Traditional medicine

Rules for surgical intervention for tumors and cysts of the mediastinum. Thoracoscopic removal of mediastinal teratoma How much does posterior mediastinal cystic surgery cost?

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of issues of anesthesia, surgical techniques, diagnosis of various mediastinal processes and neoplasms. New diagnostic methods make it possible not only to accurately establish the localization of a pathological formation, but also make it possible to evaluate the structure and structure of the pathological focus, as well as obtain material for pathomorphological diagnosis. Recent years have been characterized by the expansion of indications for surgical treatment of mediastinal diseases, the development of new highly effective, low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of mediastinal disease.

Mediastinal injuries:

1. Closed trauma and wounds of the mediastinum.

2. Damage to the thoracic lymphatic duct.

Specific and nonspecific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

According to the clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

B) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic pericardial cysts;

B) cystic lymphangitis;

B) bronchogenic cysts;

D) teratomas

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the disintegration of a pericardial tumor;

D) mediastinal cysts arising from the border areas.

Mediastinal tumors:

1. Tumors arising from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors arising from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors arising from the tissues of the mediastinum and located between organs (extraorgan tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors of nervous tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this location).

I. Tumors arising from nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

B) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

B) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

D) tumors arising from blood vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus gland:

A) thymoma;

B) thymus cysts.

D. Tumors from reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) substernal goiter;

B) intrathoracic goiter;

B) adenoma of the parathyroid gland.

The mediastinum is a complex anatomical formation located in the middle of the thoracic cavity, enclosed between the parietal layers, spinal column, sternum and lower diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but knowledge of them is mandatory and necessary from the standpoint of the requirements for providing surgical care to this group of patients.

The mediastinum is divided into anterior and posterior. The conventional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum there are: the thymus gland, part of the aortic arch with branches, the superior vena cava with its sources (brachiocephalic veins), the heart and pericardium, the thoracic part of the vagus nerves, the phrenic nerves, the trachea and the initial sections of the bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum there are: the descending aorta, azygos and semi-gypsy veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the splanchnic nerves, nerve plexuses, lymph nodes.

To establish a diagnosis of the disease, localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a full clinical examination. It should be noted that the disease in the initial stages is asymptomatic, and pathological formations are an accidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology of the pathological process. Typically, patients complain of pain in the chest or heart area, interscapular area. Pain is often preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Shortness of breath and difficulty breathing are often observed. When the superior vena cava is compressed, cyanosis of the skin of the face and upper half of the body and their swelling may be observed.

When examining the mediastinal organs, it is necessary to conduct thorough percussion and auscultation and determine the function of external respiration. Important during the examination are electro- and phonocardiographic studies, ECG data, and X-ray studies. Radiography and fluoroscopy are carried out in two projections (direct and lateral). When a pathological focus is identified, tomography is performed. The study, if necessary, is supplemented with pneumomediastinography. If the presence of a substernal goiter or an aberrant thyroid gland is suspected, ultrasound examination and scintigraphy with I-131 and Tc-99 are performed.

In recent years, when examining patients, instrumental research methods have been widely used: thoracoscopy and mediastinoscopy with biopsy. They allow a visual assessment of the mediastinal pleura, partly the mediastinal organs, and collection of material for morphological examination.

Currently, the main methods for diagnosing mediastinal diseases, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the course of individual diseases of the mediastinal organs:

Damage to the mediastinum.

Frequency - 0.5% of all penetrating chest wounds. Damage is divided into open and closed. Features of the clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the neck veins. X-ray shows darkening of the mediastinum in the area of the hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

When the vagus nerves are imbibited by blood, vagal syndrome develops: respiratory failure, bradycardia, deterioration of blood circulation, and confluent pneumonia.

Treatment: adequate pain relief, maintaining cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, puncture of the pleura and subcutaneous tissue of the chest and neck with short and thick needles is indicated to remove air.

When the mediastinum is injured, the clinical picture is complemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of external respiratory function and ongoing bleeding.

Damage to the thoracic lymphatic duct can occur with:

1. closed chest injury;
2. knife and gunshot wounds;
3. during intrathoracic operations.

As a rule, they are accompanied by a severe and dangerous complication: chylothorax. If conservative therapy is unsuccessful, surgical treatment is required within 10-25 days: ligation of the thoracic lymphatic duct above and below the injury, in rare cases, parietal suturing of the duct wound, implantation into the azygos vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the mediastinal tissue caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

Open mediastinal injuries.
1. Complications of operations on the mediastinal organs.
2. Contact spread of infection from adjacent organs and cavities.
3. Metastatic spread of infection (hematogenous, lymphogenous).
4. Perforation of the trachea and bronchi.
5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental damage, damage by foreign bodies, tumor disintegration).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the varying severity of which leads to a variety of its clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized by the clinical picture of damage or disease that preceded the development of mediastinitis or was its cause.

General manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, agitation, euphoria with transition to apathy.

With limited posterior mediastinal abscesses, the most common symptom is dysphagia. There may be a dry barking cough up to suffocation (involvement of the trachea), hoarseness (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The patient's position is forced, semi-sitting. There may be swelling in the neck and upper chest. On palpation there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus or trachea.

Local signs: chest pain is the earliest and most persistent sign of mediastinitis. The pain intensifies when swallowing and throwing the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the location of the process.

Anterior mediastinitis	Posterior mediastinitis
Chest pain	Chest pain radiating into the interscapular space
Increased pain when tapping the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gehrke's symptom	Increased pain when swallowing
Pastiness in the sternum area	Pastosity in the area of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, cyanosis of the face, swelling of the veins of the neck	Symptoms of compression of the paired and semi-gypsy veins: dilatation of the intercostal veins, effusion in the pleura and pericardium
With CT and NMR - a darkened zone in the projection of the anterior mediastinum	With CT and NMR - a darkened zone in the projection of the posterior mediastinum
X-ray - shadow in the anterior mediastinum, presence of air	X-ray - shadow in the posterior mediastinum, presence of air

When treating mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists of providing optimal access, exposing the injured area, suturing the rupture, draining the mediastinum and pleural cavity (if necessary) and applying a gastrostomy tube. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the method of N.N. Kanshin (1973): drainage of the mediastinum with tubular drainages, followed by fractional rinsing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial diseases are divided into nonspecific and specific (syphilitic, tuberculous, mycotic).

What is common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

Idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis) is of greatest surgical importance. In a localized form, this type of mediastinitis resembles a tumor or mediastinal cyst. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis and orbital pseudotumor.

The clinical picture is determined by the degree of compression of the mediastinal organs. The following compartment syndromes are identified:

Superior vena cava syndrome
Pulmonary vein compression syndrome
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is determined, its elimination leads to a cure.

Mediastinal tumors. All clinical symptoms of various mediastinal mass formations are usually divided into three main groups:

1. Symptoms from the mediastinal organs, compressed by the tumor;

2. Vascular symptoms resulting from compression of blood vessels;

3. Neurogenic symptoms developing due to compression or sprouting of nerve trunks

Compression syndrome manifests itself as compression of the mediastinal organs. First of all, the brachiocephalic and superior vena cava veins are compressed - superior vena cava syndrome. With further growth, compression of the trachea and bronchi is noted. This is manifested by cough and shortness of breath. When the esophagus is compressed, swallowing and passage of food are impaired. When the tumor of the recurrent nerve is compressed, phonation disturbances, paralysis of the vocal cord on the corresponding side. When the phrenic nerve is compressed, the paralyzed half of the diaphragm stands high.

