Organs of the upper mediastinum. Prevention of mediastinal cancer. Anterior, middle and posterior mediastinum

The posterior mediastinum includes organs located behind the respiratory tube (Fig. 120, 121). It contains the esophagus, descending aorta, unpaired and semi-unpaired veins, the lower part of the vagus nerves and the thoracic lymphatic duct.

Rice. 120. Topography of the mediastinal organs on horizontal cuts.
1 - truncus sympathicus; 2 - pleural fissure; 3 - thoracic lymphatic duct; 4-a. subclavia sinistra; 5 - n. vagus; 6-a. carotis communis sinistra; 7-n. phrenicus; S-v. brachiocephalica sinistra; 9 - clavicle; 10 - sternum; 11 - truncus brachiocephalicus; 12-v. brachiocephalica dextra; 13 - trachea, - 14 - esophagus; 15 - aortic arch; 16 - cavity of the heart shirt; 17-v. cava superior; 18-v. azygos; 19 - descending aorta; 20 - aorta with its valves; 21 - right ventricle; 22- right atrium; 23 - left atrium with pulmonary vein.

Rice. 121. Topography of the organs of the posterior mediastinum.
1-a. carotis communis; 2 - esophagus; 3 - n. recurrences; 4 - n. vagus; 5-a. subclavia; 6 - aortic arch; 7 - fork of the trachea; eight - thoracic aorta; 9 - abdominal esophagus; 10-a. coeliaca; 11 - diaphragm; 12 - The lymph nodes; 13 - I rib; - trachea; 15 - larynx; 16-v. azygos; 17 - thoracic lymphatic duct.

Esophagus(oesophagus) begins at the VI cervical vertebra and ends at the XI-XII thoracic vertebra. The thoracic region includes a section of the organ from I to XI of the thoracic vertebra, the length of the thoracic region is 16-20 cm. The esophagus forms bends. The upper, or left, bend follows to III chest vertebra; at the height of the IV vertebra, it occupies a median position and then deviates to the right, in order to shift again to the left at the level of the X thoracic vertebra. AT chest cavity the esophagus has two narrowings: the middle one (the upper one was at the beginning of the cervical region), or the thoracic, with a diameter of 14 mm, at the height of the IV thoracic vertebra, which corresponds to the level of the aortic arch, and the lower, or diaphragmatic, corresponding to the opening in the diaphragm. (XI thoracic vertebra), 12 mm in diameter. The esophagus lies on the spine behind the trachea, but at the level of the IV thoracic vertebra, going down, it gradually deviates forward, and at the diaphragm and somewhat to the left. As a result of this, the esophagus changes position in relation to the descending aorta: at first it lies to the right of it, and then it turns out to be located in front. Below the bifurcation of the trachea in front of the esophagus are the posterior wall of the left atrium and below the pericardium, which limits the oblique sinus of the cavity of the heart shirt. On the left above the descending aorta, its arch is adjacent to the esophagus and subclavian artery. On the right, the pleura of the mediastinum adjoins it. At the same time, in some cases, in the form of pockets, it can enter the posterior surface of the esophagus both in its upper section and in its lower one. Behind the esophagus is the thoracic lymphatic duct, in the middle section of the mediastinum on the right, the unpaired vein comes behind it, and in the lower section on the left - the aorta.

The thoracic esophagus is supplied with blood from branches of the descending aorta, bronchial and intercostal arteries. Venous outflow occurs through the thyroid, unpaired, semi-unpaired veins into the superior vena cava and through the gastric veins into the system portal vein. Lymphatic pathways divert lymph to the nodes: deep cervical, subclavian, tracheal, bifurcations of the trachea, posterior mediastinum, nodes of the stomach and celiac artery. The esophagus is innervated by branches of the sympathetic and vagus nerves.

Unpaired and semi-unpaired veins(vv. azygos et hemiazygos) are a continuation of the ascending lumbar veins passing through the diaphragm between its internal and intermediate legs.

The unpaired vein follows to the right of the esophagus (it can go beyond it at the height of the VI-IX thoracic vertebrae), at the level of the IV thoracic vertebra, it bends through the right bronchus and flows into the superior vena cava. It receives 9 intercostal veins, veins of the mediastinum, bronchi and esophagus. The semi-unpaired vein runs along the anterior surface of the vertebral bodies, at the height of the VIII thoracic vertebrae, it turns to the right and, after passing behind the esophagus, joins the unpaired vein. From the upper parts of the mediastinum, an accessory vein flows into the semi-unpaired vein. The intercostal veins of the corresponding side flow into these veins. The unpaired vein is an anastomosis between the superior and inferior vena cava, which is important for congestion of the inferior vena cava. The unpaired vein is also connected to the portal vein system through the gastric veins and veins of the esophagus.

thoracic lymphatic duct(ductus thoracicus) begins at the level of I-II lumbar vertebrae, where in half of the cases there is an extension (cisterna chyli), into which two lumbar lymphatic trunks and vessels from the intestine join. In the mediastinum, the trunk passes through the aortic opening in the diaphragm and is located here behind and somewhat to the right of the aorta, fused with right leg diaphragms; contraction of the legs during movements of the diaphragm promotes the movement of lymph through the duct. In the mediastinum, it follows between the unpaired vein and the descending aorta, covered in front by the esophagus. At the height of the fifth thoracic vertebra, the duct gradually deviates to the left of the midline of the body and follows the confluence of the left jugular and subclavian veins. At first, it is closer to the right pleura, and in the upper sections - to the left pleura. This explains the formation of chylothorax (outflow of lymph into the pleural cavity) on right side with injury to the thoracic duct in the lower parts of the mediastinum and on the left side with injuries in its upper sections. The intercostal lymphatic vessels, broncho-mediastinal trunk, collecting lymph from the organs of the left half of the chest cavity.

