SURGICAL DISORDERS OF MEDIASTINUM AND DIAPHRAGM Sina Ercan MD Professor of Thoracic Surgery.
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Transcript of SURGICAL DISORDERS OF MEDIASTINUM AND DIAPHRAGM Sina Ercan MD Professor of Thoracic Surgery.
SURGICAL DISORDERS OF SURGICAL DISORDERS OF MEDIASTINUM AND MEDIASTINUM AND
DIAPHRAGMDIAPHRAGM
Sina Ercan MDSina Ercan MD
Professor of Thoracic SurgeryProfessor of Thoracic Surgery
Anatomy of the Anatomy of the MediastinumMediastinum
Mediastinum is the Mediastinum is the central space within the central space within the thoracic cavity bounded thoracic cavity bounded by:by: Sternum anteriorlySternum anteriorly Lungs and parietal pleura Lungs and parietal pleura
laterallylaterally The vertebral column The vertebral column
posteriorlyposteriorly The thoracic inlet superiorlyThe thoracic inlet superiorly The diaphragm inferiorlyThe diaphragm inferiorly
Compartments of Compartments of mediastinummediastinum
Anterior mediastinum:Anterior mediastinum: the area the area posterior to the sternum and anterior posterior to the sternum and anterior to the heart and great vesselsto the heart and great vessels Thymus, substernal thyroid Thymus, substernal thyroid
glands, parathyroid, glands, parathyroid,
lymph nodes, lymph nodes,
connective tissueconnective tissue
Middle mediastinum:Middle mediastinum: the area the area between the posterior border of the between the posterior border of the anterior mediastinum and a line anterior mediastinum and a line placed along the posterior aspect of placed along the posterior aspect of the trachea and the heartthe trachea and the heart Heart, pericardium, aortic arc, Heart, pericardium, aortic arc,
brachiocephalic vessels, vena cava ,brachiocephalic vessels, vena cava ,
main pulmonary vessels, trachea, main pulmonary vessels, trachea,
main bronchi, phrenic and uppermain bronchi, phrenic and upper
parts of the vagus nerve, parts of the vagus nerve,
lymph nodeslymph nodes
Posterior MediastinumPosterior Mediastinum: The area : The area between the posterior aspect of between the posterior aspect of middle mediastinum and the middle mediastinum and the vertebraevertebrae Esophagus, azygos and hemiazygos Esophagus, azygos and hemiazygos
veins, thoracic duct, descending aorta, veins, thoracic duct, descending aorta, autonomic ganglia, symphathetic chain, autonomic ganglia, symphathetic chain,
lower portions of the vagus nerve, lower portions of the vagus nerve,
lymph nodes and connective tissuelymph nodes and connective tissue
Mediastinal PathologiesMediastinal Pathologies
Non neoplastic diseasesNon neoplastic diseases MediastinitisMediastinitis PneumomediastinumPneumomediastinum
Congenital pathologiesCongenital pathologies CystsCysts HerniasHernias
Acquired lesionsAcquired lesions BenignBenign MalignantMalignant
In adults 65% of the mediastinal lesions In adults 65% of the mediastinal lesions are anteriorare anterior
In children 52% of the mediastinal lesions In children 52% of the mediastinal lesions are posterior are posterior
40-50% of the mediastinal lesions are 40-50% of the mediastinal lesions are malignant in children compared to 25% malignant in children compared to 25% malignancies in adultsmalignancies in adults
Mediastinal Pathologic Mediastinal Pathologic LesionsLesions
Anterior mediastinal Anterior mediastinal disordersdisorders
TThymic disordershymic disorders Thymoma, Thymic Thymoma, Thymic
carcinomacarcinoma Thymic carcinoidThymic carcinoid ThymolipomaThymolipoma Thymic cystThymic cyst Thymic hyperplasiaThymic hyperplasia
TThyroid disordershyroid disorders Intrathoracic goiterIntrathoracic goiter
Germ cell tumorsGerm cell tumors TTeratomaeratoma SeminomaSeminoma OthersOthers
LymphomaLymphoma Hodgkin’s diseaseHodgkin’s disease Non-Hodgkin’s Non-Hodgkin’s
Parathyroid adenomaParathyroid adenoma Mesenchymal tumorsMesenchymal tumors
ThymomaThymoma Most common adult 1Most common adult 100 mediastinal mediastinal