When the borderline sympathetic trunk is compressed, Horner's syndrome causes drooping of the upper eyelid, narrowing of the pupil, and retraction of the eyeball.

Neuroendocrine disorders manifest themselves in the form of joint damage, heart rhythm disturbances, and disturbances in the emotional-volitional sphere.

The symptoms of tumors are varied. The leading role in making a diagnosis, especially in the early stages before the appearance of clinical symptoms, belongs to computed tomography and x-ray methods.

Differential diagnosis of mediastinal tumors themselves.

		Location		Content		Malignancy	Density
Teratoma	The most common tumor of the mediastinum	Anterior mediastinum	Significant	Mucous membrane, fat, hair, organ rudiments	Slow		Elastic
Neurogenic	Second most common	Posterior mediastinum	Significant	Homogeneous	Slow			Fuzzy
Connective tissue	Third most common	Various, most often anterior mediastinum	Various	Homogeneous	Slow
Lipoma, hibernoma		Various	Various	Mixed structure	Slow			Fuzzy
Hemangioma, lymphangioma		Various						Fuzzy

Thymomas (tumors of the thymus) are not classified as mediastinal tumors themselves, although they are considered together with them due to the peculiarities of localization. They can behave both benign and malignant tumors, giving metastases. They develop either from epithelial or lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis. The malignant variant occurs 2 times more often, is usually very severe and quickly leads to the death of the patient.

Surgical treatment is indicated:

with an established diagnosis and suspicion of a tumor or mediastinal cyst;
for acute purulent mediastinitis, foreign bodies in the mediastinum causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated if:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
the general serious condition of the patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that when choosing the scope of surgical intervention in cancer patients, one should take into account not only the growth pattern and extent of the tumor, but also the general condition of the patient, age, and the condition of vital organs.

Surgical treatment of malignant tumors of the mediastinum gives poor results. Hodgkin's disease and reticulosarcoma respond well to radiation treatment. For true mediastinal tumors (teratoblastomas, neuromas, connective tissue tumors), radiation treatment is ineffective. Chemotherapy methods for the treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgical intervention as the only way to save the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various surgical approaches are used: a) complete or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, in which both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavity; d) diaphragmotomy with and without opening the abdominal cavity; e) opening the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages at the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Work ability examination.

Clinical examination of patients

To determine the ability of patients to work, general clinical data are used with a mandatory approach to each person examined. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - disease or tumor, age, complications from the treatment, and in the presence of a tumor - possible metastasis. It is common to be placed on disability before returning to professional work. For benign tumors after radical treatment, the prognosis is favorable. The prognosis for malignant tumors is poor. Tumors of mesenchymal origin are prone to relapses followed by malignancy.

Subsequently, the radicality of the treatment and complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, and disturbances in the ventilation function of the lungs.

Security questions

1. Classification of mediastinal diseases.
2. Clinical symptoms of mediastinal tumors.
3. Methods for diagnosing mediastinal tumors.
4. Indications and contraindications for surgical treatment of tumors and mediastinal cysts.
5. Operative approaches to the anterior and posterior mediastinum.
6. Causes of purulent mediastinitis.
7. Clinic of purulent mediastinitis.
8. Methods for opening ulcers with mediastinitis.
9. Symptoms of esophageal rupture.

10. Principles of treatment of esophageal ruptures.

11. Causes of damage to the thoracic lymphatic duct.

12. Chylothorax clinic.

13. Causes of chronic mediastinitis.

14. Classification of mediastinal tumors.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Ill for 2 years. The thyroid gland is not enlarged. Basic exchange +30%. A physical examination of the patient did not reveal any pathology. An X-ray examination reveals a rounded formation 5x5 cm with clear boundaries in the anterior mediastinum at the level of the second rib on the right, the lung tissue is transparent.

What additional studies are needed to clarify the diagnosis? What is your tactic in treating a patient?

2. Patient, 32 years old. Three years ago I suddenly felt pain in my right arm. She was treated with physiotherapy - the pain decreased, but did not go away completely. Subsequently, I noticed a dense, lumpy formation on the right side of the neck in the supraclavicular region. At the same time, the pain in the right side of the face and neck intensified. At the same time I noticed a narrowing of the right palpebral fissure and a lack of sweating on the right side of the face.

Upon examination, a dense, lumpy, immobile tumor and an expansion of the superficial venous section of the upper half of the body in front were discovered in the right clavicular region. Slight atrophy and decreased muscle strength in the right shoulder girdle and upper limb. Dullness of percussion sound over the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What's your tactic?

3. Patient, 21 years old. She complained of a feeling of pressure in her chest. Radiologically, on the right, an additional shadow is adjacent to the upper part of the mediastinal shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think of? What is your tactics in treating the patient?

4. Over the past 4 months, the patient has developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. An X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus at this level is compressed, but its mucous membrane is not changed. Above the compression there is a long delay in the esophagus.

What is your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed substernal pain and swelling in the neck area on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your tactics and treatment?

6. Sick 60 years. A day ago in the hospital, a fish bone was removed at level C 7. After which swelling appeared in the neck area, temperature up to 38°, abundant salivation, palpation on the right began to detect an infiltrate of 5x2 cm, painful. X-ray signs of phlegmon of the neck and expansion of the mediastinal body from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrathoracic goiter, it is necessary to carry out the following additional examination methods: pneumomediastinography - in order to clarify the topical location and size of tumors. Contrast study of the esophagus - to identify dislocation of mediastinal organs and displacement of tumors during swallowing. Tomographic examination - to identify narrowing or pushing aside of the vein by a neoplasm; scanning and radioisotope study of thyroid function with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of a retrosternal goiter in this location is less traumatic to be carried out using a cervical approach, following the recommendations of V.G. Nikolaev to cross the sternohyoid, sternothyroid, and sternocleidomastoid muscles. If there is a suspicion of fusion of the goiter with surrounding tissues, transthoracic access is possible.

2. You can think about a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in direct and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography is necessary. In order to identify disorders of the sympathetic nervous system, the Linara diagnostic test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine react, taking on a brown color.

Treatment of a tumor that causes compression of nerve endings is surgical.

3. You can think about a neurogenic tumor of the posterior mediastinum. The main thing in diagnosing a tumor is to establish its exact location. Treatment consists of surgical removal of the tumor.

4. The patient has a tumor of the posterior mediastinum. The most likely neurogenic character. The diagnosis can be clarified by a multifaceted X-ray examination. At the same time, it is possible to identify the interest of neighboring authorities. Considering the location of the pain, the most likely cause is compression of the phrenic and vagus nerves. Treatment is surgical, in the absence of contraindications.

5. One can think about iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After an X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by sanitation of the wound.

6. The patient has perforation of the esophagus with subsequent formation of phlegmon of the neck and purulent mediastinitis. Treatment is surgical opening and drainage of neck phlegmon, purulent mediastinotomy with subsequent sanitation of the wound.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Other specified organs of the chest (D15.7), Unspecified organs of the chest (D15.9), Mediastinum (D15.2)

Oncology, Surgery

General information

Brief description

Approved
Joint Commission on Health Care Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
from August 25, 2016
Protocol No. 10

- structures that are complex in topography, they are characterized by their location in a single anatomical space, located in the middle of the chest between the right and left pleural cavities.

