 31% of tumors in the main bronchus, 25% of upper lobe tumors, and 17% of lower lobe tumors. Of the 704 patients having negative results of mediastinoscopy, 590 were subjected to thoracotomy. Ninety-three percent underwent resection (85% curative, 7% palliative) and 7% had unresectable tumors. Of the resections, 20% were pneumonectomies. At thoracotomy, 52 of the 590 patients with negative mediastinoscopic results were found to have abnormal mediastinal nodes. Sixty-two of the 296 patients with positive results of mediastinoscopy were selected for thoracotomy. Eighty-six percent had resectable lesions (67% curative, 18% palliative) and 14% unresectable. The pneumonectomy rate in this group was 35%. These current data support our previous opinion that routine mediastinoscopy can be done with negligible morbidity and provides essential information for the classification and management of cancer of the lung.     

Diagnosis and treatment of isolated tuberculous mediastinal lymphadenopathy in adults.

OBJECTIVE: To evaluate the diagnostic yield of bronchoscopy and mediastinoscopy in adults with isolated mediastinal tuberculous lymphadenitis and to assess the effect of antituberculous treatment. DESIGN: Prospective longitudinal cohort study of 34 patients with mediastinal tuberculous lymphadenitis followed for 6 to 19 months after completion of treatment. SETTING: Tertiary care hospital, Kuwait. PATIENTS: 34 consecutive patients who presented with isolated mediastinal lymphadenopathy from 1996 to 1998. INTERVENTIONS: Bronchoscopy and cervical mediastinoscopy for all patients. MAIN OUTCOME MEASURES: Diagnostic yield of bronchoscopy and mediastinoscopy, and the outcome of treatment in patients with tuberculous lymphadenopathy. RESULTS: The mean age was 35 years (range 15-58). The most common symptoms were cough, fever, and weight loss. The chest radiographs and computed tomograms showed abnormal mediastinal shadows with no evidence of parenchymal disease. All patients had right sided paratracheal lymphadenopathy. Tuberculin skin test gave a weal of >15 mm in 17 patients (50%). Sputum smears and cultures failed to grow acid-fast bacilli in any patient. Seven patients had an endobronchial abnormality and samples taken at bronchoscopy gave a definite diagnosis in 3 (9%). Paratracheal lymph node biopsy and culture by mediastinoscopy diagnosed tuberculosis in all cases. All patients were treated by a six month course of rifampicin and isoniazid supplemented initially by pyrazinamide for two months. Twenty-eight patients had a good response and the remaining patients were treated for a further 3 months. CONCLUSIONS: Bronchoscopy has a low diagnostic yield in mediastinal tuberculous lymphadenopathy in the absence of a parenchymal lesion. Mediastinoscopy is a safe but invasive procedure and provides a tissue diagnosis in most cases. Six months treatment with rifampicin and isoniazid supplemented initially by pyrazinamide is adequate treatment for most adults with tuberculous mediastinal lymphadenopathy.     

Value and current role of anterior mediastinotomy in the diagnosis of mediastinal diseases. Apropos of a series of 100 cases

One hundred anterior mediastinotomies performed between 1981 and 1987 resulted in the diagnosis of 90 malignant mediastino-hilar or anterior mediastinal tumours, 4 benign lymph node diseases and 6 non-specific lesions. This easy to perform biopsy technique was followed by low morbidity (7%) and one death after 48 hours due to major mediastinal compression. Its sensitivity and specificity make it a valuable alternative and, according to the authors, preferable to mediastinoscopy in the diagnosis of tumours of lymph node diseases in the anterior, pulmonary hila, especially on the left side, and anterior mediastinal lymph node chains.     

Role of mediastinoscopy in the diagnosis of mediastinal masses

In order to assess the diagnostic efficiency of mediastinoscopy in patients with undiagnosed mediastinal masses, a retrospective review was undertaken of the results obtained in a consecutive series of 42 patients presenting over a 5-year period. In 28 (67%) patients, a tissue diagnosis was made. Ten (24%) patients underwent a negative mediastinoscopy but were found to have significant pathology on further investigation (eight in a location outside the range of conventional mediastinoscopy). Four (10%) patients had negative findings and were confirmed to have no significant pathology on further investigation and follow-up. Overall, mediastinoscopy had a sensitivity of 74%, a specificity of 100% and an accuracy of 76%; however, for lesions within the range of mediastinoscopy, the sensitivity was 93%, the specificity 100% and the accuracy 94%. The predictive value of a negative examination was 66%. Mediastinoscopy is a valuable technique in the diagnosis of mediastinal masses but, because of the low predictive value of a negative examination, further evaluation, including thoracotomy if necessary, is still indicated if mediastinoscopy is unhelpful.     

Mediastinoscopy vs. anterior mediastinotomy in the diagnosis of mediastinal lymphoma: a randomized trial.