Thoracic descending aorta(aorta descendens) 16-20 cm long stretches from the IV to the XII thoracic vertebra, where, penetrating the diaphragm, it goes into abdominal cavity. 9-10 pairs of intercostal arteries (aa. intercostales) depart from its posterior surface, and the upper phrenic arteries (aa. phrenicae superiores), bronchial, esophageal, arteries of the heart shirt and mediastinum depart from the anterior surface. The descending aorta borders: in the upper, front section with the left bronchus and cardiac shirt, on the right with the esophagus and thoracic duct, on the left with the mediastinal pleura and behind with the semi-unpaired vein and spine; in the lower section in front and with the esophagus, on the right - with the unpaired vein and mediastinal pleura, on the left - with the mediastinal pleura and behind - with the thoracic duct and spine.

vagus nerves(nn. vagi) of the right and left sides have an independent topography. The right nerve, passing between the subclavian vessels, enters the chest cavity. Having followed in front of the subclavian artery, he gives under it a recurrent branch, which returns to the neck. Further, the vagus nerve follows the right bronchus, and approaching the esophagus at the level of the V thoracic vertebra, it is located on its posterior surface. The left vagus nerve passes from the neck into the chest cavity between the common carotid and subclavian arteries, then crosses the aortic arch in front, goes behind the left bronchus and further with level VIII the thoracic vertebra follows the anterior surface of the esophagus. Having passed the aortic arch, it gives off the left recurrent nerve, which, having rounded the arch from below and behind, rises to the neck along the left tracheoesophageal groove. Within the mediastinum, the following branches depart from the vagus nerves: anterior and posterior bronchial, esophageal, cardiac shirts.

sympathetic trunks(trunci sympatici) as a continuation of the cervical trunks in the chest cavity are located on the sides of the vertebral bodies, respectively, the heads of the ribs. Within the mediastinum, they have 10-11 nodes. From each node to the intercostal nerves there are branches connecting the sympathetic nervous system with the animal - rami communicantes. From V-IX thoracic nodes large splanchnic nerves (n. splanchnici major) are formed, from X-XI thoracic nodes - small splanchnic nerves (n. splanchnici minoris) and from XII thoracic nodes - unpaired or third, splanchnic nerves (n. splanchnici imus, s. tertius). All these nerves, having passed through the holes in the diaphragm, form nerve plexuses in the abdominal cavity. The first form solar plexus, the second - the solar and renal plexuses and the third - the renal plexus. In addition, small branches extend from the border trunks to nerve plexuses aorta, esophagus, lungs.

The anterior mediastinum occupies thymus(glandula thymus). It functions and is expressed in children younger age. It consists of two lobes, covers in front not only the large vessels of the mediastinum, but extends down to the heart, up to the neck and to the sides, approaching the roots of the lungs. With age, the gland atrophies. In an adult, it is represented by a plate of connective tissue with fatty inclusions. The thymus is supplied with blood mainly from the branches of the internal mammary artery.

Rice. 119. Topography of the anterior mediastinum after detachment of both pleural sacs. 1-a. carotis communis sinistra; 2-a. subclavia sinistra; 3 - clavicle; 4 - rib; 5-v. brachiocephalica sinistra; 6 - arcus aortae; 7-a. pulmonalis sinistra; 8 - truncus pulmonalis (relief); 9 - left bronchus; 10, 18 - n. phrenicus and a. pericardiacophrenica; 11 - left ear of the heart (relief); 12 - left pleural sac; 13 - pericardium; 14 - prepleural (parapleural) fiber; 15-f. endothoracica; 16 - right pleural sac; 17 - right ear of the heart (relief); 19-v. cava superior; 20-v. brachiocephalica dextra; 21 - goiter; 22 - truncus brachiocephalicus.

The cardiovascular complex practically occupies the rest of the anterior mediastinum. Large vessels lie above, the heart below. Both the heart and the vessels are surrounded by a heart shirt for some distance.

Pericardium(pericardium) is the third serous sac of the chest cavity. It consists of a superficial layer (pericardium) and a deep visceral layer (epicardium). The transition of one sheet to another occurs along the hollow vei, ascending aorta, pulmonary artery, pulmonary veins and back wall left atrium. The epicardium is firmly attached to the heart muscle and the vessels it facilitates. The cavity of the heart shirt contains a small amount of fluid, has bays or sinuses. The transverse sinus of the pericardium (sinus transversus pericardii) is located behind the ascending aorta and pulmonary artery. The entrance to it on the right opens when the superior vena cava is retracted to the right and posteriorly and to the left and anteriorly of the aorta, and the entrance to the left is located to the left and behind the pulmonary artery. The presence of the sinus allows the aorta and pulmonary artery to be bypassed from behind. The oblique sinus of the pericardium (sinus obliquus pericardii) is located behind the left atrium, from the sides it is limited by the transition of the pericardium to the epicardium on the pulmonary veins, the apex reaches the right branch of the pulmonary artery. Down the sinus is open. The posterior wall of the oblique sinus is the pericardium adjacent to the esophagus and descending aorta. This sinus can be pus-filled and difficult to drain. The anteroinferior sinus (sinus anterior inferior pericardii) is located at the point of transition of the anterior wall of the pericardium to the lower one. This sine is where the the largest number fluids in effusion pericarditis and blood in wounds.

The heart sac is supplied with blood from a. pericardiacophrenica, which originates from the internal mammary artery at the level of the first intercostal space, and the pericardial branches of the aorta. Deoxygenated blood via vv. pericardiacae flows into the system of the superior vena cava. The heart shirt is innervated by branches of the abdominal, vagus and sympathetic nerves.

Heart(cor) - a hollow muscular organ, consisting of the right, venous, half and left - arterial. Each half is made up of an atrium and a ventricle.

