RESUMO
Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.
RESUMO
Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS-the supxiphoid approach-closes the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.
RESUMO
Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.
