Thoracoscopic Management of Mediastinal Cysts: Experience over a Period of 13 Years

Original Research Thoracoscopic 10.5005/jp-journals-10056-0055 Management of Mediastinal Cysts Thoracoscopic Management of Mediastinal Cysts: Experience over a Period of 13 Years 1 Beejal V Sanghavi, 2 Kedar P Mudkhedkar, 3 Sandesh V Parelkar, 4 Rahulkumar Gupta, 5 Rujuta Shah 6 P Kavimozhy Ilakkiya ABSTRACT Aim: Mediastinal cysts are usually benign in the pediatric age group and are usually managed by thoracotomy, and nowadays increasingly by thoracoscopy. Thoracoscopy offers benefit in terms of superior vision, faster postoperative recovery, and lesser pulmonary complications. It is safe and feasible with minimal morbidity. The purpose of this article is to review our experience of thoracoscopic management of mediastinal cysts over a period of 13 years. Materials and methods: All cases of mediastinal cysts operated by thoracoscopy in our department from 2005 to 2017 were reviewed. The age of presentation varied from 8 weeks to 10 years. Children presented with a variety of complaints like tachypnea, respiratory distress, or recurrent lower respiratory tract infections. All patients underwent chest X-ray and computed tomography (CT) scan thorax to delineate the exact size and location of the cyst and its relationship with adjacent mediastinal structures. The ports were individualized depending on the location of the cyst on the CT scan. The cysts were excised mainly by blunt dissection. Intercostal drain was placed in all patients. Results: A total of 30 children underwent thoracoscopy. There was one intraoperative complication, one bronchial injury repaired thoracoscopically. In cases with history of recurrent respiratory tract infection, dissection was difficult because of dense adhesions. There were four conversions. Average postoperative hospital stay was 4 days. Conclusion: Thoracoscopy in mediastinal cysts in pediatric age group is a safe and effective procedure with low morbidity and a shorter hospital stay. It has the major advantage of superior vision in difficult to access areas. Meticulous and slow dissection, before aspirating the cyst, is an important technique to aid in successful thoracoscopic excision of mediastinal cysts. Keywords: Bronchogenic cyst, Mediastinal cyst, Thoracoscopy. How to cite this article: Sanghavi BV, Mudkhedkar KP, Parelkar SV, Gupta R, Shah R, Ilakkiya PK. Thoracoscopic Management of Mediastinal Cysts: Experience over a Period of 13 Years. Int J Educ Res Health Sci 2017;3(3):129-133. Source of support: Nil Conflict of interest: None INTRODUCTION Since the introduction of thoracoscopy in 1910 in adults followed by pediatric age group in 1977 by Rodgers and Talbert, 1 thoracoscopy is now being increasingly used for various pediatric procedures. It offers great advantages when compared with open surgery in terms of intraoperative vision of the entire thoracic cavity, postoperative recovery, and lesser pulmonary morbidity. It provides adequate access and space for intrathoracic dissection and manipulations. MATERIALS AND METHODS All cases of mediastinal cysts operated by thoracoscopy in Seth Gordhandas Sunderdas Medical College from 2005 to 2017 were reviewed. Most patients had complaints like tachypnea, respiratory distress, or recurrent lower respiratory tract infections. All patients underwent chest X-ray (Fig. 1) and CT scan (Fig. 2) thorax to delineate the exact size and location of the cyst and relationship with adjacent vital structures. In three cases, magnetic resonance imaging (MRI) was done as intraspinal communication was suspected. Thoracoscopy was done using conventional general anesthesia with endotracheal ventilation. Patient was placed in lateral decubitus position with pressure padding under opposite hemithorax. The first 5 mm 1 Professor, 2 Assistant Professor, 3 Professor and Head 4 Associate Professor, 5 Super-Speciality Medical Officer, 6 Senior Resident 1-6 Department of Pediatric Surgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College Mumbai, Maharashtra, India Corresponding Author: Kedar P Mudkhedkar, Assistant Professor, Department of Pediatric Surgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India, Phone: +919881464921 e-mail: kedar.mudkhedkar@gmail.com A B Figs 1A and B: X-ray view with mediastinal cyst International Journal of Education and Research in Health Sciences, July-September 2017;3(3):129-133 129