Borders of the heart projected onto the anterior wall chest, the following: the upper one runs at the level of the cartilage of the III ribs, the right border follows a curve protruding to the right of the sternum by 1.5-2.5 cm and extending from the upper edge of the cartilage of the III rib to the lower edge of the cartilage of the V rib, the left border also passes along a curve extending much to the left of the sternum and at the apex of the heart not reaching only 1 cm to the mid-clavicular line and running from the cartilage of the III rib to the fifth intercostal space, bottom line projected by following obliquely through the base xiphoid process. The apex beat of the heart is determined in the fifth left intercostal space 1.5 cm medially from the mid-clavicular line. The right atrium, right ventricle and left ventricle are projected onto the anterior wall of the chest in the form of a narrow strip. The left atrium, a small part of the left ventricle and the right atrium face the posterior mediastinum. Adjacent to the diaphragm is the left ventricle, a small portion of the right ventricle, and the right atrium.

The heart is supplied with blood from two arteries starting in the initial part of the aorta. The left cardiac artery (a. coronaria sinistra) along the border between the left atrium and the ventricle goes to the posterior surface of the heart, where it anastomoses with the right artery of the heart. Leaving under the left ear, she gives down the front interventricular artery located corresponding to the cardiac septum. Right artery heart (a. coronaria dextra) repeats the course of the left artery, but follows in the opposite direction. The veins of the heart accompany the arteries. Merging, they form the coronary sinus, which flows into the right atrium.

The lymphatic vessels of the heart are represented by three networks related to the endocardium, myocardium and pericardium. Lymph from the heart flows into the nodes of the bifurcation of the trachea and the upper anterior mediastinum.

The innervation of the heart is carried out by the branches of the vagus and sympathetic nerves, to a lesser extent - by the branches of the phrenic nerves. The aortic-cardiac plexus is formed from the branches of these nerves and extracardiac plexuses are formed on the heart itself, and intracardiac plexuses are formed from their branches.

In the upper part of the anterior mediastinum, behind the goiter, there are large vessels belonging to the cardiovascular complex.

superior vena cava(v. cava superior) is formed from the confluence of the right and left brachiocephalic veins against the chest section of the cartilage of the 1st rib on the right and follows down along the sternum. At the level of the cartilage of the third rib, the vein flows into the right atrium. The length of the vena cava is 4-5 cm. The vessel on the right and in front is lined with the mediastinal pleura. Its lower part is covered with the epicardium and is accessible from the side of the cavity of the heart shirt. By right wall veins to the level of the II rib, until the vein goes into the pericardial cavity, the right phrenic nerve passes. Near the atrium on the posterior wall of the superior vena cava, at the level of the IV thoracic vertebra, the mouth of the unpaired vein (v. azygos) opens.

Brachiocephalic veins(vv. brachiocephalicae) are formed from the confluence of the jugular and subclavian veins behind the sternoclavicular joint of the corresponding side. From here, the right vein descends almost vertically down with a short trunk. The left vein follows obliquely down and to the right, covering the vessels from the aortic arch in front. It is located behind the handle of the sternum and tissue of the goiter, crosses the mediastinum. Vv flows into the brachiocephalic veins. thymicae, thoracicae interna, thyreoideae inferior.

ascending aorta(aorta ascendens) exits the left ventricle at the height of the third intercostal space at the left edge of the sternum. It, bending forward and to the right in an arc, rises to the level of attachment of the cartilage of the II right rib, where it passes into an arc. The length of the ascending aorta is 5-6 cm. In the initial part, it has a bulbous expansion, from where the arteries of the heart depart. The ascending aorta on the right, in front and partially behind, is shrouded in the epicardium, adjacent to the cavity of the heart shirt. To the right of the aorta is the superior vena cava, separated from it by a gap in the cavity of the heart shirt leading to the transverse sinus. The pulmonary artery adjoins the aorta in front and to the left. Behind it is the transverse sinus of the cavity of the heart shirt and above - the right branch of the pulmonary artery and the right bronchus.

Aortic arch(arcus aortae) rises to the level of the first intercostal space and follows through the mediastinum back and to the left, heading to the left side of the IV thoracic vertebra, where it passes into the descending aorta. The posterior half of the left surface of the aorta is lined with pleura. In the anterior sections, a layer of fiber is wedged between the vessel and the pleura. The superior vena cava adjoins the arch to the right. Behind and to the right of it are the trachea and esophagus. Under the aortic arch is the place where the pulmonary artery divides into branches and somewhat posteriorly - the left bronchus and arterial ligament (obliterated ductus arteriosus). On the left, the aortic arch is crossed by the left phrenic and vagus nerves.

Brachiocephalic, common carotid left and subclavian depart from the aortic arch from right to left. left artery. The brachiocephalic artery (truncus brachiocephalicus) begins to the left of the midline of the body and therefore, rising up, it simultaneously deviates to the right. Having reached the level of the sternoclavicular articulation, the vessel divides into the right common carotid and subclavian arteries. The brachiocephalic artery passes in front of the trachea, crossing it obliquely. The mediastinal pleura is adjacent to the vessel to the right, the left brachiocephalic vein crosses it in front, and the left common carotid artery is located to the left. The left common carotid artery ascends the neck and passes to the left of the trachea. The vessel is separated from the left pleural sac by a small layer of fiber. Even more to the left and closer to the spine, the left subclavian artery departs from the aorta. It rises and arcs over the 1st rib. The artery passes to the left of the esophagus and to the right is in contact with the mediastinal pleura. Its arc follows in front of the dome of the pleura.