Note*: Benign neoplasms of the mediastinum, originating from various tissues, have common anatomical boundaries. They are distinguished by a variety of morphological forms, but are united by similar clinical symptoms, the nature of the course of the disease, and the methods of diagnosis and treatment used. To date, there are more than 100 types of benign mediastinal neoplasms. There are pathological processes that often develop in the mediastinum, which are of the greatest clinical interest, and rare neoplasms, the frequency of which ranges from single to several dozen cases. In this regard, early diagnosis of mediastinal tumors, which essentially belongs to the category of preventive measures for the development of severe and complicated forms of the disease, is of particular importance. The clinical picture consists of symptoms of compression of the neoplasm into neighboring organs (pain, superior vena cava syndrome, cough, shortness of breath, dysphagia) and general manifestations (weakness, fever, sweating). Diagnosis of mediastinal neoplasm includes radiation and endoscopic examination methods, transthoracic or transbronchial puncture biopsy. Treatment of a benign neoplasm of the mediastinum is surgical.

Correlation of ICD-10 and ICD codes:

ICD-10		ICD-9
Code	Name	Code	Name
D15.2	Benign neoplasms of the mediastinum	34.311	Thoracoscopic removal of posterior mediastinal tumor (neurinoma, lipoma)
D15.7	Benign neoplasms of other specified organs of the chest	34.29	Other diagnostic manipulations in the mediastinum
D15.9	Benign neoplasms of the chest organs, unspecified	34.30	Excision or destruction of the damaged area or tissue of the mediastinum
		34.22	Mediastinoscopy

Date of protocol development/revision: 2016

Protocol users: GPs, therapists, thoracic surgeons, pulmonologists, surgeons, oncologists, emergency physicians, endoscopists.

Relationship between strength of evidence and type of research:

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population .
WITH	Cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population or RCT with a very low or low risk of bias (++ or +), the results of which cannot be directly distributed to the relevant population.
D	Case series or uncontrolled study or expert opinion.

Classification

Classification
The following classifications are most convenient for differential diagnosis:

Classification of E.V. Golbert and G.A. Lavnikova (1965):
1) formations emanating from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus and others);
2) formations emanating from the walls of the mediastinum (chest wall, diaphragm and pleura, pericardium);
3) formations emanating from the tissues of the mediastinum and located between the organs (extraorgan).
The formations of the third group are true tumors of the mediastinum. They, in turn, are divided according to histogenesis: formation from nervous, connective tissue, blood vessels, smooth muscles, lymphoid tissue and mesenchyme. In addition, mediastinal cysts (from the embryonic embryo of the foregut, coelomic and lymphatic) and formations from tissue displaced into the mediastinum due to defects in embryonic development (the rudiments of the thyroid gland, parathyroid gland, multipotent cells) are isolated.

Classification developed by I.P. Dedkov and V.P. Zakharychev (1982), in which mediastinal neoplasms, according to their origin, are divided into the following groups:
1) primary formations developing from the tissues of the mediastinum itself and tissues dystopic into the mediastinum, as well as formations of the thymus gland;
2) formation of mediastinal organs (esophagus, trachea, pericardium, heart, pulmonary arteries and veins, and others);
3) formations developing from the tissues of the walls limiting the mediastinum (pleura, chest wall, diaphragm);
4) secondary malignant tumors of the mediastinum (metastases, mediastinal form of lung cancer and others);
5) mediastinal cysts.
Note*: Benign formations and cysts are much more common than malignant ones (4:1). Summary statistics of 902 patients with mediastinal masses and cysts demonstrate the following distribution of various diseases:
- congenital cysts were observed in 22.3%, neurogenic cysts - 15.8%, thymomas - 13.1%, mediastinal goiter - 5.2%, pericardial cysts - 2.8%.
- malignant tumors of the mediastinum occurred in 23.6% of cases.
- among mediastinal neoplasms, the most common are thymomas (18%), followed by dysembryomas (12%), which are divided into teratomas and seminomas.
At the same time, 24 histological types of mediastinal tumors were identified. The most common tumors were thymus gland, neurogenic formations, cysts and lymphomas.
Obviously, the most reliable criteria for constructing a classification of mediastinal neoplasms can be obtained based on the development of classifications for individual types of mediastinal neoplasms.

Classification by location - mediastinum is called the part of the thoracic cavity limited in front by the sternum, partially by the costal cartilages and retrosternal fascia, behind by the anterior surface of the thoracic spine, the necks of the ribs and prevertebral fascia, and on the sides by the layers of the mediastinal pleura. The mediastinum is limited below by the diaphragm, and above by a conventional horizontal plane drawn through the upper edge of the manubrium of the sternum.
The most convenient scheme for dividing the mediastinum, proposed in 1938 by Twining, is two horizontal (above and below the roots of the lungs) and two vertical planes (in front and behind the roots of the lungs).
In the mediastinum, therefore, three sections (anterior, middle and posterior) and three floors (upper, middle and lower) can be distinguished:
· in the anterior section of the superior mediastinum are: thymus gland, upper section of the superior vena cava, brachiocephalic veins, aortic arch and branches extending from it, brachiocephalic trunk, left common carotid artery, left subclavian artery;
· located in the posterior part of the superior mediastinum: esophagus, thoracic lymph duct, trunks of sympathetic nerves, vagus nerves, nerve plexuses of organs and vessels of the thoracic cavity, fascia and cellular spaces;
· located in the anterior mediastinum: fiber, spurs of the intrathoracic fascia, the leaves of which contain the internal mammary vessels, retrosternal lymph nodes, anterior mediastinal nodes.
In the middle part of the mediastinum there are: pericardium with the heart enclosed in it and inside the pericardial sections of large vessels, bifurcation of the trachea and main bronchi, pulmonary arteries and veins, phrenic nerves with accompanying phrenic-pericardial vessels, fascial cellular formations, lymph nodes.
In the posterior part of the mediastinum are located: descending aorta, azygos and semi-gypsy veins, trunks of sympathetic nerves, vagus nerves, esophagus, thoracic lymphatic duct, lymph nodes, tissue with spurs of the intrathoracic fascia surrounding the mediastinal organs.
According to the departments and floors of the mediastinum, certain preferential localizations of most of its neoplasms can be noted. Thus, it has been noticed, for example, that intrathoracic goiter is often located in the upper floor of the mediastinum, especially in its anterior section. Thymomas are found, as a rule, in the middle anterior mediastinum, pericardial cysts and lipomas in the lower anterior. The upper floor of the middle mediastinum is the most common location of teratodermoids. In the middle floor of the middle part of the mediastinum, bronchogenic cysts are most often found, while gastroenterogenic cysts are detected in the lower floor of the middle and posterior parts. The most common neoplasms of the posterior mediastinum along its entire length are neurogenic formations.

