Mediastinal Cysts Treatment & Management

Updated: Oct 27, 2021
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
  • Print
Treatment

Approach Considerations

Treatment selection for a given mediastinal tumor or cyst depends on the diagnosis of the lesion being investigated. Surgical resection is warranted in a large percentage of cases.

Surgical resection is indicated for most mediastinal cysts. All large and symptomatic bronchogenic cysts are included in the group, as are all enteric gastroenteric and neurenteric cysts. Some authors do not recommend resection of small asymptomatic bronchogenic cysts, whereas others advise aspiration of such cysts and resection only for those with symptoms or recurrence.

Excision of pleuropericardial cysts and simple mesothelial cysts is indicated for diagnostic purposes only. Thymic cysts require excision or enucleation. Thoracic duct cysts require excision and accompanying ligation of the thoracic duct.

Surgical removal is not indicated as primary treatment for (1) pleuropericardial cysts, lymphogenous cysts, and simple mediastinal cysts, provided that an accurate nonsurgical diagnosis has been performed, and (2) some cases of bronchogenic cysts found in adult patients in which the cyst is small and the patient has no symptoms. (This opinion varies among authors.)

Video-assisted thoracoscopic surgery (VATS) is employed by thoracic surgeons in the treatment of a number of mediastinal diseases. It has been commonly used for biopsy of masses and lymph nodes. Although VATS has been successful used to resect a variety of mediastinal cysts in both adult and pediatric patients, [25, 26] maintaining careful patient selection in these cases is important. The most important goal of these surgical procedures is complete resection of the cyst. If this cannot be accomplished by means of VATS technology, standard thoracotomy should be used. Single-port as well as multiple-port VATS approaches have been found to be feasible for mediastinal cystectomy. [27]

Robotic-assisted approaches to resection of mediastinal cysts have also been described. [28, 32]

Next:

Surgical Therapy

Surgical resection is the treatment of choice for most cysts that occur in the mediastinum. In particular, it is the treatment of choice for foregut, gastroenteric, and neurenteric cysts of the mediastinum.

The entire cyst wall should be resected to prevent recurrence. In many cases, a portion of the cyst wall may be densely adherent to adjacent structures, usually the tracheobronchial tree or the esophagus. Nevertheless, complete resection can be accomplished in most cases. In cases in which complete removal is not possible, the mucosal lining should be removed from the portion of cyst wall left within the mediastinum. This is performed in an attempt to prevent recurrence.

Pleuropericardial cysts may require resection for diagnosis, though the diagnosis is often made by nonsurgical means. Lymphangiomatous or thoracic duct cysts should be resected, and the communication with the thoracic duct should be ligated.

Preparation for surgery

The standard preoperative management applicable to all chest surgical cases also applies to the preoperative management of individuals undergoing resection of mediastinal tumors.

Airway management is of paramount importance in dealing with tumors that can produce a mass effect on these structures. For safe management of the airway distorted or narrowed by a mediastinal mass, consider a detailed preoperative assessment of the airway, and ensure adequate visualization and readily available supplementary equipment (eg, flexible bronchoscope). Placement of a double-lumen endotracheal tube to provide single-lung ventilation is usually preferred for any procedure in which a thoracotomy approach is used.

Appropriate preoperative, intraoperative, and postoperative antibiotic coverage is warranted. In cases where infected cysts are resected, modify antibiotic coverage when culture results identify the organism(s) involved.

Operative details

As in all thoracic surgical cases, the patient must be properly positioned for the indicated procedure. Tumors or cysts located in the anterior mediastinum are generally approached through a median sternotomy. Those located in the posterior or middle mediastinum and paravertebral sulci, such as most neurogenic tumors and foregut cysts, are approached through a posterolateral thoracotomy.

Use of a double-lumen endotracheal tube for single-lung ventilation is preferable for those procedures performed through a thoracotomy and for all VATS procedures.

Occasionally, emergency resection of a bronchogenic cyst is required in an infant with severe airway obstruction. Although most of these cases can be managed by using standard anesthesia techniques with positive-pressure ventilation and nitrous oxide, a few require special care. Several authors have described the intraoperative use of an ultrathin fiberoptic bronchoscope to assist in the management of the airway and the assessment of oxygen and anesthetic delivery during these difficult cases.