Chapter 16

The mediastinum is called the part of the chest cavity, bounded from below by the diaphragm, in front - by the sternum, behind - thoracic region spine and necks of the ribs, from the sides - pleural sheets (right and left mediastinal pleura). Above the manubrium of the sternum, the mediastinum passes into the cellular spaces of the neck. The conditional upper boundary of the mediastinum is a horizontal plane passing along top edge handles of the sternum. A conditional line drawn from the place of attachment of the handle of the sternum to its body towards the IV thoracic vertebra divides the mediastinum into upper and lower. The frontal plane, drawn along the posterior wall of the trachea, divides the superior mediastinum into anterior and posterior sections. The heart sac divides the inferior mediastinum into anterior, middle, and lower divisions(Fig. 16.1).

In the anterior section of the superior mediastinum, there are the proximal trachea, the thymus gland, the aortic arch and branches extending from it, the superior section of the superior vena cava and its main tributaries. In the posterior section is the upper part of the esophagus, sympathetic trunks, vagus nerves, thoracic lymphatic duct. In the anterior mediastinum between the pericardium and the sternum are the distal part of the thymus gland, fatty tissue

ka, lymph nodes. The middle mediastinum contains the pericardium, heart, intrapericardial sections large vessels, bifurcation of the trachea and main bronchi, bifurcation lymph nodes. In the posterior mediastinum, bounded in front by the bifurcation of the trachea and the pericardium, and behind the lower thoracic spine, there are the esophagus, the descending thoracic aorta, the thoracic lymphatic duct, sympathetic and parasympathetic (vagus) nerves, and lymph nodes.

Research methods

For the diagnosis of diseases of the mediastinum (tumors, cysts, acute and chronic mediastinitis), the same instrumental methods, which are used to diagnose lesions of organs located in this space. They are described in the respective chapters.

16.1. Mediastinal injuries

Allocate open and closed damage mediastinum and organs located in it.

Clinical picture and diagnosis. Clinical manifestations depend on the nature of the injury and on which mediastinal organ is damaged, on the intensity of internal or external bleeding. With a closed injury, hemorrhages almost always occur with the formation of a hematoma, which can lead to compression of the vital important organs(primarily thin-walled veins of the mediastinum). When the esophagus, trachea and main bronchi are ruptured, mediastinal emphysema and mediastinitis develop. Clinically, emphysema is manifested by intense pain behind the sternum, characteristic crepitus in the subcutaneous tissue of the anterior surface of the neck, face, and less often the chest wall.

The diagnosis is based on the data of the anamnesis (clarification of the mechanism of injury), the sequence of development of symptoms and the data of an objective examination, the identification of symptoms characteristic of the damaged organ. An x-ray examination shows the mediastinum shift in one direction or another, the expansion of its shadow, due to hemorrhage. Significant enlightenment of the shadow of the mediastinum is an x-ray symptom of mediastinal emphysema.

open injuries

usually combined with damage to the organs of the mediastinum (which is accompanied by the corresponding symptoms), as well as bleeding, the development of pneumonia

Rice. 16.1. Anatomy of the mediastinum (schematic MOMediastinum.

image). Treatment sent before

1 - top anterior mediastinum; 2 - posterior media

nie; 3 - anterior mediastinum; 4 - middle mediastinum. VITAL ORGANS (SvD-

ca and lungs). Anti-shock therapy is carried out, in case of violation of the frame function of the chest, artificial ventilation of the lungs and various methods of fixation are used. Indications for surgical treatment are compression of vital organs with a sharp violation of their functions, ruptures of the esophagus, trachea, main bronchi, large blood vessels with ongoing bleeding.

With open injuries, surgical treatment is indicated. The choice of the method of operation depends on the nature of the damage to a particular organ, the degree of infection of the wound and the general condition of the patient.

16.2. Inflammatory diseases

16.2.1. Descending necrotizing acute mediastinitis

Acute purulent inflammation of the mediastinal tissue proceeds in most cases in the form of a rapidly progressive necrotizing phlegmon.

Etiology and pathogenesis. This form of acute mediastinitis, arising from acute purulent foci located on the neck and head, is most common. The average age of the diseased is 32-36 years, men get sick 6 times more often than women. The cause in more than 50% of cases is an odontogenic mixed aerobic-anaerobic infection, less often the infection comes from retropharyngeal abscesses, iatrogenic lesions of the pharynx, lymphadenitis of the cervical lymph nodes and acute thyroiditis. The infection quickly descends along the fascial spaces of the neck (mainly along the visceral - behind the esophagus) into the mediastinum and causes severe necrotizing inflammation of the tissues of the latter. The rapid spread of infection to the mediastinum occurs due to gravity and the pressure gradient resulting from the suction action of respiratory movements.

Descending necrotizing mediastinitis differs from other forms of acute mediastinitis in the unusually rapid development of the inflammatory process and severe sepsis, which can be fatal within 24-48 hours. Despite aggressive surgical intervention and modern antibiotic therapy, mortality reaches 30%.

Perforation of the esophagus (damage by a foreign body or instrument during diagnostic and therapeutic procedures), failure of sutures after operations on the esophagus can also become sources of descending infection of the mediastinum. Mediastinitis that occurs under these circumstances should be distinguished from necrotizing descending mediastinitis, as it constitutes a separate clinical unit and requires a special treatment algorithm.

Characteristic signs of descending necrotizing mediastinitis are high body temperature, chills, pain localized in the neck and in the oropharynx, respiratory failure. Sometimes there is redness and swelling in the chin area or on the neck. The appearance of signs of inflammation outside oral cavity serves as a signal to start immediate surgical treatment. Crepitus in this area may be associated with an anaerobic infection or emphysema due to damage to the trachea or esophagus. Difficulty breathing is a sign of threatened laryngeal edema, airway obstruction.

An x-ray examination shows an increase in retro-

visceral (posterior esophageal) space, the presence of fluid or edema in this area, anterior displacement of the trachea, mediastinal emphysema, smoothing of lordosis in cervical region spine. To confirm the diagnosis, computed tomography should be performed immediately. Detection of tissue edema, accumulation of fluid in the mediastinum and in the pleural cavity, emphysema of the mediastinum and neck allows you to establish a diagnosis and clarify the boundaries of the infection.