neoplasm neoplasm Usually >40 y/oUsually >40 y/o 40-70% have symptoms related to 40-70% have symptoms related to
parathymic syndromesparathymic syndromes Myasthenia Gravis,Myasthenia Gravis, HypogammaglobulinemiaHypogammaglobulinemia Pure red cell aplasiaPure red cell aplasia Nonthymic malignanciesNonthymic malignancies
Thymomas represent neoplastic Thymomas represent neoplastic proliferation of thymic epithelial cells proliferation of thymic epithelial cells mixed with mature lymphocytesmixed with mature lymphocytes
CT demonstrates a homogenious soft CT demonstrates a homogenious soft tissue masstissue mass
CT guided needle biopsy, CT guided needle biopsy, mediastinoscopy, mediastinotomy or mediastinoscopy, mediastinotomy or VATVATS for diagnosisS for diagnosis
ThymomaThymoma
Thymic Carcinoma:Thymic Carcinoma: Malignant histologic featuresMalignant histologic features Pulmonary, regional lymph node or Pulmonary, regional lymph node or
pleural metastasis can be presentpleural metastasis can be present Thymic carcinoid: Thymic carcinoid:
a rare agressive neoplasm that originates a rare agressive neoplasm that originates from thymic neuroendocrine cellsfrom thymic neuroendocrine cells
Thymolipoma: Thymolipoma: a rare benign tumor composed of mature a rare benign tumor composed of mature
adipose and thymic tissueadipose and thymic tissue
CT image of a Thymolipoma (Exhibits fat and thymic soft tissue)
Mediastinal LymphomaMediastinal Lymphoma 10-20% of all mediastinal neoplasms in adults 10-20% of all mediastinal neoplasms in adults
May be 1May be 1oo in anterior or middle mediastinum in anterior or middle mediastinum or part of systemic malignancy or part of systemic malignancy
20-30% of patients are asymptomatic20-30% of patients are asymptomatic
Symptoms of local invasion or systemic Symptoms of local invasion or systemic symptoms (fever, weight loss, pruritis)symptoms (fever, weight loss, pruritis)
Hodgkin’s disease:Hodgkin’s disease: Bimodal age peak Bimodal age peak (20-30 years; >50 years)(20-30 years; >50 years)
Majority of patients have Majority of patients have asymmetric, bilateral mediastinal asymmetric, bilateral mediastinal LAPLAP
Non-Hodgkin’s Lymphoma:Non-Hodgkin’s Lymphoma: Usually in Usually in older patientsolder patients
Usually systemic upon presentation Usually systemic upon presentation and spreads unpredictablyand spreads unpredictably
Diffuse Large B-cell LymphomaDiffuse Large B-cell Lymphoma
Lymphoblastic LymphomaLymphoblastic Lymphoma
Mediastinal Germ-Cell Mediastinal Germ-Cell TumorsTumors
Teratomas:Teratomas: Account 60-70% of cases Account 60-70% of cases Consist of tissue that may derive from Consist of tissue that may derive from
more than one of the germ cell layersmore than one of the germ cell layers Mostly benign, radiologically spheric, Mostly benign, radiologically spheric,
lobulated, well circumscribed and may lobulated, well circumscribed and may contain calcificationcontain calcification
Seminomas:Seminomas: Affect men in 3rd and 4th decades Affect men in 3rd and 4th decades 40-50% of mediastinal malignant germ 40-50% of mediastinal malignant germ
cell tumorscell tumors
Teratoma (well formed teeth within the mass is diagnostic)
Germ cell tumor
MIDDLE MEDIASTINAL MIDDLE MEDIASTINAL DISORDERSDISORDERS
LymphomaLymphoma Benign Benign
lympadenopathylympadenopathy Granulomatous diseaseGranulomatous disease
InfectiousInfectious Non infectiousNon infectious
MiscellaneousMiscellaneous AmyloidosisAmyloidosis DrugsDrugs
Metastatic Metastatic lymphadenopathylymphadenopathy
CystsCysts Bronchogenic cystsBronchogenic cysts Pericardial cystPericardial cyst
Vascular LesionsVascular Lesions AneurismAneurism HemangiomaHemangioma
MiscellaneousMiscellaneous Diaphragmatic Diaphragmatic
herniashernias Pancreatic Pancreatic
pseudocystpseudocyst
Benign mediastinal Benign mediastinal lymphadenopathylymphadenopathy
InfectiousInfectious Tuberculosis: Usually unilateral and Tuberculosis: Usually unilateral and