VATS techniques have been used to resect bronchogenic [33] and neurenteric cysts in adults and children. Because of cyst size, location, and adherence to adjacent structures, VATS is not appropriate for every case, and careful case selection is important.

Previous
Next:

Postoperative Care

Care of patients after resection of mediastinal cysts is similar to that after any noncardiac surgery of the chest.

Extubation can be performed at the completion of the case or shortly thereafter in the postanesthesia recovery area. Patients who require ventilatory support for a longer time should be treated accordingly.

Pulmonary toilet is an essential part of postoperative management after any kind of chest surgery to prevent atelectasis and to mobilize and clear any bronchial secretions. Various methods to assist with pulmonary toilet are available.

Pain control is a critical factor in postoperative management after thoracic surgery. Adequate cough effort and ventilatory excursion cannot be maintained without satisfactory pain control. Administration of analgesic agents via thoracic epidural catheter is an excellent and highly effective method of pain management. Lumbar epidural catheters can also be used, and, with proper choice of analgesic agents, they provide good pain relief.

Patient-controlled analgesia (PCA) is another widely used method and is preferred to traditional intramuscular or intravenous administration of narcotics and other agents. It is not as efficient for pain control as epidural analgesia.

At some point after oral intake has begun, pain medication can be converted to oral analgesic agents.

Wound management is straightforward. Operative dressings are removed after 24 hours in most cases. Thoracic surgical incisions heal well and have an extremely low rate of dehiscence and infection.

Chest tubes are managed in the same way as in other forms of thoracic surgery. Most cases of mediastinal tumor or cyst resection or biopsy do not involve pulmonary or esophageal resection. Chest tubes are maintained on –20 cm of water-seal suction, and drainage from the tubes is measured daily. Patients are followed with daily chest radiographs, and films are evaluated for findings of residual undrained collections, complete pulmonary expansion, lobar atelectasis and infiltrates, and other abnormalities.

When drainage from the chest tubes is less than 50-100 mL in 24 hours, no air leak is present, and the chest radiograph shows full pulmonary expansion with no collections on the operated side, the chest tubes may be removed.

Previous
Next:

Complications

Complications that occur after resection of mediastinal cysts are similar to those that can occur after any thoracic surgical procedure.

As with any thoracic surgical procedure, postoperative pulmonary complications are most common. Atelectasis is a common postoperative complication and can develop into pneumonia if not treated aggressively. Aggressive pulmonary toilet and pain management are key factors in the prevention of these complications.

Wound infections after sternotomy or thoracotomy are rare. The chest wall has an excellent blood supply, and, with few exceptions, healing occurs readily. Also, existing intrathoracic infection is generally not a factor during resection of any of the noted mediastinal tumors, and these operations are considered clean procedures. The exception to this may be in cases of resection of some foregut cysts that may have secondary infection present.

Injury to the phrenic nerve can occur, resulting in temporary or permanent diaphragmatic paresis. This can cause the patient to have symptomatic dyspnea and atelectasis on the affected side. Children of individuals with marginal pulmonary status from underlying pulmonary disease or those with neuromuscular abnormalities causing weakness of the muscles of respiration may experience significant respiratory difficulties from this complication.

Injury to a vagus nerve can also occur during surgery of the mediastinum. Usually, only one vagus nerve is injured, and the remaining intact nerve maintains parasympathetic input to the gut without symptoms. If both vagus nerves are injured, difficulties with gastric emptying may occur because the innervation to the pylorus is disrupted.

Recurrence of the cyst is a potential long-term complication. This can occur if the entire mucosal lining of the cyst is not removed. Cases in which this is most likely are those in which a portion of the cyst is adherent to a vital mediastinal structure and is left behind. Attempted resection of infected cysts is associated with a higher likelihood of this complication. In addition, incomplete resection is more likely when VATS technology is used because visibility and mobility of the operative field are more limited than they would be with a standard thoracotomy.

In general, mortality and morbidity related to the resection of foregut and other mediastinal cysts are extremely low.

Previous
Next:

Long-Term Monitoring

Patients who undergo resection of mediastinal cysts can be followed for a short time (ie, 3-6 months) postoperatively while wound healing and progression of patient activity are being monitored.

Previous