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS

Diagnostic criteria: Recognition of mediastinal tumors is one of the difficult sections in the diagnosis of diseases of internal organs. This is due, first of all, to the variety of pathological processes encountered here, their low-symptomatic manifestations, especially in the early stages of development, the absence of pathognomonic clinical and radiological signs, as well as the topographic and anatomical features of this area.
The absence of pathognomonic symptoms in the early stages of the process, the complexity of differential diagnosis and morphological verification of the diagnosis are the main reasons for the untimely start of treatment, and if morphological verification is not possible, there is a danger of choosing irrational treatment tactics.
The final diagnosis can only be established through a morphological study of the material.
At present, there is no doubt that the leading method in recognizing mediastinal neoplasms is the radiation method, which allows from 80% to 90% of cases to establish the localization of the formation and its type, but the nature of the process is determined only by studying a histological or cytological specimen.
The most reliable diagnosis is morphological verification. For the morphological diagnosis of mediastinal neoplasms, TTPB, TTPPB, mediastinoscopy, parasternal mediastinotomy, thoracoscopy and diagnostic thoracotomy are used. Formations of the posterior mediastinum cause compression of the respiratory tract, heart and great vessels much less frequently. A manifestation of mediastinal syndrome is an increase in venous pressure in the upper half of the body with normal venous pressure in the lower half of the body. In this case, swelling of soft tissues appears on the face, occipital region, neck, shoulder region and upper extremities along with cyanosis. Cyanosis is more pronounced when the patient is horizontal, its intensity decreases when the patient stands up. Patients complain of headache, pain in the upper extremities, often cough and hoarseness of voice. Collaterals develop compensatoryly, dilatation and tension of the veins of the chest wall, neck and face occur. In some cases, deformation of the anterior chest wall is noted.
With neurogenic tumors, neurological symptoms often occur: pain in the back, behind the sternum, along the intercostal nerves, paresthesia, changes in dermographism.
With systemic lesions, symptoms of intoxication appear more often than with other diseases: weakness, sweating, shortness of breath, fever, weight loss.
However, these symptoms are also not pathognomonic. All researchers involved in the diagnosis and treatment of mediastinal tumors point to the low diagnostic value of clinical data. This is evidenced by the high percentage of erroneous diagnoses with which patients are admitted for examination.

Laboratory research: There are no laboratory diagnostic criteria.

Instrumental studies:
· radiography of the chest organs, frontal and lateral projections - space-occupying formations of the mediastinum appear in the form of an additional shadow. An important diagnostic symptom of space-occupying formations of the anterior mediastinum, revealed on radiographs and tomograms of the chest in the lateral projection, is a decrease in the transparency of the retrosternal space;
· CT scan of the chest (UD-B) - to identify the relationship of the neoplasm with surrounding tissues (according to indications, when referred to the hospital, for surgical intervention);
· Ultrasound of the chest organs (UD-V) - for surgical intervention, when referred to a hospital;

· MRI - for accurate visualization of mediastinal vessels.

Diagnostic algorithm:

Indications for the use of various research methods in the diagnosis of mediastinal tumors:

Diagnostic method	Indications	Tasks
Polypositional fluoroscopy and radiography	Establishing a topical diagnosis and, if possible, the nature of the neoplasm	Determination of localization, prevalence, size, shape, contours, presence of pulsation, relationship of the neoplasm with surrounding organs
Coagulogram	Radiological suspicion of a malignant neoplasm of the mediastinum	Determination of the state of the coagulation-lytic system in patients with mediastinal tumors
FTBS	Differential diagnosis of neoplasms located in the anterior mediastinum, accompanied by respiratory disorders	Exclusion of disease of the tracheobronchial tree, according to TTBPB indications
EFS	Differential diagnosis of neoplasms located in the posterior mediastinum, accompanied by dysphagia, and tumors of the esophagus	Clarification of the nature of neoplasms and identification of the relationship of the tumor to the esophagus
CTG	Establishing a topical diagnosis, clarifying the structure of the tumor, establishing the nature of the neoplasm	Determination of the topogram of the neoplasm, prevalence, size, shape and contours, nature of the tissue, its relationship to neighboring organs, presence of lymph nodes
MRI	Differential diagnosis of neoplasms and anomalies of large vessels, neoplasms of lymphoid and cartilaginous tissue	Clarification of the diagnosis, establishment of the nature of the tissue, determination of the topogram of the neoplasm, prevalence, size, shape and contours
Ultrasound	Differential diagnosis of mediastinal neoplasms, dynamics of the process	Determination of the nature (liquid, tissue) of decay cavities, effusion in the pleural cavity
Pre-core biopsy	Presence of enlarged lymph nodes	Determination of the condition of the lymph node, the presence of metastases
TTBPB	Differential diagnosis of mediastinal neoplasms with lymphadenopathy of the same localization	Differentiation of pathology, exclusion of respiratory tract diseases
TTPB	Differential diagnosis of benign and malignant mediastinal tumors	Verification of neoplasms
Diagnostic thoracoscopy	Establishing a final diagnosis	Decision on operability, removal of tumor

Based on these data, an algorithm of studies necessary for the diagnosis and differential diagnosis of mediastinal tumors has been compiled. When examining a patient, the following comprehensive examination program should be followed:

Stage I: the benign or malignant nature of the neoplasm is established.

II stage studies of patients with benign neoplasms of the mediastinum:

Diagnostics (ambulance)

DIAGNOSIS AND TREATMENT AT THE EMERGENCY CARE STAGE

Diagnostic measures: collection of complaints and anamnesis.

Drug treatment: symptomatic, depending on the dysfunction of the mediastinal organs.

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL

Diagnostic criteria at the hospital level:

Complaints and anamnesis, physical examination, Andinstrumental research(see paragraph 9, subparagraph 1), and also:
diagnostic thoracoscopy - allows verification between malignant and benign tumors, according to Appendix 1 of this CP.

Diagnostic algorithm: see outpatient level.

· radiography of the chest organs, frontal and lateral projection - on radiographs in the lateral projection, space-occupying formations of the mediastinum appear as an additional shadow. An important diagnostic symptom of space-occupying formations of the anterior mediastinum, revealed on radiographs and tomograms of the chest in the lateral projection, is a decrease in the transparency of the retrosternal space;
· CT scan of the chest (UD-B) - according to indications, to identify the relationship of the neoplasm with surrounding tissues (when referred to the hospital for surgical intervention);
· Ultrasound of the chest organs (UD-V) - when referred to a hospital for surgical intervention;
· fiberoptic bronchoscopy - for compression of the tracheobronchial tree;

provides for examination during emergency hospitalization and after a period of more than 10 days:
· UAC;
· OAM;
· biochemical blood test;
· coagulology;
· microbiological examination of sputum (or throat smear);
· determination of sensitivity to antibiotics;
· Ultrasound of the abdominal cavity.
· ECG.

