Thoracoscopy as the Method of Choice in Diagnosis of Mediastinal Lymphadenopathy

Aims: Determining the role of minimally invasive surgery in elucidating and differential diagnosis of patients with mediastinal lymphadenopathy. Methodology and Study Design: Results of 45 diagnostic video assisted thoracoscopic operations in lymphadenopathy of mediastinum were retrospectively studied. Men were 17 (37.8%), women were 28 (62.2%). The age of patients ranged from 12 to 62 years, the median age was 38,46±12,1 years. Adequate material for the morphological study obtained in 100% of cases. Results: In histological examination malignant lymphoma was diagnosed in 23 (51%), mediastinal form of lung cancer in 3 (6.6%), tuberculosis of intrathoracic lymph nodes in 11 (24.4%), sarcoidosis in 8 (17.7%) cases. The mean operative time was 22.9±12,3 min. Narcotic pain medications were not used. No deaths were observed after the procedure. Conclusion: Videothoracoscopy showed high effectiveness and informativeness in the diagnosis of lymphoproliferative diseases of the mediastinum.

Especially important examination stage of the patient is receiving adequate biopsy material for morphological verification of the diagnosis. Treatment tactics, and prognosis of the disease depend on the morphological options in oncology and other diseases. Obviously, qualitative morphological diagnosis requires sufficient biopsy material [1,2,4,5,11,13,15,17,19,20].
Preparation of material for morphological studies of tumor tissue is not complicated in cases when the lymph nodes, organs and tissues are available for standard invasive research methods, but in the absence of peripheral lymphadenopathy biopsy of mediastinal lymph nodes using various diagnostic interventions such as transthoracic slice tumor biopsy, mediastinoscopy, thoracoscopy and diagnostic thoracotomy endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) are indicated. Considering the invasive nature of these techniques and often severe condition of patients, the intervention needs the right choice, taking into consideration of safety and tumor localization [1,3,4,[7][8][9][12][13][14].
Each upper mentioned method has its advantages and disadvantages. As literature states, specificity of EBUS TBNA, as the other invasive methods is 100%. Sensitivity is around 71.8%-90%. Also, for performing EBUS TBNA conducting combined bronchoscopy in operation room conditions and general anesthesia with high frequency mechanical lung ventilation is vital. In standard mediastenoscopy it is technically impossible to get to the sub-aortal (#5) and anterior mediastenal (#6) and lung root lymph nodes.
To determine the role of minimally invasive surgery in qualifying and the differential

MATERIALS AND METHODS
Results of 45 diagnostic VATS operations in lymphadenopathy of mediastenum were studied. Men were 17 (37.8%) and women were 28 (62.2%). The age of patients ranged from 12 to 62 years, the median age was 38,46±12,1 years.
To evaluate the general condition of the patient, verification of the tumor process comprehensive examinations as general clinical analysis, standard biplane chest X-rays, bronchoscopy, transthoracic puncture of the tumor (by indication), cytological and histological examination of biopsy material, a CT scan of the chest with contrast vessels of the mediastinum, ultrasound study of the mediastinum, supraclavicular area, abdomen, MRI of the chest were carried out.
Quantitative variables are described by the following statistics: arithmetic mean value, standard deviation of the arithmetic mean, with the median of 25 th and 75 th percentiles. The significance of differences was determined using the non-parametric Mann-Whitney U-criteria, at the level of error p <0,05. The calculations were performed on a PC using Microsoft Excel application and package statistical analysis Statistica 5.1 for Windows ("StatInc.", USA).
Endocopic surgeries were performed in patients for whom it was unable to establish the diagnosis using complex diagnostic measures (transthoracic puncture under visual control of ultrasound and CT), of these in 31 cases (68.8%), surgery was performed from right side, in 14 (31.2%) with a left side access.
The mean size of punctured nodes in the investigated group of patients was 22±11.5 mm (5-45 mm). We used the classification of mediastinal lymph nodes and lungs proposed by T. Naruke.
In presence of pleurisy and pericarditis -5 (11.1%), in combination with clinical respiratory failure, before the intervention performed puncture of the pleural cavity and pericardium, followed by cytology.
Videosurgical procedures were conducted by usage of videosurgical standand and instruments of «Karl Storz» (Germany).
Technique of surgical intervention: The patient lays on the healthy side, with separate bronchus intubation. 3, if necessary, 4 trocarsare injectedto the pleural cavity. After the introduction of the 1 st trocar CO2 insufflation into the pleural cavity pressure of 6-8 mm Hg is performed. Next, enter the rest of the trocars and endoscopic instruments are inserted from foramen with 2 to 5 mm in diameter.
Trocar locations: -In the VII intercostal space by the midaxillary line for the telescope; -In the V or VI intercostal space on frontal axillar line for tools; -In the VI intercostal space by posterior axillar line for tools and aspirator.
During the surgery, REVISION pleural cavity and lung was done. The diaphragm, the front and rear surface of the lung were observed for the presence of adhesions, cysts or bullae. In the presence of adhesions in the pleural cavity using scissors and monopolar coagulation separation of adhesions were held, which enabled thorough investigation of the surface of the lung, mediastinum, to clarify the localization, the nature and extent of education, or the conglomerate of lymph nodes. Usually enlarged lymph nodes are located above the root of the lung or in the anterior mediastinum. Mediastinal pleura over the formation of coagulated with mono-or bipolar coagulation, after mobilization of the lymph nodes, two or three lymph nodes were removed in order to make the examinations possible, if the conglomerate nodes or in the presence of signs of sprouting in the mediastinal structures after pre-coagulation for the study took a few pieces of tumor tissue from two or more points. Upon detection of lesions in the parietal or visceral pleura, additional biopsy was performed in areas. Surgery ended with drainage of pleural cavity.
On Fig. 1 step of removing the lymph node with the anterior mediastinum is shown.

RESULTS AND DISCUSSION
Adequate material for morphological studies were obtained in 100% of cases. We analyzed the accuracy of morphological diagnosis of metastatic mediastinal lymph nodes, depending on the groups studied sites. Groupings of lymph nodes examined is shown in Table 1 After confirmation of the malignant process, for further special medical treatment, the patients were transferred to the department of chemotherapy, when confirming a tuberculous process -in the TB hospital.

SSION
Adequate material for morphological studies were obtained in 100% of cases. We analyzed the accuracy of morphological diagnosis of lymph nodes, depending on the groups studied sites. Groupings of lymph 1.
After confirmation of the malignant process, for further special medical treatment, the patients were transferred to the department of chemotherapy, when confirming a tuberculous In all interventions performed by VATS deaths weren't observed. Conversions performed in 3 (6.6%) patients. The reason for the conversion in one case was adhesions in the pleural cavity. In 2 (4.4%) patients operation volume was expanded to thoracotomy. The need for conversion in the first case due to the wall of the superior vena cava at the time of biopsy, which is associated with the complexities of identifying pathological focus due to changes in topographic and anatomic location of the vessel. In the second case, the conversion is caused due to damaging of the right side wall of the trachea, the endotracheal tube cuff inflated in the middle third of the thoracic trachea, it was considered as an enlarged paratracheal node. A defect in the side wall of th was 0,5-0,7sm, it was stitched by atraumatic sutures (2/0 prolene). All operations have finished successfully.
No deaths were observed. In all interventions performed by VATS deaths eren't observed. Conversions performed in 3 (6.6%) patients. The reason for the conversion in one case was adhesions in the pleural cavity. In 2 (4.4%) patients operation volume was expanded to thoracotomy. The need for conversion in the first case due to bleeding from the wall of the superior vena cava at the time of biopsy, which is associated with the complexities of identifying pathological focus due to changes in topographic and anatomic location of the vessel. In the second case, the conversion is sed due to damaging of the right side wall of the trachea, the endotracheal tube cuff inflated in the middle third of the thoracic trachea, it was considered as an enlarged paratracheal node. A defect in the side wall of the trachea 0,7sm, it was stitched by atraumatic sutures (2/0 prolene The average duration of the operation at the stage of development techniques was 60.9 minutes. With experience, the duration of VATS interventions decreased to 22.9±12,3 min. Due to the smooth course of the postoperative period in the study group, only 3 (6.6%) patients were in the intensive care unit, the remaining patients after extubation were transferred to the department. Narcotic pain medications were not used. Pains had moderate and weak character, were coped with the use of non-narcotic analgesics, and after removal of the drainage tubes it was very weak or absent. The duration of chest tube in the study group ranged from 1 to 3 days (on average 2,1±0,8 days) Duration of postoperative hospital stay in group thoracoscopy was 3 to 7 days (average 3±1,9 days). Active patients recovered within the first days after suffering interference.

CONCLUSION
In increasing in the mediastinal lymph nodes, video surgery was performed to clarify the nature of the changes identified through noninvasive instrumental examination, such as x-rays, ultrasound, MDCT, MRI. Videothoracoscopy showed high effectiveness and informative in the diagnosis of lymphoproliferative diseases of the mediastinum. Contraindications to the diagnostic operations are the presence of adhesions in the pleural cavity, severe condition of patients.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.