asymmetric, may have calcificationasymmetric, may have calcification Fungal infectionsFungal infections
HistoplasmosisHistoplasmosis coccidioidomycosiscoccidioidomycosis
Non infectiousNon infectious Sarcoidosis: Usually bilateral, symmetricSarcoidosis: Usually bilateral, symmetric Silicosis: nodal calsification with Silicosis: nodal calsification with
eggshell configurationeggshell configuration
Normal mediastinal lymph nodes
Sarcoidosis
Unilateral hiler enlargement
CystsCysts
Bronchogenic cyst:Bronchogenic cyst: Originate from Originate from abnormal budding of ventral foregutabnormal budding of ventral foregut
Commonly in subcarinal and Commonly in subcarinal and paratracheal regions 15% in pulmonary paratracheal regions 15% in pulmonary paranchymeparanchyme
Lined by respiratory epithelium and may Lined by respiratory epithelium and may contain serous fluid, mucus, milk of contain serous fluid, mucus, milk of calcium, blood or purulent materialcalcium, blood or purulent material
Bronchogenic cyst
Enterogenous cysts:Enterogenous cysts: Esophageal dublication and neurenteric cysts Esophageal dublication and neurenteric cysts Located in the middle or posterior Located in the middle or posterior
mediastinummediastinum Pericardial Cysts:Pericardial Cysts:
In the cardiophrenic angles (R>L)In the cardiophrenic angles (R>L) Fibrous walls and contain clear fluidFibrous walls and contain clear fluid
Diaphragmatic hernias:Diaphragmatic hernias: Hiatal herniaHiatal hernia Morgagni herniaMorgagni hernia Bochdalek herniaBochdalek hernia
Pericardial cyst
Thoracic aortic aneurisym
Vascular lesionsVascular lesions
Posterior Mediastinal Posterior Mediastinal DisordersDisorders
Neurogenic tumorsNeurogenic tumors Peripheral nervePeripheral nerve
Schwannoma, Schwannoma, neurofibroma etcneurofibroma etc
Sympathetic gangliaSympathetic ganglia Ganglioneuroma, Ganglioneuroma,
neuroblastoma etcneuroblastoma etc Paraganglionic Paraganglionic
tumorstumors pheochromocytomapheochromocytoma
Esophageal Esophageal disordersdisorders Benign tumorsBenign tumors Esophageal Esophageal
diverticulumdiverticulum SpinalSpinal
Lateral thoracic Lateral thoracic meningocelemeningocele
Paraspinal abscessParaspinal abscess MiscellaneousMiscellaneous
Thoracic duct cystsThoracic duct cysts
CT of neurofibromaExtramedullary hematopoiesis
Diagnostic ProceduresDiagnostic Procedures
Physical examination Physical examination (Signs of Sup. V. (Signs of Sup. V. Cava or Horner Syndrome)Cava or Horner Syndrome)
Plain Chest Radiography Plain Chest Radiography (PA and Left (PA and Left lateral)lateral)
CTCT
Arteriography/ VenographyArteriography/ Venography
UltrasoundUltrasound MRIMRI Barium esophagramBarium esophagram Histologic evaluationHistologic evaluation
Fine needle aspirationFine needle aspiration Mediastinoscopy/mediastinotomyMediastinoscopy/mediastinotomy Thoracoscopy (VATS)Thoracoscopy (VATS) ThoracotomyThoracotomy
Non neoplastic Disorders of the Non neoplastic Disorders of the MediastinumMediastinum
PneumomediastinumPneumomediastinum
PneumopericardiumPneumopericardium
Acute MediastinitisAcute Mediastinitis
Chronic MediastinitisChronic Mediastinitis
PneumomediastinumPneumomediastinum Caused by alveolar overdistention Caused by alveolar overdistention
and ruptureand rupture
Etiology of Etiology of pneumomediastinumpneumomediastinum
SpontaneousSpontaneous Acute asthma attackAcute asthma attack Scuba divingScuba diving Mechanic ventilationMechanic ventilation VomitingVomiting
TraumaTrauma SurgerySurgery TracheostomyTracheostomy
Bronchoscopic Bronchoscopic proceduresprocedures
Respiratory tract Respiratory tract infectionsinfections
Dental infections or Dental infections or proceduresprocedures
Acute mediastinitisAcute mediastinitis PneumoperitoneumPneumoperitoneum Esophageal Esophageal
perforationperforation
Substernal chest pain is the most Substernal chest pain is the most frequent symptomfrequent symptom