We selected 95 patients with mediastinal adenopathy and no signs of goiter, myasthenia gravis or mediastinal involvement by other disease. All patients underwent, for screening purposes, transthoracic fine needle aspiration biopsy based on chest x-ray and CT findings. Patients were then subdivided into 4 groups. One group of 22 patients with prevalent anterior mass localization underwent anterior mediastinotomy. One group of 19 patients with prevalent middle mediastinal mass localization underwent cervical mediastinoscopy. Two other groups of 27 patients each with both anterior and middle mediastinum localization randomly underwent anterior mediastinotomy or mediastinoscopy. Fifty-one Hodgkin's and 44 non-Hodgkin's lymphomas were diagnosed in total. In 11 cases (11.57%), median sternotomy (2) or thoracotomy (9) were necessary for establishing the final diagnosis. The overall diagnostic accuracy was 80.43% for cervical mediastinoscopy and 95.91% for anterior mediastinotomy. The statistical analysis performed on all patients showed a significant difference (chi 2 = 5.56, P less than 0.025, df = 1) between the two procedures.     

EBUS-TBNA在纵隔气管周围病变诊断中的应用

目的 探讨支气管内超声引导针吸活检术(EBUS-TBNA)在纵隔气管周围病变诊断中的应用价值。方法 回顾性总结2009年9月至2010年7月,34例不明原因的纵隔淋巴结肿大或纵隔肿物患者经EBUS-TBNA检查的临床资料。对EBUS-TBNA仍未能明确诊断者,进一步接受外科手术活检或至少6个月以上的临床及影像学随诊。结果 经EBUS-TBNA检查后28例获得明确诊断,其中恶性病变10例,良性病变18例,确诊率82.4％。EBUS-TBNA在纵隔病变良、恶性诊断和鉴别诊断方面的敏感性、特异性和准确性分别为90.9％、100％和97.1％。所有受检者耐受良好,无任何相关并发症发生。结论 对于纵隔气管周围病变,EBUS-TBNA是一种安全、有效的诊断方法。     

Extended cervical mediastinoscopy in the diagnosis of anterior mediastinal masses

BACKGROUND: Although transthoracic needle biopsy (TNB) has been the preferred method for the diagnosis of anterior mediastinal masses, it has inherent limitations in accuracy. In particular, lymphoma and thymoma are diagnosed less reliably using needle biopsy. Videothoracoscopy has been advocated as an alternative method for diagnosis. Our goal was to assess the usefulness of extended cervical mediastinoscopy (ECM) in the diagnosis of anterior mediastinal masses. METHODS: The ECM technique was performed in 9 patients in whom TNB and Tru-cut biopsies had been inefficient for histologic diagnosis. All lesions were in the anterior mediastinum. Extended cervical mediastinoscopy was carried out using the same incision as in a standard cervical mediastinoscopy and dissection was performed behind the sternum as previously published. Mean operative time was 50 minutes (range 40 to 70 minutes) and mean hospital stay was 8 hours (range 5 to 36 hours). RESULTS: Diagnosis of lymphoma in 4 cases, thymoma in 3 cases, and thymic hyperplasia in 2 cases were obtained by ECM. In 1 of 2 patients with suspected thymoma who underwent resectional surgical procedures, final histologic diagnosis was non-small cell lung carcinoma. There was no surgical mortality or intraoperative complication. One patient had minimal pneumothorax requiring no intervention. CONCLUSIONS: We conclude that ECM in the diagnosis of anterior mediastinal masses is technically feasible and provides an alternative to the conventional approaches in patients with paraaortic or aortopulmonary masses.     

The current role of mediastinoscopy in the evaluation of thoracic disease.

OBJECTIVE: Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease. METHODS: We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998. RESULTS: We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease. CONCLUSIONS: Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.     

Mediastinal lymph node staging in suspected lung cancer: comparison of positron emission tomography with F-18-fluorodeoxyglucose and mediastinoscopy

BACKGROUND: In patients with bronchogenic carcinoma, mediastinal lymph node staging is essential for determining treatment options. In this retrospective analysis we compared the results of positron emission tomography (PET) using F-18 fluorodeoxyglucose with those of mediastinoscopy in nodal staging for suspected bronchogenic carcinoma. METHODS: From March 1997 to June 2001, 102 patients (86 male,16 female, age 62 +/- 9 years) underwent both PET and mediastinoscopy for radiologically suspected mediastinal lymph node disease in bronchogenic carcinoma. Total body emission scans were acquired 90 to 150 minutes after injection of 230 MBq of F-18 fluorodeoxyglucose. Mediastinoscopic evaluation of lymph node stations was performed according to the method of Mountain and Dresler (1R, 1L, 2L, 2R, 4L, 4R,7). Patients were eligible if surgical staging was performed within 6 weeks after the PET scan. RESULTS. Of the 102 patients, benign lesions were diagnosed in 15. In 87 patients malignant disease was proven by histology, and bronchogenic carcinoma was found in 82. Of 469 nodal stations analyzed, malignancy was documented by histology in 84. In PET analysis 79 true-positive and 304 true-negative samples were found. Five lymph node stations were false negative, and 81 samples were false positive. False-positive findings in PET frequently were seen in inflammatory lung disease. The sensitivity of PET was 94.1%, specificity was 79% with a diagnostic accuracy of 81.6%. The positive predictive value of PET was 49.3%, and the negative predictive value was 98.4%. CONCLUSIONS: In patients with positive PET scan results histologic verification appears necessary for exact lymph node staging. In view of the negative predictive value mediastinoscopy can be omitted in patients with bronchogenic carcinoma whose PET scan results were negative.