Life-Threatening Respiratory Distress from Mediastinal Masses in Infants

From 1972 through 1974, 5 infants with severe respiratory distress secondary to mediastinal tumors were treated in the Division of Pediatric Surgery of The Johns Hopkins Hospital. The mediastinal masses included 2 intramural bronchial cysts, a giant esophageal duplication, a benign teratoma, and a highly malignant neuroblastoma. Individualized management was carried out successfully in all: total resection of the bronchial cysts and teratoma; partial resection of the duplication cyst with stripping of the remaining mucosa from the contiguous esophageal wall, thereby preserving esophageal integrity; and excision of involved chest wall and tumor combined with radiotherapy and chemotherapy for the neuroblastoma.This experience emphasizes the potential for lethal respiratory distress from mediastinal tumors in infants and supports the experience reported by others of serious consequences if resection is not performed. Primary physicians and thoracic surgeons must be aware of the lethal potential of such mediastinal tumors among the many other “surgical” causes of respiratory distress in neonates and infants.     

Hyaluronidase aspiration vs surgical excision of ganglion cysts: a randomized controlled trial

Surgical treatment of a ganglion cyst is commonly performed but excision is associated with high recurrence rates. Some authors have reported alternative, less invasive treatment regimens such as aspiration using dissolving substances. The aim of this prospective randomized controlled trial was to investigate whether injecting ganglion cysts with hyaluronidase followed by aspiration was as effective as surgical excision. In one group of patients, 150 units of hyaluronidase (HD) were injected in each ganglion cyst by a 15 gauge needle followed by a 15 min equilibration period. The contents were then aspirated with constant suction by a 20 ml syringe. In the surgical group, the ganglion cyst was dissected down its neck and excised under local anesthetics. Pain sensation was evaluated by a visual analogue scale (VAS) at various time points. A total of 38 patients were enrolled in the study. However, only 32 patients were available for analysis (HD group: 20. surgery: 12). Seventeen of the 20 patients treated with HD demonstrated recurrent disease during follow-up. In contrast, following excision only 3 out of 12 patients demonstrated recurrent disease (p<0.05). Pain during motion following surgical excision was not reduced postoperatively compared to preoperative values. HD-assisted aspiration of ganglion cysts is not effective. Surgical excision is fairly successful although some degree of pain usually persists. An observation period is indicated prior to invasive treatment since a portion of ganglion cysts resolve spontaneously.     

Mediastinal parathyroid cysts revisited

BACKGROUND: A case of a functioning mediastinal cyst is presented. METHODS: A comprehensive review of the literature found 93 patients in whom a parathyroid cyst or cysts extended into, or was completely contained within, the mediastinum. Including our patient, there were 46 men and 45 women, and the gender was not recorded in three. RESULTS: The cysts were located in the anterosuperior region in 56 patients, in the middle region of the mediastinum in 26, and in the anterior, prevascular region in 12. Thirty-nine patients had functioning cysts associated with hyperparathyroidism of varying severity; seven patients presented with a hypercalcemic crisis. Local symptomatology consisted of a neck mass, respiratory distress, and occasional dysphagia or chest pain. Recurrent laryngeal nerve paresis was present in nine patients, and innominate vein compression or thrombosis was present in two. The cysts in all but four patients were treated by open surgical excision; two were treated by thoracoscopy, and two patients only had fine-needle aspiration of the cyst. The cyst was excised via a cervical approach in 67 patients and by a thoracotomy or median sternotomy or a variation thereof in 23. There was no operative mortality and morbidity was minimal. CONCLUSION: Surgical resection was successful in all and remains the treatment of choice for mediastinal parathyroid cysts.     

Successful management of a large fetal mediastinal teratoma complicated by hydrops fetalis

This report describes a case of fetal mediastinal teratoma complicated by hydrops fetalis managed successfully by aspiration of the tumor cyst fluid. Fetal mediastinal teratomas are rare tumors that cause hydrops fetalis or fetal demise in the prenatal period and respiratory distress in the neonatal period. The patient presented with a large cystic mass in the thoracic cavity complicated by hydrops fetalis. The hydrops resolved after fetal aspiration of the tumor cyst fluid. The infant was born without respiratory distress, and tumor resection was performed at the age of 30 days. The postoperative course was uneventful, and the patient was in good health 6 months postoperatively.     