Differential diagnosis

Differential diagnosis and rationale for additional studies

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
Benign neoplasms of the mediastinum		CTG with contrast of chest vessels	Benign tumors of the mediastinum slowly enlarge and push apart surrounding tissues and organs, but do not grow inward. Cysts are thin-walled, round formations with liquid contents. There are bronchial and pericardial. An informative research method is CT, which allows you to determine its size, assess the thickness of the walls of the cyst, the nature of the contents, and the relationship with neighboring anatomical formations.
Aortic aneurysm	Shadow formation in the mediastinum	CTG with contrast of chest vessels. Ultrasound	Contrasting of an aortic aneurysm is a characteristic expansion of the wall of an artery (less commonly, a vein) or heart due to its thinning or stretching. An aneurysm is characterized by an expansion of the shadow of the vascular bundle. Most patients experience displacement of the contrast-enhanced esophagus. Ultrasound allows us to identify the presence and size of aneurysms of the ascending, descending aorta, aortic arch, abdominal aorta, the condition of the vessels extending from the aorta, as well as the presence of aortic valve defect, the nature of changes in the aortic wall. When performing computed tomography, it is possible to determine the involvement of large arteries in the process and identify signs of wall dissection.
Sarkaidosis	Shadow formation in the mediastinum	CTG of the chest	Damage to the lymph nodes and lungs. This is a systemic inflammatory disease affecting the lungs, bronchopulmonary, tracheobronchial, and intrathoracic lymph nodes. One of the forms of acute sarcoidosis is Löfgren's syndrome with a triad of symptoms: bilateral hilar lymphadenopathy, erythema nodosum, arthralgia.
Lymphoma	Shadow formation in the mediastinum	CTG of the chest
Lymphogranulomatosis	Shadow formation in the mediastinum	CTG of the chest	Damage to lymph nodes and lungs
Malignant tumors of the mediastinum	Shadow formation in the mediastinum	CTG of the chest	Tumor invasion of the surrounding tissues of the mediastinum with damage to the lymph nodes
Echinococcosis of the mediastinum and lungs	Shadow formation in the mediastinum	CTG of the chest	Presence of fibrous capsule and fluid contents
Relaxation of the diaphragm	Shadow formation in the mediastinum	CTG of the chest	Mixing of abdominal organs into the pleural cavity
Tuberculosis of intrathoracic lymph nodes -	Shadow formation in the mediastinum	CTG of the chest	Develops as a result of primary infection with tuberculosis. A CT scan of the chest reveals signs of enlarged lymph nodes in the root of the lung. Clinical is manifested by the presence of intoxication, with its inherent clinical symptoms: low-grade fever, deterioration of general condition, loss of appetite, loss of body weight, sweating, poor sleep.
Substernal goiter	Shadow formation in the mediastinum	CTG of the chest. Chest X-ray	Tumor growth into the surrounding tissues of the mediastinum with damage to the lymph nodes. A retrosternal goiter is an abnormally low-lying and pathologically enlarged thyroid gland. An enlarged gland can be identified by palpation at the upper edge of the sternum or when performing the Valsava test, when during coughing due to increased intrathoracic pressure the retrosternal goiter is displaced; CT examination is one of the most informative diagnostic methods. A characteristic radiological sign of a retrosternal goiter is the presence of darkening in the upper part of the anterior mediastinum. The retrosternal nodular form of the disease can be more accurately determined using ultrasound.

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Treatment

Drugs (active ingredients) used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT

Treatment tactics: Treatment of mediastinal tumors is surgical. Waiting tactics and dynamic observation in such cases are unjustified.

Non-drug treatment:
Mode - general;
Diet: Table No. 15 with recommendations after surgical treatment.
· For women, postpone pregnancy for a year;
· exclusion of baths for 3 months.

Drug treatment: painkillers according to indications .
Further tactics for introducing the patient: surgical treatment in specialized hospitals.

List of essential medicines: No.

painkillers:
· Ketoprofen 100-200 mg 2-3 times IM for 2-3 days.

Algorithm of actions in emergency situations:

Other types of treatment: No.

When referred to a hospital for surgery.
· consultation with a cardiologist, therapist, gastroenterologist, pulmonologist and other specialized specialists - as indicated.

Monitoring the patient's condition: local observation, the outpatient card notes: in the postoperative - the general condition of the patient, the presence/absence of discomfort in the mediastinum.

· timely diagnosis;
regression of symptoms of the disease;
· absence of pathological formations in the mediastinum in the postoperative period.

Preventive measures:
· timely diagnosis;
· examination according to clinical indications;
· dispensary observation;
· prevention of relapse after treatment.

Treatment (inpatient)

INPATIENT TREATMENT

Treatment tactics: The main method of treatment is surgical.

Non-drug treatment:
Mode - free;
Diet: Table - 15.

Drug treatment

List of essential medicines:
Painkillers 1-3 days after surgery :
· Ketoprofen, 100-200 mg, 2-3 times, IM, IV, orally.

List of additional medicines: according to indications.

No.	INN name	dose	multiplicity	method of administration	duration of treatment	note	UD
Antibacterial drugs for the prevention of mediastenitis
1	ceftriaxone or	1-2 gr.	1 time per day	i/v and i/m	7-14 days	3rd generation cephalosporins	A
2	levofloxacin	250-750 mg 250-750 mg	1 time per day	i.v. and i.m.	7-10 days	fluoroquinolones	A
Antiseptics
1	povidone - iodine	10%	daily	externally	as needed	for treating skin and drainage systems	IN
2	chlorhexidine	0,05%		externally		for treating skin and drainage systems	IN
3	ethanol	solution 70%;	for processing the surgical field, surgeon's hands	externally		for treating skin	A
4	hydrogen peroxide	1-3% solution	as needed	externally locally	according to indications	oxidizer for wound treatment	A
5	brilliant green	1% solution	after surgery	externally locally	As needed	for wound treatment	A

Surgical intervention indicating the indications for surgical intervention, in accordance with Appendix 1 to this CP;
1. VTS, removal of a mass from the mediastinum.
2. Thoracotomy/sternotomy, removal of mediastinal mass .

Other treatments: No.

Indications for consultation with specialists:
· consultation with a pulmonologist - in order to determine the degree of respiratory failure, lung functionality in COPD;
· consultation with an anesthesiologist-resuscitator - to resolve the issue of anesthesia;
· consultation with a clinical pharmacologist - in order to select adequate therapy with antibacterial and supportive, accompanying drugs before, during and after surgery and throughout the entire treatment;
· consultation with a therapist, cardiologist and other specialized specialists - as indicated.

Indications for transfer to the intensive care unit:
In the postoperative period, observation by an anesthesiologist until complete awakening and stabilization of the condition.

Indicators of treatment effectiveness:
regression of symptoms of the disease;
· absence of pathological formations according to radiological research methods;
· normalization of KBC and LBC indicators;
· normalization of physical parameters of the body.

Further management:
standard rehabilitation of the patient after abdominal surgery;
Limiting physical activity for 3 months;
· control of UAC, BAK
· fluorography 6 months after surgery;
· control of CTOGK, 1 year after surgery;
· dispensary observation for 2 years.

MEDICAL REHABILITATION: No.

PALLIATIVE CARE: No.

Hospitalization

INDICATIONS FOR HOSPITALIZATION, INDICATING THE TYPE OF HOSPITALIZATION

Indications for planned hospitalization: presence of mediastinal neoplasm.

Indications for emergency hospitalization: neoplasm of the mediastinum with dysfunction of the chest organs.

