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Outpatient mediastinoscopy
General Thoracic Surgery
Outpatient mediastinoscopy The reported experience with outpatient mediastinoscopy is limited. We have performed 65 mediastinoscopies in a hospital-based ambulatory surgical unit during the past 2% years. This represents 54 % of our total mediastinoscopies during the period and 85% of the total for the past year. One patient was admitted overnight because of hypoxemia that was relieved by thoracentesis. All other patients were discharged from the outpatient recovery room without problems. No other early and no late complications occurred. The cost savings were substantial, and patient satisfaction was high. We conclude that mediastinoscopy can be performed safely in the outpatient setting in many patients. (J THoRAc CARDIOVASC SURG 1993;106:686-8)
John Bonadies, MD,a Richard S. D'Agostino, MD,a Alan F. Ruskis, MD,b and Ronald B. Ponn, MD,a
New Haven, Conn.
Mediastinoscopy is a valuable technique for the evaluation of mediastinal masses and adenopathy. Complications of the procedure, although rare, can be serious. Consequently, mediastinoscopy has traditionally been performed in the inpatient setting. The current realities of medical economics, however, favor ambulatory surgery when feasible. Vallieres, Page, and Verdant! in Canada recently detailed their favorable experience with outpatient mediastinoscopy and mediastinotomy. We have found no similar series from the United States. The present report describes our experience with outpatient mediastinoscopy.
Patients and methods The outpatient surgery facility at the Hospital of St. Raphael is a hospital-controlled autonomous unit because it is located within the main hospital structure but maintains its own separate facilities and personnel for preoperative, intraoperative, and From the Departments of Surgery" and Anesthesia," The Hospital of St. Raphael, New Haven,Conn. Received for publication Oct. 12, 1992. Accepted for publication Nov. 30, 1992. Address for reprints: R. Ponn, MD, 40 Temple St., New Haven, CT 06510. Copyright
w
1993 by Mosby-Year Book, Inc.
0022-5223/93 $1.00
686
+ .10 12/1/44667
recovery-room care.' The anesthesiologists and nurse anesthetists rotate between the inpatient and outpatient operating rooms. Selection of patients for outpatient mediastinoscopy was based on the surgeon's assessment of their general medical condition. No specific age criteria were applied. Diabetes, hypertension, and cardiac and pulmonary disease were not considered contraindications provided symptoms were stable and well controlled with a medical regimen. A family member or friend had to be available to transport the patient to and from the hospital and stay with the patient during the first postoperative night. The indications for mediastinoscopy included the diagnosis of mediastinal masses or adenopathy and the staging of known or suspected bronchogenic carcinoma. Our use of mediastinoscopy is selective rather than routine in patients with lung cancer. We believe that mediastinal exploration is indicated when radiographic evaluation shows lymph node enlargement, a large central tumor, or signs of direct invasion in patients who would otherwise be candidates for curative resection. The procedures were performed while the patient was under general endotracheal anesthesia. Pulse oximetry was used in all cases, and a right radial arterial line was inserted in most patients. The surgical technique was standard.' Needle aspiration was done before specimens were obtained, so that inadvertant biopsy of vascular structures could be avoided. Patients with lung cancer routinely underwent sampling at several nodal levels. Biopsy sites in other cases were dictated by the radiographic and operative findings. Cardiac monitoring and oximetry were continued in the recovery area. Postoperative x-ray films of the chest were obtained only if entry into the pleural space was suspected. Laboratory tests were performed only when indicat-
The Journal of Thoracic and Cardiovascular Surgery Volume 106, Number 4
ed (e.g., testsforglucose in patientswithdiabetes, potassium in patients with ectopy, and arterial blood gases in patients with low oxygen saturation). Patients were discharged from the recovery room after about 2 hours of observation. Acetaminophen with codeine was generally prescribed for pain. Office evaluation was scheduled 3 to 5 days later. Results Sixty-five patients underwent outpatient mediastinoscopy during a 2V2-year period, including 35 men and 30 women ranging in age from 25 to 82 years (mean 56 years). Forty-seven patients had malignant neoplasms. In this group there were 41 cases of bronchogenic carcinoma, three lymphomas, and three metastatic cancers (two breast, one colon). Twelve patients had sarcoidosis, two had tuberculosis, and four had nonspecific inflammatory adenopathy. These 65 procedures represent 54% of the total number of mediastinoscopies we performed during this period. The proportion of outpatient procedures has increased to 85% over the past 12 months, reflecting our increasing confidence in this approach. Twelve patients (18%) had no physical, psychiatric, or laboratory abnormality in addition to the pulmonary or mediastinal problem being investigated and were in American Society of Anesthesiologists physical status class I. Forty-two patients (63%) were in class II because of the presence of compensated systemic disease, principally emphysema, hypertension, and diabetes. The remaining 11 patients were in American Society of Anesthesiologists class III because of current cardiac or pulmonary disease that limited activity or a history of myocardial infarction or revascularization. The single complication in the series (1.5%) involved a patient who required admission to the hospital after mediastinoscopy. She was a 36-year-old woman with mediastinal adenopathy, a right middle lobe infiltrate, and a pleural effusion. In the recovery room she had symptoms of dyspnea. Pulse oximetry and subsequent measurement of arterial blood gas showed moderate hypoxemia. A chest radiograph showed a significant increase in the pleural effusion since the previous film had been taken. Thoracentesis yielded 1200 ml of serous fluid. Her breathing and oxygenation improved, and she was hospitalized for observation and discharged the following morning. A diagnosis of lymphoblastic lymphoma was made from the lymph node samples obtained at mediastinoscopy. The remaining 64 patients were discharged from the outpatient facility. The period of observation in the recovery room ranged from 45 to 220 minutes with a mean of 71 ± 29 minutes. Only three patients spent more than 2 hours in the recovery area. None required subse-
Bonadies et al. 6 8 7
quent admission for any problem associated with the outpatient surgical procedure. There were no instances of excessive bleeding, pneumothorax, wound infection, recurrent laryngeal nerve injury, or chylothorax. A cost analysis documented considerable savings when mediastinoscopy was performed in the outpatient unit. In most hospitals the per-minute operating and recovery room charges are higher for inpatients than for outpatients. The mean charges for the operating and recovery rooms, including surgical and anesthesia supplies, was $950 (range $782 to $1482) in our outpatient group. The bill for the same services for the inpatients averaged $2368 (range $1446 to $4381). Total hospital charges for the outpatients, including laboratory, electrocardiography, radiology, pharmacy, and the ever-present miscellaneous category, averaged $1400 (range $892 to $2354). The comparable figures for patients who underwent inpatient mediastinoscopy and had a length of stay of only 1 day was $4110 (range $2647 to $7640). Discussion Transcervical mediastinoscopy is a low-risk procedure. Ashbaugh" reported an operative mortality of 0.1% in a series of 6490 cases collected from 36 authors. Foster, Munro, and Dobe1l5 found three deaths (0.08%) in a review of 14 reports with a total of 3742 patients. The overall complication rate varied between 0.9% and 3%.4-7 Analysis of the specific complications in these reports yields a 0.6% to 1.5% prevalence of procedure-related problems that might potentially require postoperative hospitalization. This range is probably somewhat high because it includes all cases of bleeding, pneumothorax, and pleural tear, some of which might have been managed without hospital admission. Despite the infrequent occurrence of complications associated with mediastinoscopy, serious problems can occur. Minor injuries to the pulmonary artery, the superior vena cava, the azygos vein, and even the aortic arch and its branches can be controlled in some instances through the cervical incision. Hemorrhage, however, may be massive and life threatening and require sternotomy or thoracotomy for control. In the reviews cited."? the prevalence of immediate operation for hemorrhage varied between 0.01% and 0.6%. Similarly, inadvertent entry into the trachea or bronchi can sometimes be treated by packing alone'' or may be severe enough to compromise ventilation and require open repair." Pneumothorax after mediastinoscopy is usually discovered in the immediate postoperative period with physical examination and chest radiography. Most patients do not require tube thoracostomy." Furgang and Saidman'? reported one case of
The Journal of Thoracicand Cardiovascular Surgery October 1993
6 8 8 Bonadies et al.
bilateral tension pneumothorax with hemodynamic decompensation after mediastinoscopy. The cause of the problem, however, was more likely barotrauma to severely diseased lungs than any surgical mishap. These uncommon procedure-specific complications of mediastinoscopy, as well as the rare cases of esophageal perforation, phrenic nerve injury, and recurrent laryngeal nerve damage, require hospital admission in many instances. All of these complications are recognized either during the operation or in the early recovery period with routine monitoring, physical examination, and radiographs when indicated. It is therefore unlikely that a patient would be discharged with an unrecognized lifethreatening problem. In addition, pain after mediastinoscopy is minimal. Because patients are able to walk and resume their customary activities immediately after discharge, the chance of a serious subacute problem occurring, such as venous thrombosis, pulmonary embolus, atelectasis, or pneumonia, is low. Although it appears reasonable to perform most routine mediastinoscopies in the outpatient setting, we found only one reported series describing this approach. Vallieres, Page, and Verdant! performed mediastinoscopy or anterior mediastinotomy on 158 outpatients during a 9-year period. There were no operative deaths and six complications (3.8%). Five of these complications, including atrial fibrillation, cervical hematoma, pulmonary artery branch injury controlled by local packing, and two cases of hemoptysis, were found before the patients would have been discharged. The sixth complication was pneumonia, which occurred in a patient admitted electively from the outpatient unit for early thoracotomy. The pneumonia developed while the patient was in the hospital waiting for an operative date. There were no late complications. Twenty-two patients (14%) were admitted the same day. Nine patients were admitted for elective operation because of bed availability and five for nonmedical reasons (lack of transportation, late operation, patient's request). Eight admissions (5%) were for medical reasons, five because of the aforementioned early complications and three because of slow recovery from general anesthesia. Our experience confirms the feasibility of mediastinoscopy in the ambulatory surgical setting. No serious early or late problems occurred. Hospitalization was required in only one instance (1.5%), and patient satisfaction was high. The cost savings were considerable. Because hospital charge systems vary, the cost differential may not be
as great in other institutions. Outpatient charges, however, are universally lower than inpatient fees for similar services. There is also a tendency for hospitalized patients to undergo more radiologic and laboratory tests than are necessitated by the clinical situation. Experience has taught residents and attending surgeons to "cover all bases" in the postoperative orders, which often results in medication orders for a pain pill, an injection if the pill is ineffective, and remedies for potential problems such as insomnia or upper and lower gastrointestinal distress. A pharmacy charge is generally assessed for each of these orders and a far greater charge is assessed if the medications are actually used. The sum of these incremental fees can be substantial. We currently offer outpatient mediastinoscopy to all patients who are in good general health. We reserve inpatient mediastinoscopy for those who are already hospitalized, lack adequate home support, or have severe cardiopulmonary or systemic disease. The potential for severe acute problems, although small, warrants performance of the procedure in a hospital-based ambulatory surgical facility where equipment and personnel for thoracotomy or sternotomy are immediately available. REFERENCES 1. Vallieres E, Page A, Verdant A. Ambulatory mediastinoscopy and anterior mediastinotomy. Ann Thorac Surg 1991; 52:1122-6. 2. Davis JE. The major ambulatory surgical center and how it developed. Surg Clin North Am 1987;67:671-92. 3. LoCicero J. Surgical mediastinal exploration. Chest Surg Clin North Am 1992;2:659-64. 4. Ashbaugh DG. Mediastinoscopy. Arch Surg 1970;100: 569-73. 5. Foster ED, Munro DD, Dobell ARC. Mediastinoscopy: a review of anatomical relationships and complications. Ann Thorac Surg 1972;13:273-86. 6. Jepsen O. Mediastinoscopy. Copenhagen: Munksgaard, 1966. 7. Trinkle JK, Bryant LR, Hiller AJ, Playforth RH. Mediastinoscopy: experience with 300 consecutive cases. J THORAC CARDIOVASC SURG 1970;60:297-300. 8. Puhakka HJ. Complications of mediastinoscopy. J LaryngoIOtoI1989;103:312-5. 9. Schubach SL, Landreneau RJ. Mediastinoscopic injury to the bronchus: use of in-continuity bronchial flap repair. Ann Thorac Surg 1992;53:1101-3. 10. Furgang FA, Saidman LJ. Bilateral tension pneumothorax associated with mediastinoscopy. J THORAC CARDIOVASC SURG 1972;63:329-33.
Outpatient mediastinoscopy The reported experience with outpatient mediastinoscopy is limited. We have performed 65 mediastinoscopies in a hospital-based ambulatory surgical unit during the past 2% years. This represents 54 % of our total mediastinoscopies during the period and 85% of the total for the past year. One patient was admitted overnight because of hypoxemia that was relieved by thoracentesis. All other patients were discharged from the outpatient recovery room without problems. No other early and no late complications occurred. The cost savings were substantial, and patient satisfaction was high. We conclude that mediastinoscopy can be performed safely in the outpatient setting in many patients. (J THoRAc CARDIOVASC SURG 1993;106:686-8)
John Bonadies, MD,a Richard S. D'Agostino, MD,a Alan F. Ruskis, MD,b and Ronald B. Ponn, MD,a
New Haven, Conn.
Mediastinoscopy is a valuable technique for the evaluation of mediastinal masses and adenopathy. Complications of the procedure, although rare, can be serious. Consequently, mediastinoscopy has traditionally been performed in the inpatient setting. The current realities of medical economics, however, favor ambulatory surgery when feasible. Vallieres, Page, and Verdant! in Canada recently detailed their favorable experience with outpatient mediastinoscopy and mediastinotomy. We have found no similar series from the United States. The present report describes our experience with outpatient mediastinoscopy.
Patients and methods The outpatient surgery facility at the Hospital of St. Raphael is a hospital-controlled autonomous unit because it is located within the main hospital structure but maintains its own separate facilities and personnel for preoperative, intraoperative, and From the Departments of Surgery" and Anesthesia," The Hospital of St. Raphael, New Haven,Conn. Received for publication Oct. 12, 1992. Accepted for publication Nov. 30, 1992. Address for reprints: R. Ponn, MD, 40 Temple St., New Haven, CT 06510. Copyright
w
1993 by Mosby-Year Book, Inc.
0022-5223/93 $1.00
686
+ .10 12/1/44667
recovery-room care.' The anesthesiologists and nurse anesthetists rotate between the inpatient and outpatient operating rooms. Selection of patients for outpatient mediastinoscopy was based on the surgeon's assessment of their general medical condition. No specific age criteria were applied. Diabetes, hypertension, and cardiac and pulmonary disease were not considered contraindications provided symptoms were stable and well controlled with a medical regimen. A family member or friend had to be available to transport the patient to and from the hospital and stay with the patient during the first postoperative night. The indications for mediastinoscopy included the diagnosis of mediastinal masses or adenopathy and the staging of known or suspected bronchogenic carcinoma. Our use of mediastinoscopy is selective rather than routine in patients with lung cancer. We believe that mediastinal exploration is indicated when radiographic evaluation shows lymph node enlargement, a large central tumor, or signs of direct invasion in patients who would otherwise be candidates for curative resection. The procedures were performed while the patient was under general endotracheal anesthesia. Pulse oximetry was used in all cases, and a right radial arterial line was inserted in most patients. The surgical technique was standard.' Needle aspiration was done before specimens were obtained, so that inadvertant biopsy of vascular structures could be avoided. Patients with lung cancer routinely underwent sampling at several nodal levels. Biopsy sites in other cases were dictated by the radiographic and operative findings. Cardiac monitoring and oximetry were continued in the recovery area. Postoperative x-ray films of the chest were obtained only if entry into the pleural space was suspected. Laboratory tests were performed only when indicat-
The Journal of Thoracic and Cardiovascular Surgery Volume 106, Number 4
ed (e.g., testsforglucose in patientswithdiabetes, potassium in patients with ectopy, and arterial blood gases in patients with low oxygen saturation). Patients were discharged from the recovery room after about 2 hours of observation. Acetaminophen with codeine was generally prescribed for pain. Office evaluation was scheduled 3 to 5 days later. Results Sixty-five patients underwent outpatient mediastinoscopy during a 2V2-year period, including 35 men and 30 women ranging in age from 25 to 82 years (mean 56 years). Forty-seven patients had malignant neoplasms. In this group there were 41 cases of bronchogenic carcinoma, three lymphomas, and three metastatic cancers (two breast, one colon). Twelve patients had sarcoidosis, two had tuberculosis, and four had nonspecific inflammatory adenopathy. These 65 procedures represent 54% of the total number of mediastinoscopies we performed during this period. The proportion of outpatient procedures has increased to 85% over the past 12 months, reflecting our increasing confidence in this approach. Twelve patients (18%) had no physical, psychiatric, or laboratory abnormality in addition to the pulmonary or mediastinal problem being investigated and were in American Society of Anesthesiologists physical status class I. Forty-two patients (63%) were in class II because of the presence of compensated systemic disease, principally emphysema, hypertension, and diabetes. The remaining 11 patients were in American Society of Anesthesiologists class III because of current cardiac or pulmonary disease that limited activity or a history of myocardial infarction or revascularization. The single complication in the series (1.5%) involved a patient who required admission to the hospital after mediastinoscopy. She was a 36-year-old woman with mediastinal adenopathy, a right middle lobe infiltrate, and a pleural effusion. In the recovery room she had symptoms of dyspnea. Pulse oximetry and subsequent measurement of arterial blood gas showed moderate hypoxemia. A chest radiograph showed a significant increase in the pleural effusion since the previous film had been taken. Thoracentesis yielded 1200 ml of serous fluid. Her breathing and oxygenation improved, and she was hospitalized for observation and discharged the following morning. A diagnosis of lymphoblastic lymphoma was made from the lymph node samples obtained at mediastinoscopy. The remaining 64 patients were discharged from the outpatient facility. The period of observation in the recovery room ranged from 45 to 220 minutes with a mean of 71 ± 29 minutes. Only three patients spent more than 2 hours in the recovery area. None required subse-
Bonadies et al. 6 8 7
quent admission for any problem associated with the outpatient surgical procedure. There were no instances of excessive bleeding, pneumothorax, wound infection, recurrent laryngeal nerve injury, or chylothorax. A cost analysis documented considerable savings when mediastinoscopy was performed in the outpatient unit. In most hospitals the per-minute operating and recovery room charges are higher for inpatients than for outpatients. The mean charges for the operating and recovery rooms, including surgical and anesthesia supplies, was $950 (range $782 to $1482) in our outpatient group. The bill for the same services for the inpatients averaged $2368 (range $1446 to $4381). Total hospital charges for the outpatients, including laboratory, electrocardiography, radiology, pharmacy, and the ever-present miscellaneous category, averaged $1400 (range $892 to $2354). The comparable figures for patients who underwent inpatient mediastinoscopy and had a length of stay of only 1 day was $4110 (range $2647 to $7640). Discussion Transcervical mediastinoscopy is a low-risk procedure. Ashbaugh" reported an operative mortality of 0.1% in a series of 6490 cases collected from 36 authors. Foster, Munro, and Dobe1l5 found three deaths (0.08%) in a review of 14 reports with a total of 3742 patients. The overall complication rate varied between 0.9% and 3%.4-7 Analysis of the specific complications in these reports yields a 0.6% to 1.5% prevalence of procedure-related problems that might potentially require postoperative hospitalization. This range is probably somewhat high because it includes all cases of bleeding, pneumothorax, and pleural tear, some of which might have been managed without hospital admission. Despite the infrequent occurrence of complications associated with mediastinoscopy, serious problems can occur. Minor injuries to the pulmonary artery, the superior vena cava, the azygos vein, and even the aortic arch and its branches can be controlled in some instances through the cervical incision. Hemorrhage, however, may be massive and life threatening and require sternotomy or thoracotomy for control. In the reviews cited."? the prevalence of immediate operation for hemorrhage varied between 0.01% and 0.6%. Similarly, inadvertent entry into the trachea or bronchi can sometimes be treated by packing alone'' or may be severe enough to compromise ventilation and require open repair." Pneumothorax after mediastinoscopy is usually discovered in the immediate postoperative period with physical examination and chest radiography. Most patients do not require tube thoracostomy." Furgang and Saidman'? reported one case of
The Journal of Thoracicand Cardiovascular Surgery October 1993
6 8 8 Bonadies et al.
bilateral tension pneumothorax with hemodynamic decompensation after mediastinoscopy. The cause of the problem, however, was more likely barotrauma to severely diseased lungs than any surgical mishap. These uncommon procedure-specific complications of mediastinoscopy, as well as the rare cases of esophageal perforation, phrenic nerve injury, and recurrent laryngeal nerve damage, require hospital admission in many instances. All of these complications are recognized either during the operation or in the early recovery period with routine monitoring, physical examination, and radiographs when indicated. It is therefore unlikely that a patient would be discharged with an unrecognized lifethreatening problem. In addition, pain after mediastinoscopy is minimal. Because patients are able to walk and resume their customary activities immediately after discharge, the chance of a serious subacute problem occurring, such as venous thrombosis, pulmonary embolus, atelectasis, or pneumonia, is low. Although it appears reasonable to perform most routine mediastinoscopies in the outpatient setting, we found only one reported series describing this approach. Vallieres, Page, and Verdant! performed mediastinoscopy or anterior mediastinotomy on 158 outpatients during a 9-year period. There were no operative deaths and six complications (3.8%). Five of these complications, including atrial fibrillation, cervical hematoma, pulmonary artery branch injury controlled by local packing, and two cases of hemoptysis, were found before the patients would have been discharged. The sixth complication was pneumonia, which occurred in a patient admitted electively from the outpatient unit for early thoracotomy. The pneumonia developed while the patient was in the hospital waiting for an operative date. There were no late complications. Twenty-two patients (14%) were admitted the same day. Nine patients were admitted for elective operation because of bed availability and five for nonmedical reasons (lack of transportation, late operation, patient's request). Eight admissions (5%) were for medical reasons, five because of the aforementioned early complications and three because of slow recovery from general anesthesia. Our experience confirms the feasibility of mediastinoscopy in the ambulatory surgical setting. No serious early or late problems occurred. Hospitalization was required in only one instance (1.5%), and patient satisfaction was high. The cost savings were considerable. Because hospital charge systems vary, the cost differential may not be
as great in other institutions. Outpatient charges, however, are universally lower than inpatient fees for similar services. There is also a tendency for hospitalized patients to undergo more radiologic and laboratory tests than are necessitated by the clinical situation. Experience has taught residents and attending surgeons to "cover all bases" in the postoperative orders, which often results in medication orders for a pain pill, an injection if the pill is ineffective, and remedies for potential problems such as insomnia or upper and lower gastrointestinal distress. A pharmacy charge is generally assessed for each of these orders and a far greater charge is assessed if the medications are actually used. The sum of these incremental fees can be substantial. We currently offer outpatient mediastinoscopy to all patients who are in good general health. We reserve inpatient mediastinoscopy for those who are already hospitalized, lack adequate home support, or have severe cardiopulmonary or systemic disease. The potential for severe acute problems, although small, warrants performance of the procedure in a hospital-based ambulatory surgical facility where equipment and personnel for thoracotomy or sternotomy are immediately available. REFERENCES 1. Vallieres E, Page A, Verdant A. Ambulatory mediastinoscopy and anterior mediastinotomy. Ann Thorac Surg 1991; 52:1122-6. 2. Davis JE. The major ambulatory surgical center and how it developed. Surg Clin North Am 1987;67:671-92. 3. LoCicero J. Surgical mediastinal exploration. Chest Surg Clin North Am 1992;2:659-64. 4. Ashbaugh DG. Mediastinoscopy. Arch Surg 1970;100: 569-73. 5. Foster ED, Munro DD, Dobell ARC. Mediastinoscopy: a review of anatomical relationships and complications. Ann Thorac Surg 1972;13:273-86. 6. Jepsen O. Mediastinoscopy. Copenhagen: Munksgaard, 1966. 7. Trinkle JK, Bryant LR, Hiller AJ, Playforth RH. Mediastinoscopy: experience with 300 consecutive cases. J THORAC CARDIOVASC SURG 1970;60:297-300. 8. Puhakka HJ. Complications of mediastinoscopy. J LaryngoIOtoI1989;103:312-5. 9. Schubach SL, Landreneau RJ. Mediastinoscopic injury to the bronchus: use of in-continuity bronchial flap repair. Ann Thorac Surg 1992;53:1101-3. 10. Furgang FA, Saidman LJ. Bilateral tension pneumothorax associated with mediastinoscopy. J THORAC CARDIOVASC SURG 1972;63:329-33.