Duplication of the cervical esophagus. An unrecognized cause of respiratory distress in infants

Infants with respiratory distress demand prompt action and thorough evaluation for possible causes. An urgent but infrequent source of upper airway obstruction is a duplication cyst of the cervical esophagus. Standard references omit this diagnosis in the consideration of both respiratory distress and neck masses in infants. Two patients were admitted with respiratory distress and delayed recognition of a neck mass. Contrast and sonographic studies revealed a cystic mass displacing the trachea in each case. Careful excision promptly relieved symptoms, and histopathologic evaluation confirmed the diagnosis. Duplication of the esophagus can compromise the normal airway, thereby presenting with respiratory difficulty prior to recognition of a neck mass. X-ray studies demonstrating displacement of the trachea or esophagus due to a soft-tissue mass and documentation of a cyst by ultrasound will aid in establishing the diagnosis. Surgical principles include aspiration and excision of the mucosal lining, with preservation of the muscular coat and mucosal septum. Duplication of the cervical esophagus should be considered in the differential diagnosis of both respiratory distress and an enlarging neck mass in infants.     

巨大纵隔肿瘤的外科治疗

目的　探讨巨大纵隔肿瘤外科治疗的经验。方法　回顾性分析 1993年 5月～ 2 0 0 3年 5月收治的 13例病人临床资料。结果　 13例病人中良性肿瘤 8例 ( 62 % ) ,恶性肿瘤 5例( 3 8% ) ,肿瘤完整切除 11例 ,部分切除 1例 ,1例因术中大出血死亡。 10例随访 3个月～ 10年 ,良性肿瘤无复发 ,恶性肿瘤 2例复发。结论　巨大纵隔肿瘤以手术治疗为主。囊性肿瘤及其他肿瘤有液化者可在术前穿刺减压 ,术中暴露困难时可先部分切除 ,注意处理复张性肺水肿及术中大出血。     

Seudoquiste adrenal grande que simula feocromocitoma quístico: exéresis minimizando el acceso laparoscópico

IntroductionAdrenal cysts and pseudocysts are rare and usually benign and asymptomatic; they are discovered either accidentally or during examination for non-specific abdominal discomfort. Less frequently, they may cause gastrointestinal symptoms or abdominal or lumbar pain, particularly when they are quite large. Histologically, they are classified as epithelial, endothelial, parasitic and pseudocysts (with a fibrous wall but no epithelium). The differential diagnosis for adrenal cysts must consider cystic adrenal carcinoma and cystic pheochromocytoma, which are both extremely rare, but more severe and difficult to treat.Patients and resultsA 55 year-old woman reported right-side flank pain; imaging studies discovered a 10cm cystic adrenal tumour, with radiological indications of cystic pheochromocytoma. Total transperitoneal laparoscopic excision was performed through three access ports. The cyst was drained by intra-abdominal bagging and aspiration before excision, in order to minimise surgical incisions. Pathological study showed benign pseudocyst.ConclusionsAs less invasive laparoscopic procedures become widespread, an increasing number of case reports and series of cases regarding adrenal cyst operations have recently been reported. A review of the literature shows that the cysts are generally benign, but it is not always possible to identify cystic adrenal carcinoma or cystic pheochromocytoma from the radiology image. Draining the cyst using an aseptic and oncologically safe procedure is useful for minimising surgical wounds and increases the benefits of laparoscopic access.     

Giant Transdiaphragmatic Duodenal Duplication with an Intraspinal Neurenteric Cyst as Part of the Split Notochord Syndrome: Report of a Case

We report the case of a 6-month-old girl with a giant transdiaphragmatic duodenal duplication connecting to a cervical intraspinal cyst, which compressed the heart and lung, causing severe respiratory distress. We removed the intraspinal neurenteric cyst through a posterior cervical incision at the C6 and C7 level, and the duodenal duplication cyst in the mediastinum was removed through a right thoracotomy. Her respiratory symptoms were completely resolved by these operations.     

Complicated solitary biliary cysts

With development of ultra sound, solitary hepatic cyst (SHC) appears as a common and benign affection. Complications can occur in 10 per cent of cases. We report here four cases of complicated SHC: vena caval obstruction, intracystic bleeding, rupture, intracystic infection. Those four patients were successfully treated by partial excision of the cyst in the first 3 cases, and by percutaneous drainage with CT scan guidance in the latter. Complications of SHC occur only in large cysts, with a diameter up to 8 cm. So, small SHC do not require any treatment, while large SHC must be treated to avoid complications. Percutaneous aspiration and direct injection of alcohol can lead to recurrence. Surgical therapy by partial excision is successful, with low rates of mortality and morbidity.     

