Diagnostic Anterior Mediastinotomy

Thoracic vascular structures often preclude transbronchial access to central lung parenchymal lesions and lymph nodes, thereby necessitating either a surgical or transvascular needle aspiration (TVNA) approach for diagnostic sampling. The aim of this study was to evaluate the safety and efficacy of endobronchial ultrasound (EBUS) TVNA in the diagnosis and staging of mediastinal tumors.

We performed a retrospective analysis of 35 cases of EBUS-TVNA. Cases were reviewed in the Cerner electronic medical records between March 2013 and October 2018. Records were reviewed for patient comorbidities, smoking status, anticoagulation intake, procedural details, sample results, and postprocedural complications.

Thirty-five EBUS-TVNA procedures were reviewed. Twenty-nine of them were performed by traversing the main pulmonary artery or its branches. Three involved transvascular access through the azygous vein, 2 via the brachiocephalic artery and 1 through the superior vena cava. Only 4 patients (11.4%) experienced postprocedural complications, which included mild hemoptysis, moderate hemoptysis requiring epinephrine and saline infusion, acute exacerbation of chronic obstructive pulmonary disease, and a rapid ventricular rate on top of preexisting atrial fibrillation. The yield of TVNA for malignancy was 22 (95.6%) of 23 patients. Overall yield was 31 (88.6%) of 35, with a need for additional intervention in 4 (11.4%) of 35 patients. Mutational analysis was adequate when ordered.

In our single-center experience, the EBUS-TVNA procedure had a high diagnostic yield and was associated with low rates of postprocedural complications. Further trials are needed to assess its efficacy compared to more invasive procedures.

Mediastinal masses are a common reason for referral. Accurate diagnosis is important, but in this relatively inaccessible location, also challenging. Malignant node involvement by carcinoma must be distinguished from various primary mediastinal tumors including lymphoma, as well as from a wide variety of nonmalignant causes of lymphadenopathy and benign enlargement of mediastinal structures. Metastasis to mediastinal or hilar lymph nodes by cancer is among the commonest causes of intrathoracic node enlargement in adults, especially those with risk factors for lung and other cancers. The clinical evaluation of mediastinal masses requires knowledge of anatomy, radiology, pathology, and a systematic differential diagnostic approach.

To highlight some of the legendary figures in the medical field who have paved the path of thoracic surgery today.

We reviewed historical articles and landmark studies published in anesthesiology, pulmonology, and thoracic surgery, and summarized them as they pertain to current practice.

Throughout our article, we have attempted to chronologically depict how our field has evolved, starting from the development of the stethoscope to reconstructing the esophagus using an extracorporeal tube to minimally invasive complex surgeries that we practice today.

We hope that our article can inspire the young minds to further grow the field and take it to higher levels.