Thoracoscopic resection of a paraaortic bronchogenic cyst
© Mondello et al; licensee BioMed Central Ltd. 2010
Received: 4 August 2010
Accepted: 15 October 2010
Published: 15 October 2010
Bronchogenic mediastinal cysts (BMC) represent 18% of primitive mediastinal tumors and the most frequent cystic lesions in this area. Nowadays, BMC are usually treated by VATS. However, the presence of major adhesions to vital structures is often considered as an unfavourable condition for thoracoscopic treatment. The authors report the thoracoscopic treatment of a BMC having dense adhesions to the aortic arch. Diagnosis and surgical treatment is described. Review of the literature and surgical options on this topic are discussed.
Bronchogenic mediastinal cysts (BMC) represent 18% of primitive mediastinal tumors, and are the most frequent cystic lesions in this anatomic region [1, 2]. Surgical resection is recommended. Video assisted thoracic surgery (VATS) has been reported for the resection of these lesions. However, the presence of major adhesions to vital structures is considered by some authors as an unfavorable condition for BMC treatment by VATS. We report a surgical approach by VATS for a BMC with adhesion to the aortic arch. Diagnosis and treatment of the specific case is reported with literature review and therapeutic options.
They represent congenital malformations arising from an abnormal division of the tracheobronchial tree. In relation to the time of separation from the main tracheobronchial tree, the cysts may localize into the lung parenchyma or in the mediastinum, with percentages of 33% and 66%, respectively [4–6].
They are usually unilocular, rarely multilocular. Their wall is represented by a ciliated columnar epithelium lining, cartilage structure and occasionally may contain a mucinoid filling. BMC are usually asymptomatic, and often casually diagnosed. When present, symptoms are usually related to the area of occurrence and include chest pain, cough, dyspnoea, dysphagia, or emoptysis [7, 8].
Complications may occur, including infection, emoptysis, trachea or superior vena cava compression, intracystic haemorrhage, rupture, bronchial fistula, pneumothorax, and malignant changes, which have all been reported [9–13]. For this reason once the diagnosis of MBC is done, even if asymptomatic, surgical resection may be recommended. Complete resection represents the therapeutic gold standard, minimizing the recurrence incidence. Standard treatment has been usually by thoracothomy . VATS treatment gradually became the first option also for BMC [15–17]. However, the presence of BMC with major adhesion to vital structures has been considered as an unfavorable condition for VATS treatment . In our case, we treated the BMC by VATS despite the important adhesion on the aortic arch. We believe that cautious dissection of the cystic lesion after needle aspiration may prove useful in this setting. Intraoperative cyst aspiration may help in the handling of the lesion, reducing the risk of rupture. The advantage of thoracoscopy treatment is evidenced by reduced discomfort for the patient. The decreased postoperative pain is a result of the lack of intercostal incisions. Hospital stay and chest tube duration are lower as compared to open thoracothomy . A relevant reason for conversion to open surgery would be major pleural adhesions [9, 14]. Aspiration of the cyst fluid has been recommended with the aim of facilitating cyst preparation . We used cyst aspiration during surgical dissection in order to better separate the cystic structure from the underlying aorta. When the cyst has adhesion to vital structures, surgical removal may be somewhat hazardous and incomplete removal may predispose to recurrence. In those cases, the use of diathermy may be useful in completing the surgical excision [8, 19]. In our case, even after total excision, we completed the surgical approach with the use of electrocautery to the area of cyst attachment. Late recurrences have been reported, even after 25 years . In any case, incomplete cyst excision has been reported not only for VATS but also for open surgery [5, 8–10, 14]. Cyst rupture during preparation does not prevent the procedure being completed by VATS . Accurate preoperative imaging studies have been recommended to better plan the operative strategy. Computed tomography (CT) scan and magnetic resonance imaging (MRI) are considered the best methodologies for preoperative diagnosis, with 100% reported accuracy for MRI . Transesophageal ultrasonography may be useful, especially if an esophageal duplication cyst with communication to the esophagus is suspected .
In conclusion, we believe a bronchogenic cyst should be treated by complete surgical resection. As previously reported by others, in relation to the advantages of the minimally invasive approach, we believe VATS treatment should be considered as the gold standard therapy. This approach may prove useful also in cases where there are adhesions to vital structures such as the aortic arch.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor in chief of this journal.
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