Pericardial cysts of the mediastinum

Pericardial cysts are an uncommon benign disease. Their treatment, in the past, was based on excision by thoracotomy or, in selected cases, on percutaneous aspiration. The progress of video-assisted thoracoscopy gave new possibilities, but most surgeons still consider the thoracotomic approach as the treatment of choice. The aim of this study is to report our experience and to discuss the role of different therapeutic procedures in the management of pericardial cysts. Between 1970 and 1996, 24 patients with pericardial cysts were treated at the first Department of Surgery of the University of Rome . Of 24 cysts, six were located in the right cardiophrenic angle, three in the left cardiophrenic angle, two in the subcarenal areas, one in the paracardiac area and one on the posterior mediastinum. Ten patients were asymptomatic. Diagnosis was performed preoperatively only in patients with cysts typically located in the cardiophrenic angle. Twenty-three patients were surgically treated by a standard posterolateral thoracotomy or limited thoracotomy with sparing of muscles. One patient underwent CT-guided transparietal fine-needle aspiration. There were no cases of operative mortality. Morbidity was 12.5% and consisted of retained secretions, moderate hypoxemia and partial atelectasis. All patients were submitted to a long-term follow-up and no cyst recurrences were found. We conclude that excision via thoracotomy is an optimal treatment for pericardial cysts. Limited thoracotomy with sparing muscles offers a good cosmetic result and a rapid functional respiratory recovery. Percutaneous cyst aspiration may be, in selected patients, an attractive alternative to surgery.     

Retroperitoneal lymphangioma. A case report

Retroperitoneal cystic lymphangiomas are rare benign tumours. Ultrasonography, computed tomography, lymphography or fine-needle percutaneous aspiration may be used to make the diagnosis pre-operatively. Complete excision of the cyst without rupture is the preferred treatment. However, in complicated cases a conservative surgical approach is mandatory.     

Cystic schwannoma of the pelvis

Schwannomas are benign tumours that arise from the Schwann cells of nerve fibres. They commonly occur in the head and neck, mediastinum and extremities. They are extremely rare in the pelvis. These are usually slow growing tumours and are often detected incidentally. Pre-operative diagnosis is extremely difficult as there are no definitive signs on imaging. Aspiration biopsy is often inconclusive or misleading. Surgical excision is both diagnostic and therapeutic. As these tumours are often large in size, open excision is most commonly performed. We describe a case of a large, cystic schwannoma of the pelvis causing bladder outlet obstruction and bilateral hydroureteronephrosis. Complete surgical excision was performed laparoscopically.     

Benign teratomas of the mediastinum

Approximately 8% of all mediastinal tumors are benign teratomas. We reviewed 86 cases of benign teratoma seen at the Mayo Clinic from 1930 through 1981. The mean age of the patients was 28 years and the sex distribution was approximately equal. The most common symptoms were chest, back, or shoulder pain, dyspnea, and cough, but 36% were asymptomatic at the time of presentation. Chest roentgenograms showed a well-circumscribed anterior mediastinal mass which often protruded into one lung field. Detectable calcification was observed in 22 patients: a calcified tumor wall in seven, bone or teeth in the mediastinum of seven, and nonspecific calcifications in eight. Surgical excision remains the best means of diagnosing and treating this benign tumor. Though the tumors are histologically benign, they may present difficult surgical problems because of the vital structures involved. Since 1952 there has been a change in the clinical presentation of patients with this entity: More patients are asymptomatic and have smaller tumors and fewer complications than prior to 1952.     

Laparoscopic resection of a nonparasitic liver cyst

The spectrum of treatment options for symptomatic, benign, nonparasitic hepatic cysts has ranged from percutaneous aspiration to liver transplantation. Most large series have demonstrated that complete resection of the cyst is associated with the lowest rate of recurrence. However, a conventional open laparotomy may subject these patients to unacceptable morbidity given the benign nature of most of these lesions.We successfully performed a complete resection of a large hepatic cyst using a laparoscopic approach. Using an endoscopic GIA stapling device we were able to remove the cyst with minimal blood loss and in minimal operative time. The patient tolerated the procedure well, was discharged home on postoperative day 2, and in follow-up has been without recurrent symptoms.     