Information

Sources and literature

Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2016
1. 1) Aliev M.A., Ioffe L.Ts., Dashiev V.A., Beisebaev A.A., Matybaev N.K. Diagnostic and operative thoracoscopy: Guidelines. -Alma-Ata, 1982. -28 p. 2) Trishin V.M., Orzheshevsky O.V., Reshetov A.V., Andreev A.L. Diagnosis and surgical treatment for mediastinal tumors [[Bulletin of Surgery. –2001. -No. 3-4. –P.11-14. 3) Kirov S.A., Tregubov V.S., Trunov A.D., Yastrebov V.V. Benign neoplasms of the mediastinum [[ Thoracic and cardiovascular surgery. -1990. -No.9. -WITH. 68-70. 4) Avilova O.M., Getman V.G., Afrasiab-ogly Vagif., Sokur P.P. Diagnosis and treatment of benign tumors and mediastinal cysts. Oncology issues. -1987. -No.5. -P.75-78. 5) Aliev M.A., Voronov S.A., Rakishev G.B., Shafransky L.L. Surgical treatment of mediastinal cysts and primary tumors in children [[ La Chir. Torac. 1991. Vol. 44-No.5. -RR.161-164. 6) Wagner E.A., Dmitrieva A.M., Bruns V.A., Firsov V.D., Kubarikov A.P. Benign tumors and cysts of the mediastinum [[ Bulletin of Surgery named after. I.I. Grekova. -1985. -No. 3. -WITH. 3-8. 7) Vishnevsky A.A., Adamyan A.A. Mediastinal surgery. - M., 1985. - 150 p. 8) Mayo JR., Hartman TE., Lee KS. CT of the chest: minimal tube current required for good image quality with the least radiation dose [[ AJR. American Journal of Roentgenology.-1995.-164(3).-P.603-7. 9) Ermakov N.P., Biryukov Yu.V., Imamov Ch. Analysis of CT data for mediastinal neoplasms [[ Abstract. report 1st All-Union Symposium: Computed tomography in the clinic. -M., -1987. -WITH. 83-84. 10) Galil-Ogly G.A., Kharchenko V.P., Alipchenko L.A. Primary tumors of the thymus gland - thymoma [[ Physiol., morphol. and pathology of the thymus. -M., -1986. -WITH. 77-81. 11) Durnov L.A., Dvoirin V.V. Malignant tumors in children [[ Bulletin of the All-Russian Scientific Research Center of the USSR Academy of Medical Sciences. -1991. -No. 2. P.47-52. 12) Pykov M.I., Vatolin K.V. Ultrasound diagnostics in pediatrics [[Computer technologies in medicine.-1997.-No.1.-P.51-53. 13) Chissov V.I., Trakhtenberg A.Kh. Errors in clinical oncology: a guide for doctors. M., Medicine-1993.-544 p. 14) Shulutko M.L. Diagnosis and surgical treatment of mediastinal forms of malignant tumors [[Bulletin of Surgery named after. Grekova.-1994.-No. 3-4.-p.129-132. 15) Labetsky I.I., Koshechkina N.A. Radiation diagnostics of malignant tumors in children [[Children's Oncology.-1995.-No. 2-3.-P.32-37. 16) Belyakov P.D., Iskra L.P., Kasimov A.V. Pulmonary embolism in cancer patients [[ Diagnosis and treatment of pulmonary embolism. – M., 1980. P.20-21. 17) Borodulin B.P., Khudzik L.B. Prevention and treatment of thromboembolic complications in patients with malignant neoplasms [[Proceedings of the 2nd All-Union Conference “Vascular wall damage and hemostasis”. – M., 1983. – P. 513-514. 18) Naito S., Inoue S., Kings H., Tanake K. Thromboplastic and fibrinlytic activities of cultured human gastric cancer all lines [[ Cann. – 1983. – Vol. 74. No. 2. – P. 240-247. 19) Kudryavtseva L.K. The state of the hemostatic system in cancer of the uterus and ovaries: Diss. Ph.D. – M. -1984. –178s. 20) Kher A., Hilgard P. Development et dissemination deus tumors maligns et hemostase [[ Pathol. Biol. – 1982. – Vol. 30, no. 10. –P. 861-867. 21) Vishnevsky A.A., Efendiev I.Kh., Imamov Ch. Current state of the problem of diagnosing tumors and mediastinal cysts [[ Thoracic surgery. -1982. -No. 2. -WITH. 74-79. 22) Getman V.G., Kizimenko V.M. Thoracoscopic diagnosis of some types of intrathoracic tumors and cysts [[Breast surgery. - 1988. -№6. -WITH. 52-57. 23) Glushkov V.R. X-ray and bioptic diagnosis of mediastinal diseases: Abstract of thesis. diss. Candidate of Medical Sciences -M., 1979. -22 p. 24) Gredzhev A.F., Stupachenko O.N., Kravets V.S. etc. Surgical treatment of neoplasms of the thymus gland [[Breast surgery. -1986. -No. 4. -WITH. 59-63. 25) Imamov Ch. Modern differential diagnosis of neoplasms and cysts of the mediastinum: Abstract of thesis. diss. Ph.D. honey. Sci. -M., 1986. -21 p. 26) Ioffe L.Ts., Dashiev V.A. Diagnostic and operative thoracoscopy [[Sb. scientific works: Diagnosis and treatment of nonspecific lung diseases. - Alma-Ata. -1981. -WITH. 5-15. 27) Boutin C., Viallat J., Cargino P., Rey F. Thoracoscopic lung biopsy: experimental and clinical preliminary study [[ Chest. -1982. -Vol. 82. -P. 44-48. 28) Dashiev V.A. The use of thoracoscopy for the diagnosis and treatment of lung diseases. pleura and mediastinum and endoscopic operations: abstract. diss. Ph.D. honey. Sci. -Alma-Ata, 1984. -20 p. 29) Oakes D., Sherck J., Brodsky J., Mark J. Therapeutic thoracoscopy [[ J. Thorac. Cardiovasc. Surg. -1984. -Vol. 87. -P. 269-273. 30) Avilova O.M., Getman V.G., Makarov A.V. Thoracoscopy in emergency thoracic surgery [[ Coll. scientific works scientific and practical. conference.-Kyiv. -1986. - P. 128. 31) Dotsenko A.P., Pirozhenko V.V., Baidan V.I., Shipulin P.P. Diagnosis and surgical treatment of tumors and mediastinal cysts [[ Thoracic surgery. -1987. -No.3. -WITH. 69-72. 32) Demidov V.P. Tactics of recognition and treatment of tumors and cysts of the mediastinum: Abstract of thesis. diss. doc. honey. Sci. -M., 1973. -40 p. 33) Perelman M.I., Biryukov Yu.V., Sedova T.N. Surgery of mediastinal neoplasms [[Surgery.-1988.-No.6. -WITH. 56-62. 34) V.A. Tarasov, Yu.K. Sharov, S.N. Kichemasov. Features of automyoplasty for extensive resections of the pericardium and diaphragm [[ Journal “Thoracic and Cardiovascular Surgery”.-Moscow. -Medicine. -2000. -No. 1.-P.72-73. 35) Petrovsky B.V. Mediastinal surgery. -M., 1960. -256 p. 36) Jaretki A., Penn A., Younger D. et al. “Maximum” thymectomy for myasthenia gravis. Results [[ J. Thorac. Cardiovasc. Surg. -1998. -Vol.95. -P. 747-757. 37) Miller J., Hatcher C. Limited resection of bronchogenic carcinomain the patient with marked impairment of pulmonary function [Ann. Thorac. Surg. –1987. –Vol.44. –P. 340-343. 38) Bogush L.K., Zharakhovich I.A. Biopsy in pulmonology.-M.: Medicine. - 1977.-240s. 39) Gentry SE., Harris MA. Posterior mediastinal mass in a patient with chest pain [.
  More often it is possible to complete surgery in the initial phases of malignancy of benign tumors and mediastinal cysts.
  
  The literature provides numerous history diseases, the analysis of which can lead to a conclusion about common complications observed with benign mediastinal tumors and cysts. They primarily depend on the growth of the tumor and compression of its vessels, trachea, heart, as well as on infection of the contents of the cyst [Yu. Yu. Dzhanelidze, 1929; Goyer and Andrus (Goyer, Andrus, 1940); Key (Key, 1954), etc.]. According to G. B. Bykhovsky (1899), with dermoid cysts of the mediastinum treated conservatively, the prognosis is poor in 100% of cases (24 patients were observed).
  