Treatment. The rapid spread of infection and the possibility of developing sepsis with a fatal outcome within 24-48 hours oblige to start treatment as soon as possible, even with doubts about the presumptive diagnosis. It is necessary to maintain normal breathing, apply massive antibiotic therapy, and early surgical intervention is indicated. With swelling of the larynx and vocal cords airway patency is provided by tracheal intubation or tracheotomy. For antibiotic therapy, broad-spectrum drugs are empirically chosen that can effectively suppress the development of anaerobic and aerobic infections. After determining the sensitivity of the infection to antibiotics, appropriate drugs are prescribed. Treatment is recommended to start with penicillin G (benzylpenicillin) - 12-20 million units intravenously or intramuscularly in combination with clindamycin (600-900 mg intravenously at a rate of not more than 30 mg per 1 min) or metronidazole. A good effect is observed with a combination of cephalosporins, carbopenems.

The most important component of treatment is surgery. The incision is made along the front edge m. sternocleidomastoideus. It allows you to open all three fascial spaces of the neck. During the operation, non-viable tissues are excised and cavities are drained. From this incision, the surgeon cannot access infected mediastinal tissues, therefore, in all cases, it is recommended to additionally perform a thoracotomy (transverse sternotomy) to open and drain abscesses. AT last years for drainage of the mediastinum, interventions with the help of video equipment are used. Along with surgical intervention, the entire arsenal of intensive care means is used. Lethality at intensive treatment is 20-30%

7 6.2.2. Postoperative mediastinitis

Acute postoperative mediastinitis occurs more often after longitudinal sternotomy used in cardiac surgery. International statistics show that its frequency ranges from 0.5 to 1.3%, and with heart transplantation up to 2.5%. Mortality in postoperative mediastinitis reaches 35%. This complication increases the duration of the patient's stay in the hospital and dramatically increases the cost of treatment.

The causative agents in more than 50% of cases are Staphylococcus aureus, Staphylococcus epidermidis, less often Pseudomonas, Enterobacter, Escherichia coli, Serratia. Risk factors for the development of mediastinitis are obesity, previous heart surgery, heart failure, and the duration of cardiopulmonary bypass.

Clinical picture and diagnosis. Symptoms that make it possible to suspect postoperative mediastinitis are increasing pain in the wound area, displacement of the edges of the dissected sternum when coughing or palpation, fever, shortness of breath, redness and swelling of the wound edges. They usually appear on the 5-10th day

ki after surgery, but sometimes after a few weeks. Diagnosis is hampered by the fact that fever, moderate leukocytosis and slight mobility of the edges of the sternum can be observed in other diseases. The absence of changes in computed tomography does not exclude mediastinitis. The edema of mediastinal tissues and a small amount of fluid found in this study are the basis for a presumptive diagnosis of mediastinitis in 75% of cases. The diagnostic accuracy increases to 95% when using scintigraphy with labeled leukocytes, which are concentrated in the area of inflammation.

Treatment. Early surgical treatment is indicated. Often, resection of the sternum and removal of altered tissues are performed with simultaneous closure of the wound with flaps from the large pectoral muscles, the rectus abdominis muscle, or the omentum. The use of an omentum, sufficiently large, well vascularized, containing immunocompetent cells, to close the wound was more successful than the use of muscles. The method made it possible to reduce mortality from 29 to 17% (Lopez-Monjardin et al.).

Radical excision of altered tissues is also successfully used, followed by open or closed drainage, with washing the wound with solutions of antibiotics or antiseptics. With open drainage, tamponing with hydrophilic ointments (dioxidine ointment, levomikol, etc.) is effective. Some authors recommend filling the wound with tampons containing sugar and honey, which have hyperosmolarity and bactericidal properties like ointments. The wound is quickly cleared, covered with granulations.

Acute postoperative mediastinitis may occur due to suture failure after resection or perforation of the esophagus, operations on the bronchi and trachea. Its diagnosis is difficult due to the fact that the initial symptoms of mediastinitis coincide with the symptoms characteristic of the postoperative period. However, an inexplicable deterioration in the patient's condition, an increase in body temperature and leukocytosis, pain in the back of the back near the spine, and shortness of breath make it possible to suspect the development of mediastinitis. X-ray and computed tomography studies allow you to establish the correct diagnosis.

With perforation of the esophagus, trachea and main bronchi, mediastinal and later subcutaneous emphysema occurs. Gas in the mediastinum or in the subcutaneous tissue may be a sign of suture failure in the bronchi, esophagus, or a consequence of the development of gas-forming anaerobic flora.

X-ray reveals the expansion of the shadow of the mediastinum, the level of fluid, less often - its enlightenment due to emphysema or accumulation of gas. If there is a suspicion of suture failure or esophageal perforation, x-ray examination with oral administration of a water-soluble contrast agent, which makes it possible to detect the release of contrast outside the organ, as well as bronchoscopy, in which in most cases it is possible to detect a defect in the bronchus wall. The most informative is computed tomography of the chest, which reveals changes in the relative x-ray density of mediastinal fatty tissue that have arisen in connection with edema, imbibition with pus or gas accumulation; in addition, changes are found in the surrounding organs and tissues (empyema of the pleura, subdiaphragmatic abscess, etc.).

So, in acute mediastinitis, urgent surgical treatment is indicated, aimed primarily at eliminating the cause that caused this complication.

If the sutures of the esophageal anastomosis or bronchus stump fail, an emergency operation is performed to stop the flow of contents into the cellular spaces of the mediastinum. Surgical intervention is completed with drainage pleural cavity and the corresponding department of the mediastinum with double-lumen tubes to remove exudate and air. Depending on the localization of the purulent process, drainage can be carried out through the cervical, parasternal, transthoracic or laparotomy access.

