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Mediastinoscopy vs. VATS

Mediastinoscopy vs. VATS. G. Alexander Patterson, MD Evarts A. Graham Professor of Surgery Chief, Department of Cardiothoracic Surgery Washington University School of Medicine Barnes-Jewish Hospital. History of Mediastinal Staging of NSCLC. Cervical mediastinoscopy

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Mediastinoscopy vs. VATS

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  1. Mediastinoscopy vs. VATS G. Alexander Patterson, MD Evarts A. Graham Professor of Surgery Chief, Department of Cardiothoracic Surgery Washington University School of Medicine Barnes-Jewish Hospital

  2. History of Mediastinal Staging of NSCLC • Cervical mediastinoscopy • Carlens (Karolinska Institute – Sweden) Dis Chest 1959; 36:343. • Pearson(University of Toronto – Canada) JTCVS 1965; 49:11.

  3. History of Mediastinal Staging of NSCLC • 1966: Anterior mediastinotomy • Chamberlain (Aortopulmonary window) Ann Thorac Surg 1966; 22:260.

  4. History of Mediastinal Staging of NSCLC • 1987: Extended mediastinoscopy • Ginsberg (University of Toronto) JTCVS 1987; 94:673.

  5. Prof. Antoon Lerut • 3-field lymphadenectomy • Video mediastinoscopy

  6. TxN1 NSCLCa

  7. Mediastinoscopy • Retrospective review of 2,137 patients who underwent mediastinoscopy over a 10-year period • 1,369 patients with lung cancer • 422 patients had metastatic carcinoma identified in the mediastinal nodes • 947 had a thoracotomy after negative mediastinoscopy • 76 (8%) patients were subsequently found to have mediastinal lymph nodes that contained metastatic carcinoma Hammoud et al. J ThoracCardiovascSurg 1999;118:894-9

  8. Mediastinoscopy • Sensitivity 85.2% • Specificity 100% • Complications • Death 1 • Esophageal perforation 1 • Pulmonary artery laceration 1 • Excessive bleeding 1 • Pneumothorax 1 • Hypotension 1 • IV fluid extravasation 1 • Arrhythmia 6 Hammoud et al. J ThoracCardiovascSurg 1999;118:894-9

  9. Mediastinoscopy for Staging Lung Cancer

  10. Adebibe, M et al. Interactive CardiovascThoracSurg 2012; 14:316-19

  11. Video Assisted Mediastinoscopy • Improved visualization • Better teaching • Higher lymph node yields • More lymph node stations Anraku, M et al. AnnThoracSurg 2010; 89:1577-81 Leschber, G et al. EJCTS 2008; 33:289

  12. Mediastinoscopy: An obsolete procedure • Inflammatory vs malignancy • Lymphoma • Small size nodes • Molecular profiling • Non-diagnostic EBUS • Training Rusch, V JTCVS 2011; 142:1400

  13. Mediastinoscopy vs. VATS Target location is paramount Detterbeck et al. Chest 2007; 132:202s

  14. Obiols, C et al. EJCTS 2012; 41:1043

  15. Extended Cervical Mediastinoscopy1998 – 2010 • Routine 89 • Selective 132 • Yield and safety profile do not compete with VATS Obiols, C et al. EJCTS 2012; 41:1043

  16. Re-do Mediastinoscopy

  17. Technical Details • Sharp dissection • Focus on target node • Needle aspiration for confirmation

  18. Indications • Inadequate prior mediastinoscopy • Obvious nodal target • No other minimally invasive option • i.e. VATS, Chamberlain, EBUS, EUS

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