  Similar data for fibroids mediastinum reported by Goyer and Endras (1940). It should be noted that there is a high percentage of malignancy in benign cysts and tumors. So, according to Kent (Kent, 1944), it is 37-41%.
  
  So the experience majority surgeons speaks of the presence of direct indications for surgery in all patients with benign tumors and mediastinal cysts.
  
  Similar indications are also accepted for retrosternal goiter, the dangers of which are especially clearly revealed in the upper aperture of the chest, where the tumor is strangulated. In such cases, the trachea usually moves to the side or is displaced by a growing tumor.
  
  At the same time, success surgery in recent years have significantly reduced the risk of surgical intervention for foreign bodies, tumors and mediastinal cysts. Mortality after such operations was 7-10% by 1956, and has now decreased even more.
  All of the above also confirms the need to expand the indications for surgical treatment of mediastinal diseases.
  
  Bazarov D.V., Charchyan E.R., Shestakov A.L.
  A rare and difficult clinical case is presented. A 70-year-old patient has a history of emergency stenting of a thoracic aortic aneurysm at the height of profuse pulmonary hemorrhage. For 2 years after aortic stenting, the quality of life is good. By the end of 2 years...
  
  Grigorchuk A.Yu., Boranov E.V.
  Tumors of the posterior mediastinum most often originate from nerve tissue, that is, they are classified as neurogenic tumors. Surgical treatment is currently the only effective treatment for such tumors. This film shows a modern approach to removing such tumors when...
  
  Grigorchuk A.Yu., Abdumuradov K.O., Seregina O.I.
  A young woman developed throbbing headaches. The fluorogram revealed an expansion of the heart shadow and was sent for Computed Tomography (CT). CT data revealed a cystic-solid formation (tumor with a large cavity in its central part). The patient independently contacted...
  
  Grigorchuk A.Yu., Bazarov D.V., Boranov E.V.
  Video of thoracoscopic surgery. At the same time, the RIGHT tumor was removed! lung and mediastinal tumor on the LEFT! through a right-side thoracoscopic approach (without a large incision under video camera control). An X-ray revealed a mediastinal tumor in the patient and sent...
  
  Bazarov D.V., Grigorchuk A.Yu., Epifantsev E.A.
  A 66-year-old patient came to the Department of Thoracic Surgery of the Russian Scientific Center for Surgery named after Academician B.V. Petrovsky with complaints of pain and discomfort behind the sternum. X-ray revealed a large tumor of the anterior mediastinum, bordering both pleural cavities. A completely closed thoracoscopic operation was performed: removal...
  
  Grigorchuk A.Yu., Abdumuradov K.O.
  A relatively rare case of a neurogenic tumor of the right vagus nerve. A peculiarity of the operation is the inaccessible location of the proximal “leg” of the tumor, which originated from the side of the neck in a narrow gap between the right brachiocephalic vein and the bifurcation of the brachiocephalic trunk into the common carotid and subclavian...
  
  Bazarov D.V., Belov Yu.V., Grigorchuk A.Yu., Volkov A.A., Boranov E.V.
  In a patient with a mediastinal germ cell tumor growing into the left atrium, the tumor was removed with resection of the left atrial appendage on a beating heart.
  