With mediastinitis upper division the mediastinum uses an incision above the manubrium of the sternum, bluntly spreading the tissues as it moves behind the sternum. When defeated posterior divisions upper mediastinum access is used parallel and anteriorly to the left sternocleidomastoid muscle. In a blunt way, parallel to the esophagus, they penetrate into the deep cellular spaces of the mediastinum. With mediastinitis of the anterior mediastinum, parasternal access is used with resection of 2-4 costal cartilages. In case of damage to the lower parts of the posterior mediastinum, median laparotomy is usually used in combination with diaphragmotomy, drainage of the mediastinum. With extensive damage to the posterior mediastinum and empyema of the pleura, thoracotomy is indicated, an appropriate intervention to prevent the contents of the esophagus from entering the pleural cavity, and drainage of the pleural cavity.

An important role in the treatment of mediastinitis belongs to massive antibiotic therapy, detoxification and infusion therapy, parenteral and enteral (tube) nutrition. Enteral nutrition is most often used for damage to the esophagus and is carried out using a nasointestinal probe passed into the duodenum using an endoscope. The enteral route of nutrition has a number of advantages over the parenteral route, since nutrients (proteins, fats, carbohydrates) are much better absorbed, there are no complications associated with the introduction of drugs into the bloodstream. In addition, this method is cost-effective.

The prognosis for acute purulent mediastinitis depends primarily on the cause that caused it and the extent of the inflammatory process. On average, the mortality rate in this case reaches 25-30% or more. The highest frequency of adverse outcomes is observed in patients with cancer.

16.2.3. Sclerosing (chronic) mediastinitis

Sclerosing mediastinitis is often called fibrous. It is a rare disease characterized by acute and chronic inflammation and progressive proliferation fibrous tissue in the mediastinum, which causes compression and a decrease in the lumen of the superior vena cava, small and large bronchi, pulmonary artery and vein, esophagus. Sclerosing mediastinitis affects people aged 20-40 years, men get sick slightly more often than women.

Etiology and pathogenesis. The true cause of the disease is unknown. Knox (1925) suggested that the disease is associated with a fungal infection. Currently, an abnormal acute and chronic inflammatory response to fungal antigens is considered the most likely cause of the disease, indicating a certain connection of this disease with histoplasmosis,

aspergillosis, tuberculosis, blastomycosis. Some authors believe that sclerosing mediastinitis has an autoimmune nature, similar to retroperitoneal fibrosis, sclerosing cholangitis, Riedel's thyroiditis.

Fibrosis forms limited tumor-like structures in the root of the lung or grows diffusely in the mediastinum. Localized nodes are associated with the formation of a granuloma, which sometimes contains calcium deposits and compresses the anatomical structures in contact with it. Diffuse forms of fibrosis affect the entire mediastinum. Fibrous tissue may compress the superior vena cava, pulmonary artery and veins, trachea, and main bronchi.

During surgical interventions, dense, like concrete, fibrous masses are found that compress the anatomical elements of the mediastinum. Biopsy reveals hyalinized sclerosis, accumulation of fibroblasts, lymphocytes and plasma cells, collagen fibers, and granulomas with areas of calcification.

Clinical picture and diagnosis. By the time the disease is diagnosed, many patients do not complain. More than 60% of patients have symptoms of compression of the anatomical structures of the mediastinum. The most common manifestations of the disease are cough, shortness of breath, shortness of breath, compression syndrome of the superior vena cava. Dysphagia, chest pain, and blood with sputum are much less common.

The diagnosis of fibrosing mediastinitis often has to be established by exclusion. Anamnesis and objective examination can reveal symptoms of compression of some organs and structures of the mediastinum, establish a relationship between the disease and the above pathogenetic factors. An x-ray examination shows changes in the contours of the mediastinum, compression of the pulmonary artery and veins. The most informative is a computed tomography study, which allows to determine the prevalence of fibrosis, identify granuloma and calcium deposits in it, compression of the anatomical structures of the mediastinum. Vascular changes are more easily diagnosed with contrast-enhanced computed tomography. Depending on the symptoms of the disease, bronchoscopy (narrowing, displacement of the bronchi, bronchitis), fluoroscopy of the esophagus and esophagoscopy, ultrasound of the heart and other methods may be required for diagnosis, since the diagnosis of mediastinitis is often made by exclusion. Useful information is provided by the determination of the complement fixation titer to fungal antigens, which helps in the choice of treatment with antifungal drugs. A biopsy is necessary to differentiate fibrous mediastinitis from mediastinal tumors.

Treatment. Medical therapy, including steroid hormones, is practically unsuccessful. If the development of mediastinitis is associated with a fungal infection, treatment with antifungal drugs may be effective. It is recommended to prescribe treatment with ketoconazole 400 mg per day for a year (it is better tolerated by patients compared to other drugs). Despite some successes in antifungal therapy, a number of patients need surgical care: shunting of the superior vena cava, decompression of the trachea, bronchi, pulmonary vessels, lung resection. Surgery for sclerosing mediastinitis is risky and dangerous and should therefore be recommended with caution in patients with advanced fibrosis who have life-limiting symptoms.

16.3. superior vena cava syndrome

Obturation and obstruction of the superior vena cava is accompanied by an almost unmistakable combination of symptoms known as superior vena cava syndrome. The resulting violation of the outflow of venous blood from the head, arms and upper body can manifest itself, depending on the degree and duration of the period during which this occurs, either insignificant or life threatening symptoms. The faster the process of thrombus formation develops, the less time for the development of collaterals, the more severe the symptoms. With the slow development of thrombosis, collaterals have time to develop, which compensate for the violation of the outflow of venous blood. In these cases, the disease may be asymptomatic or accompanied by mild symptoms.