Beejal V Sanghavi et al A B C Figs 2A to D: Computed tomography scan of chest with mediastinal cyst D Fig. 3: Port position Fig. 4: Specimen taken out via port site trocar was usually placed in the fourth or fifth intercostal space in the midaxillary line with an open technique. Insufflation was done at this stage to create pneumothorax if required to assist with lung deflation. A 30 degree scope was used to view size, location, and relationship of the cyst with the adjacent structures. Two additional 5 mm ports were placed between the anterior and posterior axillary lines to triangulate the lesion (Fig. 3). In selected cases, 3 mm working ports were used. For patients operated with three-dimensional (3D) system, 10 mm optical port was used. In very few cases, additional port was used for retraction. After placement of ports, the pleura over the cyst was incised and the cyst was dissected from surrounding structures by blunt dissection and sharp dissection. We used the hook, harmonic scalpel as well as thoracoscopic suction cannula for dissection. Care was taken not to 130 twist the cyst or pull too hard on it during the dissection. In some difficult cases with adhesions and large size, to make the manipulation easy, the cyst was initially aspirated and decompressed, and then dissected. In cases with dense adhesions with either esophagus or tracheobronchial tree or major vessels, partial excision was done keeping densely adherent part behind. Cauterization of the mucosa was done in such cases. Specimen was removed from one of the ports (Fig. 4). Intercostal drainage tube was inserted before the trocars were removed. In suspected cases of hydatid cysts, povidone-iodine was used as a scolicidal agent with careful prevention of spillage of fluid. 2 In these cases, a needle suction tip was inserted into the exocyst, and cyst fluid was aspirated. The endocyst was removed with the aid of a medium pressure suction cannula and extracted, taking care to minimize spillage. After the procedure, the pleural cavity

Thoracoscopic Management of Mediastinal Cysts was lavaged with a dilute betadine solution to prevent pleural as well as port site recurrence. We sutured the ectocyst as an extra precaution to prevent prolonged air leak from a missed or unidentified small bronchial communication leading to bronchopleural fistula. 2 RESULTS A total of 30 patients underwent thoracoscopy. The age of presentation varied from 8 weeks to 10 years. There were 22 males and 8 females. Right side was involved in 21 cases, left side in 5 cases, 4 were mainly subcarinal. Three patients had anterior and 26 had posterior mediastinal cysts. The duration of surgery varied from 45 to 150 minutes. Blood loss on an average was 15 ml (5 90 ml). Intercostal drain was removed after good lung expansion, usually within 48 to 72 hours (2 13 days), and the patients were discharged later, usually by the 4th postoperative day (3 15 days). Histopathology showed bronchogenic cysts in 13 cases, while there were 10 enteric (esophageal/foregut) duplication cysts, 1 thymic cyst, 1 cystic hygroma, and 5 hydatid cysts (Fig. 5). All the patients are asymptomatic over a follow-up period of 2 to 12 months. There was one intraoperative complication the bronchus was opened inadvertently which was immediately diagnosed and repaired thoracoscopically. In 26 patients, complete excision was possible while in 4 cases, some part was left behind as it was densely adherent to esophagus or tracheobronchial tree or major vessels. In one such patient redo surgery was done to remove the remaining part of the cyst. There were four conversions in our series three with dense adhesions with airways either bronchus or trachea and one with dense adhesions with the great vessels (Table 1). Fig. 5: Thoracoscopic enucleation of hydatid cyst DISCUSSION Thoracoscopy in adults was described in 1910, while in pediatric age group it was first reported by Rodgers and Talbert in 1976. 1 Bronchogenic and other types of foregut cysts consist of 10 to 18% of all the mediastinal masses identified in infants and children, and when all age groups are included, 20 to 32% of all mediastinal masses. Symptoms are usually caused by compression of intrathoracic structures. Respiratory complaints are the predominant symptoms. 3 Radiological investigations like X-ray and CT scan are considered essential for displaying morphology, density, and extent of mediastinal cysts and in delineating any communication with esophagus or bronchus. 4 In cases where a neurenteric cyst is suspected because of associated vertebral anomaly, the spinal extension of the lesion should be evaluated using MRI and the spinal component should usually be approached first. 3 We did MRI in three of our cases. Various other minimally invasive modalities of treatment like percutaneous or transbronchial aspiration, injection of sclerosing agents, and excision via mediastinoscopy have also been reported as treatment modalities of these cysts. Even aspiration of a large bronchogenic cyst under CT guidance using a percutaneous approach has been described. 5 However, the recurrence rates with these methods are much higher than reported following surgical excision. 6 Michel et al 7 reported a series of 21 children with mediastinal cysts, of which 18 were successfully treated by thoracoscopy, rest of them required thoracotomy because of difficult dissection. Bratu et al, 3 with their experience of thoracoscopic excision in 11 patients, stated that magnification provided by thoracoscopy may be advantageous for the complete meticulous excision of foregut duplication cysts in different locations. Creating artificial pneumothorax collapses the lung and gives good exposure. 8 Aspiration of the cyst improves the vision and facilitates the dissection. 3 Amine et al 9 reported a series of 25 cases with pulmonary hydatid cysts treated using the thoracoscopic approach and found to be feasible. For better results, they recommended for cysts smaller than 5 cm. Ma et al 10 reported in their study the feasibility and safety of videoassisted thorascopic surgery for pediatric pulmonary hydatid disease treatment. If the cyst shares a common wall with the trachea or esophagus, this portion of the cyst wall can be left behind and the mucosa is stripped or destroyed by electrocautery. 11 Various studies pertaining to pediatric thoracoscopy have shown adhesions, large cysts, and subcarinal cysts are associated with high conversion International Journal of Education and Research in Health Sciences, July-September 2017;3(3):129-133 131