  The mediastinum is a complex of organs and neurovascular formations located in the thoracic cavity and limited by the mediastinal pleura on the sides, behind - by the thoracic spine, below - by the diaphragm, from above directly communicates with the organs of the neck through the upper aperture of the chest.
  The position of the mediastinum is asymmetrical, its size and shape in different sections are not the same. Since the distance from the sternum to the spine is greater at the bottom than at the top, the sagittal size of the mediastinum increases downwards. The sternum is shorter than the thoracic spine, so the mediastinum is shorter anteriorly than posteriorly. The mediastinal sections of the pleura, which make up the lateral borders of the mediastinum, are not located in the sagittal plane; they diverge significantly above and below due to the position of the heart and other anatomical formations. In the region of the roots of the lungs, the mediastinal pleura come closer together and, therefore, in the frontal plane the mediastinum has an hourglass shape.
  Taking into account the peculiarities of the topography of the mediastinal organs, as well as in connection with surgical access to them, until recently it was common among topographic anatomists to divide the mediastinum into anterior and posterior. The conventional boundary between these sections is the frontal plane, drawn through the trachea and main bronchi. The anterior mediastinum is divided into an upper section, containing the thymus, large vessels and nerves, and a lower section, containing the pericardium and heart. The posterior mediastinum above and below is represented by the same organs, so there is no need to divide it.
  The International Anatomical Nomenclature (PNA) distinguishes 5 sections of the mediastinum (Fig. 66): the upper - from the upper border of the thoracic cavity to the tracheal bifurcation (a conventional horizontal plane drawn through the angle of the sternum and the intervertebral disc between the IV and V thoracic vertebrae) and the lower, in which the anterior (between the sternum and the pericardium), the middle (between the anterior and posterior layers of the pericardium) and the posterior (between the pericardium and the spine) are distinguished. The superior mediastinum includes the following anatomical formations: the thymus gland, brachiocephalic veins, superior vena cava, aortic arch and its branches, trachea, esophagus, thoracic duct, sympathetic trunks, vagus and phrenic nerves. The middle mediastinum contains the pericardium with the heart and intrapericardial sections of large vessels, the bifurcation of the trachea and the main bronchi, pulmonary arteries and veins, phrenic nerves and pericardial diaphragmatic vessels. The posterior mediastinum contains the esophagus, descending aorta, azygos and semi-gypsy veins, thoracic duct, sympathetic trunks, splanchnic nerves and vagus nerves.
  Rice. 66. Sagittal section of the chest cavity. I – superior mediastinum; II – anterior mediastinum; III – middle mediastinum; IV – posterior mediastinum. 1 – right pulmonary artery; 2 – right atrium; 3 – esophagus; 4 – thoracic aorta; 5 – left brachiocephalic vein; 6 – thymus gland; 7 – ascending aorta; 8 – pericardium; 9 – aortic bulb 10 – right ventricle; 11 – diaphragm; 12 – trachea.
  During the practical lesson, based on knowledge of anatomy, the skeletopy, syntopy and holotopy of the mediastinal organs, as well as their blood supply, innervation and lymphatic drainage are analyzed.
  Injuries to the pericardium and heart during penetrating chest wounds are quite common (12%). The clinical picture and features of surgical tactics depend on the location, size and depth of the heart wound. The closer the inlet hole is to its projection on the anterior chest wall, the greater the possibility of injury to the heart. Bleeding into the pericardial cavity is often observed, which can lead to cardiac tamponade. When blood accumulates in the pericardial cavity, the right atrium and thin-walled vena cava are compressed, then the function of the ventricles of the heart is impaired due to their mechanical compression. Acute cardiac tamponade is manifested by Beck's triad (a drop in blood pressure, a sharp increase in central venous pressure and a weakening of heart sounds).
  One of the ways to diagnose hemorrhage in the pericardial cavity and provide emergency assistance for cardiac tamponade is pericardial puncture. The puncture is performed with a thick needle or thin trocar. More often, pericardial puncture is done according to the Larrey method (Fig. 67).
  Rice. 67. Puncture of the pericardial cavity according to the Larrey method. a – front view; b – on a sagittal section.
  The puncture is made into the angle between the attachment of the left seventh costal cartilage and the base of the xiphoid process to a depth of 1.5-2 cm, then the needle is passed in the cranial direction until it feels like it is falling into the cavity. There is no need to be afraid if the needle penetrates the heart cavity. It is necessary to slowly withdraw the needle to the pericardial cavity and remove the contents.
  The success of treatment for a heart injury depends on the time it takes for the victim to be delivered to a medical facility, the speed of surgery and the effectiveness of intensive care. If a victim with a heart injury survives to enter the operating room, then his life, as a rule, is saved.
  Surgical access for wounds of the heart should be simple, low-traumatic and provide the possibility of inspection of all organs of the chest cavity. In recent years, anterolateral thoracotomy along the fourth intercostal space on the left has been widely used. To suture a cardiac wound, synthetic threads with atraumatic needles should be used as suture material. The suture on the ventricles of the heart should cover the entire thickness of the myocardium, but not penetrate into the heart cavity, in order to avoid the formation of blood clots. For small wounds of the heart, interrupted sutures are applied; for large wounds, mattress sutures are used. When applying sutures to the wall of the heart, the branches of the coronary arteries must not be sutured, as this can lead to myocardial infarction and cardiac arrest. If the coronary arteries are damaged, a vascular suture should be attempted to restore blood flow. The cycle of the heart when applying sutures has no practical significance. The pericardium is sutured with rare interrupted single sutures to ensure adequate outflow of residual blood from the pericardium.
  Congenital heart defects and large blood vessels are divided into three groups: isolated heart defects (ventricular or atrial septal defect, patent foramen ovale); isolated defects of large vessels (coarctation of the aorta, pulmonary stenosis, patent ductus botallus); combined defects of the heart and large blood vessels (triad, tetralogy, pentad of Fallot, etc.). Fallot's triad is characterized by narrowing of the pulmonary trunk, right ventricular hypertrophy and ventricular septal defect. Tetralogy of Fallot - narrowing of the pulmonary artery, right ventricular hypertrophy, ventricular septal defect and dextraposition of the aorta (Fig. 68). With the pentade of Fallot, the fifth sign is the presence of an atrial septal defect.
  Surgical treatment of combined heart defects and large blood vessels is divided into two groups: radical operations - suturing of defects of the interventricular or interatrial septum, excision of a narrowed section of the aorta or pulmonary trunk (prosthesis); palliative operations - aimed at creating anastomoses between the vessels of the systemic and pulmonary circulation (between the aorta and the pulmonary artery, between the subclavian artery and the left pulmonary artery, between the superior vena cava and the right pulmonary artery).
  Rice. 68. Tetralogy of Fallot (Isakov Yu.F., Doletsky S.Ya., Pediatric surgery. -1971).
  The choice of treatment usually depends on the general condition of the patient. To carry out radical operations on the heart, it is necessary to use a heart-lung machine (ACB) (Fig. 69). The AIC replaces the activity of the heart and lungs. The heart can be disconnected from the blood circulation and opened only if the blood circulation is maintained artificially. The AIC consists of two main devices: a pump that performs the work of the left ventricle; an oxygenator that saturates the blood with oxygen instead of non-functioning lungs. The AIK is connected to the body's vascular system using tubes made of synthetic material. Through them, extracorporeal blood flows from the patient to the artificial circulation machine, where it is saturated with oxygen, and then, using a pump, it is returned to the patient’s body.
  To connect the heart-lung machine to the patient, the heart is exposed and the venous catheters of the device are inserted through the appendage of the right atrium into the superior vena cava, and the second through the wall of the right atrium into the inferior vena cava. Both venous catheters are carefully fixed with purse-string sutures. Through these catheters, blood from the patient enters the oxygenator. In it, the blood is saturated with oxygen coming from an oxygen cylinder. A thermostat is connected to the oxygenator, with the help of which the blood is cooled or heated as necessary, using for this purpose different proportions of cold and hot water. From the oxygenator, oxygenated blood enters the AI pump. The pump performs the function of the left ventricle, so the arterial cannula is inserted into the ascending aorta (usually into the femoral artery below the inguinal ligament). The artery is opened with a transverse incision, which, after the operation is completed and the cannula is removed, is sutured with thin threads on an atraumatic needle. Once these conditions are reached, the heart and lungs can be cut off from circulation. To maintain the vital activity of the heart, during artificial circulation the entire body is cooled to 26-27 0. At this temperature, the heart muscle tolerates complete anoxia well for 30 minutes, without the slightest signs of damage.
  Rice. 69. Heart-lung bypass machine (ACB).
  
  Palliative correction of tetralogy of Fallot (12-14% of all congenital heart defects), performed in 1945, was the first operation that marked the beginning of modern heart surgery. In those days there was no AIK yet. They tried to help cyanotic, easily tired patients by returning part of the blood abundantly entering the aorta, bypassing the narrowing, into the pulmonary trunk. With such a heart defect, an insufficient amount of blood enters the pulmonary circulation, so surgical correction consists of creating artificial anastomoses between the vessels of the systemic and pulmonary circulation.
  Thus, Blalock (1945) proposed an anastomosis between the left subclavian artery and the pulmonary artery. Potts (1946) developed a technique for anastomosis between the descending aorta and the pulmonary artery. A. N. Bakulev and E. N. Meshalkin proposed an anastomosis between the superior vena cava and the right pulmonary artery. The use of AIK has pushed palliative operations into the background. Currently, the above-mentioned palliative operations with the formation of shunts are used only in children under three years of age. And then radical operations are performed. Radical elimination of tetralogy of Fallot is not an easy operation, however, its technique is well developed.
  In conclusion, it is worth highlighting the methods of surgical treatment of chronic coronary insufficiency, since coronary heart disease remains the leading cause of morbidity and mortality (10% of the total population). In recent years, methods of endovascular angioplasty (balloon angioplasty, stenting) have been developed and widely used for the treatment of atherosclerotic lesions of the coronary arteries, which are covered in the lecture on operative surgery of blood vessels. However, with 70% occlusion of the coronary arteries, coronary artery bypass grafting is indicated. The development of cardiac vascular surgery followed the path of creating autovenous coronary artery bypass grafts proposed by American surgeons. In this case, the affected coronary artery, below the site of narrowing, is connected to the ascending aorta with an autovenous graft. The right coronary artery, anterior interventricular and circumflex branches of the left coronary artery are subject to bypass surgery. In most cases, the great saphenous vein is used as a vascular graft. However, performing such an operation is difficult in patients with disease of the veins of the lower extremities (varicose veins, thrombophlebitis).
  In recent years, an increasing number of surgeons performing coronary artery operations have used the internal mammary artery for myocardial revascularization. The topographic and anatomical rationale for the use of the internal mammary artery (creation of a thoraco-coronary anastomosis) for myocardial revascularization in chronic coronary insufficiency is given in detail at the beginning of this lecture.
  Thus, surgical treatment of breast organs and vessels requires good topographic and anatomical preparation - knowledge of external and internal (intraoperative) landmarks, individual and age-related variability of anatomical structures. Performing breast surgery is a complex task, the solution of which requires knowledge not only of the basics of general surgical techniques, but also the rules for performing surgical interventions on each of the organs of the chest cavity.