Crepitation; air dissecting under the Crepitation; air dissecting under the skinskin
DyspneaDyspnea DysphagiaDysphagia DysphoniaDysphonia Hypotension (hemodynamic changes)Hypotension (hemodynamic changes)
Physical examination reveals Physical examination reveals palpable subcutaneous emphysema palpable subcutaneous emphysema in the neckin the neck
On auscultation of the chest a On auscultation of the chest a clicking sound over the pericardium clicking sound over the pericardium synchronous with the heartbeat synchronous with the heartbeat (Hamman’s sign)(Hamman’s sign)
Treatment:Treatment: SupportiveSupportive Supplemental oxygenSupplemental oxygen Management of causesManagement of causes Surgery, chest tube insertion when Surgery, chest tube insertion when
hemodynamic deterioriation is present hemodynamic deterioriation is present or when associated with mechanical or when associated with mechanical ventilationventilation
Iatrogenic esophageal perforation is the most Iatrogenic esophageal perforation is the most common cause of acute mediastinitiscommon cause of acute mediastinitis
Can also be:Can also be: Postemetic (Boerhaave’s syndrome)Postemetic (Boerhaave’s syndrome) TraumaTrauma Operative injuryOperative injury Cancer erosionCancer erosion Foreign bodyForeign body
Esophageal perforationEsophageal perforation
Esophageal perforationEsophageal perforation
Clinical signs and symptomsClinical signs and symptoms
Abrupt onset of severe chest pain, fever, Abrupt onset of severe chest pain, fever, dyspnea, SVC symptomsdyspnea, SVC symptoms
Tachypnea, tachycardia, hypotension, Tachypnea, tachycardia, hypotension, cervical emphysemacervical emphysema
Shock develops quicklyShock develops quickly Chest Radiology:Chest Radiology: Upper mediastinal Upper mediastinal
enlargement, emphysema, enlargement, emphysema, hydropnomothorax, multiple air fluid hydropnomothorax, multiple air fluid levelslevels
Mediastinitis
Treatment:Treatment: Surgical debridement of the necrotic Surgical debridement of the necrotic
tissuetissue Closure of the perforationClosure of the perforation DrainageDrainage Broad spectrum antibiotics with Broad spectrum antibiotics with
anaerobic coverageanaerobic coverage Mortality rises when the treatment delay Mortality rises when the treatment delay
is more than 24 hoursis more than 24 hours
Diseases of the DiaphragmDiseases of the Diaphragm Diaphragma is a dome shaped Diaphragma is a dome shaped
musculotendinous structure that musculotendinous structure that separates thoracic and abdominal separates thoracic and abdominal cavitiescavities
It consists of two parts:It consists of two parts: Right hemidiaphragmRight hemidiaphragm Left hemidiaphragmLeft hemidiaphragm
Middle portion is made of the central Middle portion is made of the central tendon that doesn’t contract, it has two tendon that doesn’t contract, it has two holes onholes on The caval openingThe caval opening The esophageal hiatusThe esophageal hiatus
Diaphragma thoracic view
Diaphragma abdominal view
The muscle fibers of the crural part The muscle fibers of the crural part originate from lomber vertebraeoriginate from lomber vertebrae
The muscle fibers of the costal part The muscle fibers of the costal part originate from the processus originate from the processus xiphoideus and 7-12 ribsxiphoideus and 7-12 ribs
The costal part contraction lowers The costal part contraction lowers the diaphragm and increases the rib the diaphragm and increases the rib cagecage
When the crural part contracts only When the crural part contracts only the diaphragm moves downwardthe diaphragm moves downward
Motor inervation comes from cervical Motor inervation comes from cervical motor neurons (C3-5) conducted via motor neurons (C3-5) conducted via N. FrenicusN. Frenicus
Diaphragm is the major inspiratuar Diaphragm is the major inspiratuar muscle responsible from 70% of muscle responsible from 70% of normal breathing.normal breathing.