Video-assisted mediastinoscopic resection of a large symptomatic bronchogenic cyst

Bronchogenic cysts are congenital lesions from the primitive foregut, mostly located in the mediastinum. Surgical excision in symptomatic cases is often challenging. Video-assisted mediastinoscopy offers a safe and effective approach with less morbidity and shorter hospital stay compared to open sternotomy or posterolateral thoracotomy. We describe a case of a young female with a large symptomatic cyst located in the superior mediastinum. The cyst was completely removed through a video-assisted cervical mediastinoscopy.     

Adventitial cystic disease of the popliteal artery: early recurrence after CT guided percutaneous aspiration

Adventitial cystic disease of the popliteal artery is a rare condition of debated aetiology. The recommended treatment has been cyst removal with or without replacement of the artery. Recently percutaneous aspiration has been suggested as another method of treatment for this condition. In this case, percutaneous aspiration was performed twice. Surgical intervention was eventually performed because of early cyst recurrence. Our experience suggests that aspiration is a treatment option but, if used, close long-term follow-up is necessary to detect recurrence.     

Total Occlusion of the Superior Vena Cava Due to Bronchogenic Cyst

Bronchogenic cysts are the most common form of congenital cystic lesions in the mediastinum. Of all cases with bronchogenic cysts, 1/3 are symptomatic. The symptoms vary depending on the location and compression of the adjacent structures of the cyst. Some mediastinal bronchogenic cysts can cause severe respiratory distress due to airway and vascular compression. We herein present a case with a bronchogenic cyst that required venoplasty to the superior vena cava (SVC) due to total occlusion of the SVC.     

Mediastinoscopy in the treatment of mediastinal cysts.

OBJECTIVE: Primary cysts constitute 25% of all masses in the mediastinum. Because radiological investigations are often inconclusive, many adults require mediastinoscopy, thoracotomy, video-assisted thoracic surgery, or computed tomography-guided transbronchial, transesophageal, or transcutaneous aspiration to confirm the cystic nature of these lesions. Minimally invasive procedures fail when the cyst contents are gelatinous and mucoid (failure to aspirate) or when the cyst wall continues to secrete fluid. Though Pursel reported mediastinoscopic extirpation of benign cysts 35 years ago, it remains a "therapeutic curiosity" with sporadic reports of its usage. We report 2 successful mediastinal cyst extirpations performed as outpatient procedures and review the literature with regards to its management. METHODS: A rigid, 8-mm mediastinoscope was inserted into the anterior mediastinum following the creation of a 2-cm suprasternal incision and dissection along the anterior surface of the trachea. After aspiration, cytology of the contents revealed their benign nature. Right paratracheal cysts in 2 adult males were successfully removed mediastinoscopically by blunt and sharp dissection. RESULTS: Histopathology revealed benign mesothelial cysts in both instances. Both patients had an uncomplicated procedure and were discharged within 23 hours. No other pathology was detected on mediastinoscopy, and follow-up at 3 months and 6 months has revealed no recurrence. CONCLUSION: Mediastinoscopic cyst removal is a minimally invasive procedure with a very low morbidity and mortality rate. Morbidity, recovery, and discharge times are much less than those of more invasive procedures (video-assisted thoracic surgery / thoracotomy). We suggest that it should be the first-choice procedure for the excision of appropriately located benign mediastinal cysts.     

A BRONCHOGENIC CYST CAUSING RESPIRATORY DISTRESS

A case is reported of acute respiratory distress in an adult that was caused by a bronchogenic cyst. Bron chogenic cyst in an adult may be seen on chest X-ray and confirmed by computerized tomography (CT) scanning. Surgical excision can provide dramatic relief.     

机器人辅助腹腔镜切除盆腔表皮样囊肿1例报告并文献复习

目的:结合文献探讨腹膜后表皮样囊肿的诊治方法,介绍机器人辅助腹腔镜切除盆腔腹膜后巨大肿瘤的手术经验。方法:为1例青年男性盆腔腹膜后巨大肿瘤患者行机器人辅助腹腔镜手术切除,并结合文献探讨腹膜后表皮样囊肿的诊治方法。结果:患者行机器人辅助腹腔镜下表皮样囊肿切除术,手术完整切除肿瘤,手术时间1.5 h、出血量约8 ml。术后病理诊断为表皮样囊肿。术后1周出院,随访8个月未见囊肿复发及转移。结论:腹膜后表皮样囊肿在临床症状上缺乏特异性,需要与脊索瘤、畸胎瘤等相鉴别;因有感染、恶变的倾向,治疗上应手术切除。机器人辅助腹腔镜手术治疗位于盆腔的腹膜后巨大肿瘤具有良好的适应性。