Among the many reasons that can cause impaired patency of the superior vena cava, the main one is extravasal compression by tumors (90%). Vein compression can also be caused by the growth of malignant tumors of the mediastinum into the vein wall, followed by obliteration of the lumen, aortic aneurysm, benign neoplasms, or mediastinal fibrosis (sclerosing mediastinitis). Thrombosis of the superior vena cava is relatively rare with prolonged stay in the vena cava of the central venous catheter or pacemaker electrodes (frequency - from 0.3 to 4 per 1000).

clinical picture. Approximately 2 / 3 patients complain of swelling of the face, neck, shortness of breath at rest, cough, inability to sleep in the supine position due to an increase in the severity of these symptoms. Almost 1/3 of patients have stridor, indicating swelling of the larynx and the danger of airway obstruction. An increase in pressure in the veins may be accompanied by cerebral edema with corresponding symptoms and apoplexy.

On examination, attention is drawn to the overflow of blood and swelling of the face, neck, upper limbs, cyanosis and dilation of superficial veins.

The main methods for diagnosing the syndrome of the superior vena cava are computed tomography, magnetic resonance imaging and phlebography (radiocontrast or magnetic resonance). In addition, it is absolutely necessary to examine the organs of the chest and mediastinum (X-ray and CT) to determine the disease that can cause occlusion of the superior vena cava.

Treatment. The use of bypass shunting does not give good long-term results and is often impossible due to the severity of the patient's condition, the spread of the tumor to other organs. Currently, the most promising method for treating compression of the superior vena cava by tumors or mediastinal fibrosis is percutaneous endovascular balloon angioplasty with the installation of a stent in the narrowed portion of the vein.

16.4. Tumors and cysts of the mediastinum

Tumors of the mediastinum are usually divided into primary and secondary. The first group includes congenital or acquired neoplasms of a benign or malignant nature, developing from various tissues. Secondary tumors are essentially metastases of tumors of various organs of the chest or abdominal cavity to the lymph nodes of the mediastinum. Primary tumors may originate from the nervous, co-

unifying, lymphoid tissue, from tissues dystopic in the mediastinum in the process of embryogenesis, as well as from the thymus gland. Mediastinal cysts are divided into congenital (true) and acquired.

Depending on the tissues from which mediastinal tumors develop, they are classified as follows:

neurogenic tumors: neurofibroma, neurinoma, neurolemmoma, ganglioneuroma, neurosacoma, sympticoblastoma, paraganglioma (pheochromocytoma);

mesenchymal: lipoma (liposarcoma), fibroma (fibrosarcoma), leiomyoma (leiomyosarcoma), hemangioma, lymphangioma, angiosarcoma;

lymphoid: lymphogranulomatosis (Hodgkin's disease), lymphosarcoma, reticulosarcoma;

disembryogenetic: intrathoracic goiter, teratoma, chorionepithelialoma, seminoma;

thymoma: benign, malignant.

True cysts of the mediastinum include coelomic pericardial cysts, bronchogenic, enterogenic cysts, as well as cysts of the thymus gland. Echinococcal cysts are the most common among acquired cysts.

A significant variety of tumors and cysts of the mediastinum, a similar clinical picture makes the diagnosis and differential diagnosis of these neoplasms difficult. To simplify the diagnostic search, it is necessary to take into account the most frequent localization of various tumors of the mediastinum.

Anatomical localization of neoplasms of the mediastinum:

upper mediastinum: thymomas, retrosternal goiter, lymphomas;

anterior mediastinum: thymomas, mesenchymal tumors, lymphomas, teratomas;

mediastinum: pericardial cysts, bronchogenic cysts, lymphomas;

posterior mediastinum: neurogenic tumors, enterogenic cysts.

Most of the tumors and cysts of the mediastinum do not have specific clinical symptoms and are discovered by chance during examination of patients for other reasons or are manifested as a result of compression of neighboring organs, the release of hormones and peptides by tumors, or the development of infection. Signs of compression of the intrathoracic organs depend on the size, degree of compression of adjacent organs and structures, localization of tumors or cysts. They can be manifested by chest pain, cough, shortness of breath, difficulty breathing (stridor) and swallowing, superior vena cava syndrome, neurological symptoms (Horner's symptom, paresis or paralysis of the phrenic or recurrent nerves).

With a significant pressure of a large tumor on the heart, pain occurs behind the sternum, in the left half of the chest, and heart rhythm disturbances are often observed. Tumors of the posterior mediastinum, penetrating through the intervertebral foramens into the spinal canal, cause paresis and paralysis of the limbs, dysfunction of the pelvic organs. Malignant tumors have a short asymptomatic period and grow quite rapidly, often causing symptoms of compression of vital organs. More than 40% of patients have distant metastases by the time they consult a doctor. Quite often there are effusion in the pleural cavities, hyperthermia. Only some types of tumors (thymoma, paraganglioma, etc.) have specific clinical signs that allow a preliminary diagnosis to be made at the very beginning of the examination.

Sometimes chest pain is perceived as a cardiovascular problem or associated with another disease. Tumors of the mediastinum due to their localization are not immediately noticeable. Often, saving a patient's life depends on early detection pathology.

Definition

Formations that occur in the mediastinal zone are large group tumors. They originate in different types of cells, differ in morphological terms.

The space, called the mediastinum, is located between four conventionally marked boundaries:

sternum (from its inner side) - in front,
the thoracic spine with all structural elements (the inner side is considered) - behind,
pleura, which lines the boundary layer on the sides;
a conditional plane that lies horizontally and passes above the roots of the lungs - the upper border;
pleura that lines the diaphragm - the lower border.

Classification

Tumors of the mediastinum are often benign in nature, oncological formations of different morphology occupy 20 ÷ 40%. Tumors develop from tissue cells:

which arose in the mediastinum as a result of a pathological process that occurred in the perinatal period;
organs in the mediastinum,
that are between the organs.