Contraction of the diaphragm has the Contraction of the diaphragm has the following effects that promote air following effects that promote air movement into the lungsmovement into the lungs It decreases intrapleural pressureIt decreases intrapleural pressure It raises and inflates the rib cageIt raises and inflates the rib cage It expands the rib cage by generating It expands the rib cage by generating
positive intraabdominal pressurepositive intraabdominal pressure
Diaphragmatic paralysis:Diaphragmatic paralysis:
Can be bilateral or involve only one Can be bilateral or involve only one side (unilateral)side (unilateral)
In this setting the accessory muscles In this setting the accessory muscles of the respiration assume some or all of the respiration assume some or all the work of breathingthe work of breathing
Patients with Patients with bilateral diaphragmatic bilateral diaphragmatic paralysisparalysis typically present with typically present with dyspneadyspnea.. It is associated with It is associated with tachypnea and rapid shallow breathingtachypnea and rapid shallow breathing
Paradoxal motion of the anterior Paradoxal motion of the anterior abdominal wall during inspiration can abdominal wall during inspiration can be detectedbe detected
Hypoxemia is common due to Hypoxemia is common due to atelectasis and V/Q mismatch which atelectasis and V/Q mismatch which worsens with sleepworsens with sleep
Disease progression is associated with Disease progression is associated with progresive hypercapniaprogresive hypercapnia
Unilateral diaphragmatic paralysisUnilateral diaphragmatic paralysis is is more commonmore common
Often discovered incidentally on a chest Often discovered incidentally on a chest radiograph and diagnosis can be made radiograph and diagnosis can be made only by radiology (fluoroscopic sniff test)only by radiology (fluoroscopic sniff test)
Patients who do not have underlying Patients who do not have underlying lung disease are usually asymphtomaticlung disease are usually asymphtomatic
In fluoroscopic sniff test paradox In fluoroscopic sniff test paradox elevation of the paralysed elevation of the paralysed hemidiaphragm is positive >90% of the hemidiaphragm is positive >90% of the patientspatients
Diaphragmatic EventrationDiaphragmatic Eventration
Eventration of the diaphragm is a Eventration of the diaphragm is a disorder in which all or part of disorder in which all or part of the the diaphragmatic muscle is diaphragmatic muscle is replaced by fibroelastic tissuereplaced by fibroelastic tissue..
Eventration of the diaphragm can be Eventration of the diaphragm can be congenital or acquiredcongenital or acquired
Many patients are asymptomatic, Many patients are asymptomatic, especially when the eventration is especially when the eventration is localized localized
Can be seen incidentally on chest x Can be seen incidentally on chest x ray and ray and The diagnosis is confirmed The diagnosis is confirmed by fluoroscopy or ultrasonography. by fluoroscopy or ultrasonography.
In infants the management depends In infants the management depends on the extent of the respiratory on the extent of the respiratory distress, often no need to treatment distress, often no need to treatment
Diaphragmatic HerniaDiaphragmatic Hernia
Hiatal Hernias:Hiatal Hernias:Result when an abdominal structure usually Result when an abdominal structure usually the stomach extends through the the stomach extends through the diaphragmatic esophageal hiatus into the diaphragmatic esophageal hiatus into the thorax. Manifests as a retrocardiac mass in thorax. Manifests as a retrocardiac mass in the middle mediastinumthe middle mediastinum
Traumatic ruptureTraumatic ruptureSeen in 1-4% of blunt chest or abdominal Seen in 1-4% of blunt chest or abdominal trauma usually on the left posterolateral trauma usually on the left posterolateral regionregion
Traumatic rupture of the left hemidiaphragm
Congenital Hernias:Congenital Hernias:These are due to the failure of the normal fusion These are due to the failure of the normal fusion of the diaphragmatic components during of the diaphragmatic components during embryologic developmentembryologic development Morgagni hernias:Morgagni hernias: herniation of omentum and herniation of omentum and
other abdominal contents into the thorax other abdominal contents into the thorax manifest as a right cardiophrenic angle massmanifest as a right cardiophrenic angle mass
Bochdaleks hernias:Bochdaleks hernias: May protrude into the May protrude into the posterior mediastinumposterior mediastinum
Diagnosis can be established in diaphragmatic Diagnosis can be established in diaphragmatic hernias by gastrointestinal barium study or CT. hernias by gastrointestinal barium study or CT. Treatment is surgical in symptomatic cases.Treatment is surgical in symptomatic cases.
Morgagni hernia
Bochdaleks hernia