Beejal V Sanghavi et al Table 1: Case details Age/gender Location Excision Histopathology report Remark (if any) 5 yr/m Right posterior Complete Bronchogenic cyst 4 yr/m Right posterior Incomplete Bronchogenic cyst Dense adhesions with main bronchus so converted 2 yr/m Right posterior Complete Enteric duplication cyst 3 yr/f Subcarinal Complete Bronchogenic cyst 1 yr/m Right posterior Incomplete Foregut duplication cyst Densely adhered to the esophagus 2 yr/f Left posterior Complete Cystic hygroma 3 mo/m Right posterior Complete Bronchogenic cyst 3D scope used 6 mo/m Right posterior Complete Enteric duplication cyst 6 yr/f Right posterior Complete Bronchogenic cyst 10 yr/m (Fig. 5) Right anterior Complete Hydatid cyst Spillage prevented meticulously 5 yr/f Right posterior Incomplete Enteric duplication cyst Some part left on esophagus 6 yr/m subcarinal Complete Thymic cyst 5 mo/m Right posterior Complete Enteric duplication cyst 7 yr/m Right posterior Complete Hydatid cyst 8 yr/f Right posterior Complete Foregut duplication cyst Conversion being very near to great vessels 8 yr/m Left posterior Complete Bronchogenic cyst 6 yr/f Right posterior Complete Hydatid cyst Conversion as large bronchial communication 1 yr/m Right posterior Complete Enteric cyst 8 yr/m Right posterior Incomplete Foregut duplication cyst Operated by 3D. Some remnant on esophageal wall 8 yr/m Right posterior Complete Bronchogenic cyst 9 yr/f Right posterior Complete Hydatid cyst Conversion as densely adherent to airway 14 mo/m Subcarinal Complete Bronchogenic cyst 8 weeks/m Left anterior Complete Bronchogenic cyst 4 mo/f Right posterior Complete Bronchogenic cyst Bronchus opened, sutured thoracoscopically 8 yr/m Right posterior Complete Hydatid cyst 5 yr/m Subcarinal Complete Esophageal duplication cyst 4 yr/m Left posterior Complete Bronchogenic cyst 3 yr/m Right posterior Complete Esophageal duplication cyst 6 yr/m Left posterior Incomplete Bronchogenic cyst Cyst wall densely adherent to trachea and pulmonary vessels 2.5 yr/m Right posterior Incomplete complete Bronchogenic cyst Redo surgery for remnant in symptomatic patient operated by 3D scope rates. Compressive cysts with emphysema of lung and mediastinal shift were considered contraindication for thoracoscopy 6 but in our series, we could do thoracoscopy successfully in four such patients even in the presence of these comorbid factors. Thoracoscopy permitted good exposure of the mediastinum, provided adequate maneuverability, better knowledge of the anatomic relationship by magnification, and decrease in the surgical morbidity and sequalae. In one patient, part densely attached to esophagus was left behind owing to close adherence. In patients with hydatid cysts, meticulous care was taken to prevent spillage during dissection and removal (Table 2). 12,13 CONCLUSION Thoracoscopy in mediastinal cysts in the pediatric age group is a safe and effective procedure with low morbidity and a shorter hospital stay. It has the major advantage of superior vision in difficult to access areas. Meticulous and slow dissection, before aspirating the cyst, is an important technique to aid in successful thoracoscopic excision of mediastinal cysts. 132 Table 2: Case series of pediatric mediastinal masses Series No of patients Conversions Complication Michel et al 7 21 3 (14.28%) Esophageal injury, recurrent pneumothorax Bratu et al 3 11 0 Tracheal injury in three, esophageal injury in two Hazelrigg et al 12 9 1 (11.11%) One incomplete Partrick et al 13 38 1 (2.63%) A sarcoma converted because of extensive disease Amine et al 9 25 2 (8%) Ma et al 10 44 4 (9.09%) Present series 30 4 (13.33%) Bronchus injury sutured thoracoscopically ACKNOWLEDGMENT Authors would like to thank pediatric anesthetists as well as operation theater staff along with pediatric surgery residents.

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