Neurogenic formations

A third of the formations in the mediastinal region are neurogenic tumors. With pathology nerve cells occur:

sympathogonioma,
paragangliomas,
ganglioneuromas.

Disease of the nerve sheaths can initiate the type of formations:

neurogenic sarcomas,

Mesenchymal

Formations occupy the fourth part of all mediastinal tumors. Here the formations arising in soft tissues with different morphology. It:

leiomyoma.

Disembryogenetic

Pathology arises from the three elements of the germ layer. Half of all cases of neoplasms are benign.

This type of pathology includes:

intrathoracic goiter,
chorionepithelioma,

Neoplasms of the thymus

AT total number pathologies of the mediastinum, tumors associated with thymus is a relatively rare occurrence. Of these, only five percent are classified as cancers.

Diagnostics can reveal:

mucoepidermoid cancer.

Lymphoid

This type of pathology directly affects the lymphoid tissue or lymph nodes. Considered as a disease of the immune system.

lymphosarcoma,
reticulosarcoma,

Pseudotumors

These include this type of problem that resembles tumors, but they are not:

enlarged lymph nodes.

true brushes

it hollow formations may be acquired or congenital. These include:

echinococcal cysts,
coelomic cysts of the pericardium,
bronchogenic cysts,
enterogenic cysts.

They are also distinguished:

primary education- pathologies that have arisen in the tissues that are deployed in the mediastinal zone;
secondary tumors- appeared as a result of metastasis from organs that are outside the mediastinum.

Risk factors and localization

The causes of tumors of the upper and posterior mediastinum arise for the following reasons:

, and the degree of harm increases with the experience and the number of cigarettes smoked per day;
with age, the protective functions of the body decrease, it is important to keep healthy lifestyle life;
There are many environmental influences that can cause cell mutation:
- ionizing radiation,
- contact with harmful chemicals,
- exposure to radon indoors,
- household dust or industrial dust,
- unfavorable environment in the place of residence,
stressful situations
improper nutrition.

The mediastinal area is conditionally divided into floors:

upper,
average,
lower.

Also, the mediastinal region is divided conditionally vertical planes for departments:

front,
average,
rear.

Accordingly, tumors that occur in specific departments correspond to the pathology of organs and tissues between them located in these zones.

Front

Tumors of the anterior mediastinum:

teratoma,
mesenchymal tumors,
lymphomas,
thymomas.

Upper

Formations of the upper part of the mediastinum:

retrosternal goiter,
lymphomas,
thymomas.

rear

Tumors of the posterior mediastinum may be:

neurogenic tumors,
enterogenic cysts.

Symptoms of mediastinal tumors

The onset of the disease often proceeds without giving tangible signals. Since mediastinal pathologies have different nature, then the signs of the disease of each type are different from each other.

The symptoms of the disease also depend on which part of the mediastinum the pathology appeared, its size. With an increase in education, the likelihood also increases that it will begin to put pressure on neighboring organs and tissues and cause problems.

The most common symptoms:

asthenic syndrome manifests itself through signs:
- fatigue,
- the temperature may rise
- general malaise,
with a disease of the nerves, pain is present,
myasthenia syndrome causes weakness of the muscles of a certain group; it is difficult for the patient, for example:
- turn your head
- raise a hand,
- open eyes,
if the superior vena cava is compressed:
- headache,
- dilated veins,
- dyspnea,
- swelling of the neck and face,
- cyanosis of the lips
if the formation causes squeezing of the organs that are in the mediastinal zone:
- cough,
- dyspnea,
- hemoptysis.

Diagnostic methods

When examining a patient, a specialist in his complaints may prescribe an instrumental examination.

One of the main methods of diagnosing a patient with a suspected tumor in the mediastinal zone is an X-ray examination. This method includes:
- fluorography,
- fluoroscopy
- and other ways.
With the help of the study, information is obtained about how the tumor is located in space, its size and effect on neighboring tissues.
allows you to examine some types of formations and take material for.
Magnetic resonance imaging provides the most detailed information about soft tissues. The method provides an opportunity to obtain all the data on the pathology necessary for the doctor.
Mediastinoscopy - allows you to see the condition of some lymph nodes, while it is possible to take material for a biopsy.

Treatment

The most favorable type of treatment for tumors of the mediastinum is to detect the pathology in time and remove it. This applies to examples when the nature of the formation is malignant and in the case of a benign tumor. Methods of treatment of mediastinal tumors in children and adult patients do not differ.

Operation

A non-cancerous tumor can become malignant over time, so early surgery can prevent a negative development.

Oncological education tends to increase rapidly and metastasize over time. In this case, the operation is all the more indicated.

Apply:

The closed method is thoracoscopic. This method belongs to the category of endoscopic interventions. It is safe and low-traumatic, video surveillance is provided. Thoracoscopic method can be used to remove some types of tumors.
open way:
the method is used in difficult cases when it is not possible to perform a closed operation.

Chemotherapy

With a malignant nature of the formation, they must be used. They select drugs that are capable of killing the cells of the tumor that was detected during the diagnosis.

The procedure for appointing a specialist can be carried out:

before surgery to reduce education;
after it, to deprive the viability of the cancer cells that remained after the operation;
separate method when intervention is not possible.

Chemotherapy, which is carried out without surgery, can maintain the patient's condition, but not cure completely.

Radiation therapy

It is applied in the same way as the previous method, being auxiliary means in the periods before and after surgery. It can also be an independent procedure, if the operation is not indicated for the condition of the patient or the degree of development of the pathology.

Forecast

The hope for a favorable outcome of mediastinal tumors in different cases is ambiguous.

The result of treatment depends on:

from the size of education,
localization,
tumor maturity,
whether it began to spread to the tissues of other organs,
whether there are metastases,
the patient is operable or not.

The best option - early detection tumors and complete removal her.

Video about modern surgical technologies in treatment malignant tumors mediastinum: