{"id":1462,"date":"2013-03-25T11:34:29","date_gmt":"2013-03-25T11:34:29","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1462"},"modified":"2013-06-11T07:35:29","modified_gmt":"2013-06-11T07:35:29","slug":"4-onemocneni-mediastina-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1462","title":{"rendered":"4 Onemocn\u011bn\u00ed mediastina"},"content":{"rendered":"

4.1 Anatomie, fyziologie mediastina<\/h3>\n
\"Obr.<\/a>

Obr. 1
Kompartmenty mediastina dle Shieldse
(P \u2013 p\u0159edn\u00ed, S \u2013 st\u0159edn\u00ed, Z \u2013 zadn\u00ed)<\/i><\/p><\/div>\n

Mediastinum (mezihrud\u00ed) je prostor mezi ob\u011bma pleur\u00e1ln\u00edmi dutinami ohrani\u010den\u00fd krani\u00e1ln\u011b horn\u00ed hrudn\u00ed aperturou a dist\u00e1ln\u011b br\u00e1nic\u00ed. Zep\u0159edu je ohrani\u010duje sternum, vzadu p\u00e1te\u0159, later\u00e1ln\u011b je vymezeno mediastin\u00e1ln\u00ed pleurou. M\u00e1 tvar nepravideln\u00e9ho komol\u00e9ho kaud\u00e1ln\u011b roz\u0161i\u0159uj\u00edc\u00edho se hranolu, obsahuje v\u0161echny nitrohrudn\u00ed org\u00e1ny vyjma plic. Existuje \u0159ada d\u011blen\u00ed mediastina, d\u0159\u00edve pou\u017e\u00edvan\u00e1 nomenklatura d\u011blila mezihrud\u00ed na horn\u00ed a doln\u00ed, p\u0159i\u010dem\u017e doln\u00ed mediastinum se d\u00e1le \u010dlenilo na p\u0159edn\u00ed, st\u0159edn\u00ed a zadn\u00ed. Anatomick\u00e9 pom\u011bry (chyb\u011bn\u00ed p\u0159irozen\u00fdch anatomick\u00fdch bari\u00e9r) a klinick\u00e9 konsekvence (mo\u017enost \u0161\u00ed\u0159en\u00ed infekce v \u0159\u00eddk\u00e9m pojivu pod\u00e9l viscer\u00e1ln\u00edch struktur) vedly Shieldse k jednodu\u0161\u0161\u00ed definici mediastin\u00e1ln\u00edch kompartment\u016f na p\u0159edn\u00ed (previscer\u00e1ln\u00ed), st\u0159edn\u00ed (viscer\u00e1ln\u00ed) a zadn\u00ed (paravertebr\u00e1ln\u00ed). V\u0161echny odd\u00edly jsou krani\u00e1ln\u011b ohrani\u010deny horn\u00ed hrudn\u00ed aperturou, kaud\u00e1ln\u011b br\u00e1nic\u00ed a later\u00e1ln\u011b pleurou. P\u0159edn\u00ed mediastin\u00e1ln\u00ed kompartment se rozprost\u00edr\u00e1 od zadn\u00ed plochy sterna po velk\u00e9 c\u00e9vy srde\u010dn\u00ed stopky a perikard, obsahuje thymus, lymfatickou tk\u00e1\u0148, mamm\u00e1rn\u00ed c\u00e9vy, mediastin\u00e1ln\u00ed tuk a p\u0159\u00edpadn\u011b dystopickou tk\u00e1\u0148 strumy \u010di p\u0159\u00ed\u0161titn\u00fdch t\u011bl\u00edsek. St\u0159edn\u00ed (viscer\u00e1ln\u00ed) prostor je zep\u0159edu ohrani\u010den vaskul\u00e1rn\u00ed, resp. perikardi\u00e1ln\u00ed lini\u00ed, vzadu p\u00e1te\u0159\u00ed. Le\u017e\u00ed zde srdce v perikardu, velk\u00e9 c\u00e9vy, pr\u016fdu\u0161nice a velk\u00e9 pr\u016fdu\u0161ky, j\u00edcen, m\u00edzovod, bloudiv\u00e9 a br\u00e1ni\u010dn\u00ed nervy. Zadn\u00ed (paravertebr\u00e1ln\u00ed, retroviscer\u00e1ln\u00ed) prostor je zep\u0159edu ohrani\u010den perikardem, c\u00e9vami srde\u010dn\u00ed stopky, tracheou a j\u00edcnem, zezadu p\u00e1te\u0159\u00ed, hrudn\u00ed st\u011bnou pak paravertebr\u00e1ln\u011b (obr. 1). Na p\u0159\u00ed\u010dn\u00e9m \u0159ezu m\u00e1 ledvinovit\u00fd tvar, prob\u00edhaj\u00ed zde nervov\u00e9 struktury, dist\u00e1ln\u011b v. azygos.<\/p>\n

4.2 Diagnostick\u00e9 postupy\u00a0u onemocn\u011bn\u00ed mediastina<\/h3>\n
Klinick\u00e1 prezentace<\/h5>\n

Symptomatologie onemocn\u011bn\u00ed mediastina je pov\u011bt\u0161inou chud\u00e1 a nespecifick\u00e1. P\u0159\u00edznaky, kter\u00e9 ukazuj\u00ed na z\u00e1n\u011bt \u010di n\u00e1dor v mediastinu, d\u011bl\u00edme na respira\u010dn\u00ed, cirkula\u010dn\u00ed, algick\u00e9, nervov\u00e9, polykac\u00ed a celkov\u00e9.<\/p>\n

Respira\u010dn\u00ed pot\u00ed\u017ee za\u010d\u00ednaj\u00ed v\u011bt\u0161inou nen\u00e1padn\u011b, n\u00e1mahovou du\u0161nost\u00ed, kter\u00e1 m\u016f\u017ee progredovat do klidov\u00e9 a b\u00fdt z\u00e1visl\u00e1 na poloze (nap\u0159\u00edklad vle\u017ee na z\u00e1dech u objemn\u00fdch n\u00e1dor\u016f p\u0159edn\u00edho mediastina). Typick\u00e9 je zhor\u0161en\u00ed p\u0159i interkurentn\u00ed infekci, kter\u00e9 \u010dasto vede k diagnostick\u00e9mu n\u00e1lezu. P\u0159i \u00fatlaku d\u00fdchac\u00edch cest se m\u016f\u017ee objevit stridor. Hemopt\u00fdza nen\u00ed pro afekce v mediastinu typick\u00e1, je p\u0159\u00edznakem pozdn\u00edm, signalizuj\u00edc\u00edm pror\u016fst\u00e1n\u00ed n\u00e1doru mezihrud\u00ed do velk\u00fdch cest d\u00fdchac\u00edch. \u010cast\u00fd je dr\u00e1\u017ediv\u00fd, neproduktivn\u00ed ka\u0161el v paroxysmech, n\u011bkdy v\u00e1zan\u00fd na ur\u010ditou polohu.<\/p>\n

Poruchy cirkulace jsou d\u00e1ny v\u011bt\u0161inou \u00fatlakem velk\u00fdch \u017eil v mediastinu n\u00e1dorem nebo jejich tromb\u00f3zou. P\u0159i \u00fatlaku n\u00e1dorem je v\u011bt\u0161inou v\u00fdvoj p\u0159\u00edznak\u016f pomal\u00fd a m\u016f\u017ee b\u00fdt dlouho kompenzov\u00e1n. Lze pozorovat zv\u00fd\u0161enou n\u00e1pl\u0148 kr\u010dn\u00edch \u017eil, lehk\u00fd ed\u00e9m v obli\u010deji, na krku a v nadkl\u00ed\u010dc\u00edch s lehkou cyan\u00f3zou, zhor\u0161uj\u00edc\u00ed se p\u0159i fyzick\u00e9 n\u00e1maze, ka\u0161li, del\u0161\u00edm hovoru apod. Posl\u00e9ze se vyv\u00edj\u00ed kolater\u00e1ln\u00ed \u017eiln\u00ed ob\u011bh na horn\u00ed polovin\u011b t\u011bla. Pokud je \u017eiln\u00ed uz\u00e1v\u011br nad \u00fast\u00edm v. azygos, kolater\u00e1ln\u00ed \u017eiln\u00ed dren\u00e1\u017e vede do horn\u00ed dut\u00e9 \u017e\u00edly cestou mamm\u00e1rn\u00edch, prevertebr\u00e1ln\u00edch a interkost\u00e1ln\u00edch \u017eil. M\u016f\u017ee b\u00fdt pouze jednostrann\u00e1 p\u0159i uz\u00e1v\u011bru jedn\u00e9 z brachiocefalick\u00fdch \u017eil. P\u0159i uz\u00e1v\u011bru horn\u00ed dut\u00e9 \u017e\u00edly postihuj\u00edc\u00edm \u00fast\u00ed v. azygos nebo centr\u00e1ln\u011b pod n\u00edm je \u017eiln\u00ed krev horn\u00ed poloviny t\u011bla vedena povrchn\u00edmi a hlubok\u00fdmi torakoabdomin\u00e1ln\u00edmi kavokav\u00e1ln\u00edmi spojkami do povod\u00ed doln\u00ed dut\u00e9 \u017e\u00edly, b\u00fdv\u00e1 m\u00e9n\u011b n\u00e1padn\u00e1.<\/p>\n

V p\u0159\u00edpad\u011b trombotick\u00fdch uz\u00e1v\u011br\u016f b\u00fdv\u00e1 symptomatologie velmi rychl\u00e1 (otok hlavy, krku a horn\u00ed \u010d\u00e1sti hrudn\u00edku s chem\u00f3zou spojivek a cyan\u00f3zou), pokud se poda\u0159\u00ed terapeuticky zas\u00e1hnout, nesta\u010d\u00ed se kolater\u00e1ln\u00ed cirkulace vyvinout. Syndrom doln\u00ed dut\u00e9 \u017e\u00edly je vz\u00e1cn\u00fd, v\u00e1zan\u00fd v\u011bt\u0161inou na konstriktivn\u00ed perikarditidu. Projevuje se \u017eiln\u00edm m\u011bstn\u00e1n\u00edm v doln\u00ed polovin\u011b t\u011bla, hepatomegali\u00ed, refraktern\u00edm ascitem, otokem doln\u00edch kon\u010detin, kolater\u00e1ln\u00ed cirkulace neb\u00fdv\u00e1 z\u0159eteln\u00e1. Poruchy pr\u016fchodnosti velk\u00fdch syst\u00e9mov\u00fdch tepen jsou raritn\u00ed, \u010dast\u011bj\u0161\u00ed pror\u016fst\u00e1n\u00ed n\u00e1doru do plicn\u00edch c\u00e9v je v\u011bt\u0161inou zn\u00e1mkou inoperability procesu.<\/p>\n

Bolest m\u00edv\u00e1 neur\u010dit\u00fd charakter, n\u011bkdy jde sp\u00ed\u0161e o pocity t\u00edhy \u010di tlaku na hrudn\u00edku, jindy o v\u00fdrazn\u00e9 neuralgie, jejich\u017e charakter je d\u00e1n pokro\u010dilost\u00ed procesu a anatomick\u00fdm vztahem k senzitivn\u00edm nervov\u00fdm struktur\u00e1m (interkost\u00e1ln\u00ed, cervikobrachi\u00e1ln\u00ed, br\u00e1ni\u010dn\u00ed nervy, plexus pulmonalis, plexus cardiacus).<\/p>\n

Dysfagie \u010di odynofagie prov\u00e1z\u00ed afekce viscer\u00e1ln\u00edho kompartmentu mediastina. Krom\u011b n\u00e1dor\u016f postihuj\u00edc\u00edch \u010di utla\u010duj\u00edc\u00edch j\u00edcen je typick\u00fdm pr\u016fvodn\u00edm znakem mediastinitid, zejm\u00e9na perfora\u010dn\u00edch, tehdy b\u00fdv\u00e1 spojena s bolest\u00ed a mediastin\u00e1ln\u00edm emfyz\u00e9mem.<\/p>\n

Par\u00e9zy nerv\u016f jsou v\u017edy pozdn\u00edm p\u0159\u00edznakem. Mohou b\u00fdt zp\u016fsobeny \u00fatlakem, p\u0159\u00edmou infiltrac\u00ed \u010di inflamac\u00ed kdekoli za pr\u016fb\u011bhu nervu mediastinem. Par\u00e9za jednoho br\u00e1ni\u010dn\u00edho nervu b\u00fdv\u00e1 dob\u0159e tolerov\u00e1na, oboustrann\u00e1 se projevuje v\u00fdznamnou du\u0161nost\u00ed. Par\u00e9za jednoho vratn\u00e9ho nervu m\u00e1 za n\u00e1sledek dysfonii, je \u010dast\u011bj\u0161\u00ed vlevo z d\u016fvodu del\u0161\u00edho pr\u016fb\u011bhu lev\u00e9ho rekurentu mediastinem. Oboustrann\u00e1 par\u00e9za vede k afonii s r\u016fzn\u011b vyj\u00e1d\u0159enou du\u0161nost\u00ed. Dysfonie m\u016f\u017ee b\u00fdt i jin\u00e9ho p\u016fvodu: nap\u0159\u00edklad p\u0159i otoku laryngu p\u0159i mediastinitid\u011b nebo p\u0159i mediastin\u00e1ln\u00edm a larynge\u00e1ln\u00edm emfyz\u00e9mu.<\/p>\n

Claud-Bernard-Hornerova tri\u00e1da (mi\u00f3za, pt\u00f3za, enoftalmus) ukazuje na stejnostrann\u00e9 posti\u017een\u00ed horn\u00edho hrudn\u00edho sympatiku. Irita\u010dn\u00ed \u010di z\u00e1nikov\u00e9 jevy v\u00e1zan\u00e9 na plexus brachialis m\u016f\u017ee m\u00edt na sv\u011bdom\u00ed Pancoast\u016fv tumor apexu pl\u00edce.<\/p>\n

Celkov\u00e9 p\u0159\u00edznaky mohou b\u00fdt velmi akutn\u00ed, tehdy jsou v\u011bt\u0161inou v\u00e1zan\u00e9 na z\u00e1n\u011btliv\u00e9 afekce. Mediastinitida se projevuje rychle progreduj\u00edc\u00edm septick\u00fdm stavem, vysok\u00fdmi teplotami, tachykardi\u00ed, t\u0159esavkou, bolestmi za sternem a v epigastriu, dysfoni\u00ed, dysfagi\u00ed, otokem hlavy a krku a krepitac\u00ed v jugulu. N\u00e1dorov\u00e9 afekce prob\u00edhaj\u00ed naopak v nadpolovi\u010dn\u00ed v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f oligo- \u010di asymptomaticky, bez specifick\u00fdch projev\u016f. Typickou souvislost ale maj\u00ed t\u0159eba myastenick\u00e9 projevy p\u0159i onemocn\u011bn\u00edch thymu.<\/p>\n

Mediastin\u00e1ln\u00ed syndromy<\/h6>\n

Podle ulo\u017een\u00ed patologick\u00e9 l\u00e9ze v mediastinu se li\u0161\u00ed komplexn\u00ed symptomatologie. Proto rozezn\u00e1v\u00e1me p\u0159edn\u00ed, st\u0159edn\u00ed, zadn\u00ed a difuzn\u00ed mediastin\u00e1ln\u00ed syndrom.<\/p>\n

P\u0159edn\u00ed mediastin\u00e1ln\u00ed syndrom<\/h6>\n

Je charakteristick\u00fd bolestmi za sternem, symptomy z \u00fatlaku horn\u00ed dut\u00e9 \u017e\u00edly a pr\u016fdu\u0161nice (kolater\u00e1ln\u00ed ob\u011bh, du\u0161nost, ka\u0161el, stridor).<\/p>\n

St\u0159edn\u00ed mediastin\u00e1ln\u00ed syndrom<\/h6>\n

Posti\u017een\u00ed viscer\u00e1ln\u00edho kompartmentu se nej\u010dast\u011bji projevuje komplikacemi z \u00fatlaku pr\u016fdu\u0161nice a velk\u00fdch bronch\u016f (ka\u0161el, du\u0161nost, stridor, atelekt\u00e1zy, pleur\u00e1ln\u00ed komplikace). M\u00e9n\u011b obvykl\u00e9 jsou dysfagie, odynofagie a posti\u017een\u00ed nerv\u016f (zejm\u00e9na lev\u00e9ho vratn\u00e9ho a br\u00e1ni\u010dn\u00edho s chrapotem, \u0161kytavkou \u010di par\u00e9zou br\u00e1nice), stejn\u011b jako kardi\u00e1ln\u00ed pot\u00ed\u017ee (palpitace, arytmie).<\/p>\n

Zadn\u00ed mediastin\u00e1ln\u00ed syndrom<\/h6>\n

L\u00e9ze v zadn\u00edm mediastinu se nej\u010dast\u011bji projevuj\u00ed neurologicky (vertebrogenn\u00ed pot\u00ed\u017ee, posti\u017een\u00ed m\u00edchy nebo hrudn\u00edho sympatiku). P\u0159i ulo\u017een\u00ed v oblasti horn\u00ed hrudn\u00ed apertury se p\u0159idru\u017euje du\u0161nost, stridor a dysfagie.<\/p>\n

Difuzn\u00ed mediastin\u00e1ln\u00ed syndrom<\/h6>\n

Je zap\u0159\u00ed\u010din\u011bn rozs\u00e1hl\u00fdmi afekcemi mediastina (invazivn\u00ed neoplazie, rozs\u00e1hl\u00e9 metastatick\u00e9 posti\u017een\u00ed, mediastinitida). M\u00e1 kombinovanou symptomatologii, ukazuje na pozdn\u00ed n\u00e1lez a velmi v\u00e1\u017enou progn\u00f3zu.<\/p>\n

Zobrazovac\u00ed metody<\/h5>\n

Zadop\u0159edn\u00ed projekce a bo\u010dn\u00fd skiagram hrudn\u00edku obvykle p\u0159in\u00e1\u0161ej\u00ed prvn\u00ed informace o patologii mediastina. \u00datvar nasedaj\u00edc\u00ed na konturu mezihrud\u00ed, roz\u0161\u00ed\u0159en\u00ed mediastin\u00e1ln\u00edho \u010di srde\u010dn\u00edho st\u00ednu, zm\u011bna pr\u016fb\u011bhu tracheobronchi\u00e1ln\u00edho stromu, roz\u0161\u00ed\u0159en\u00ed velk\u00fdch c\u00e9v, cystick\u00e9 formace \u010di zn\u00e1mky mediastin\u00e1ln\u00edho emfyz\u00e9mu v\u0161ak vy\u017eaduj\u00ed dal\u0161\u00ed up\u0159esn\u011bn\u00ed. Ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f je dosta\u010duj\u00edc\u00ed kontrastn\u00ed v\u00fdpo\u010detn\u00ed tomografie (computed tomography \u2013 CT), kter\u00e1 v nal\u00e9hav\u00fdch p\u0159\u00edpadech (akutn\u00ed mediastinitida) sm\u011bruje nemocn\u00e9ho p\u0159\u00edmo k chirurgick\u00e9 revizi, u neoplazi\u00ed p\u0159in\u00e1\u0161\u00ed cenn\u00e9 informace o velikosti, ohrani\u010den\u00ed \u010di invazi n\u00e1doru do okoln\u00edch struktur, pom\u00e1h\u00e1 vylou\u010dit satelitn\u00ed l\u00e9ze \u010di trombotick\u00e9 komplikace. Dut\u00e9 struktury lze pomoc\u00ed CT rekonstruovat trojdimenzion\u00e1ln\u011b, pod\u00e1n\u00edm kontrastn\u00ed l\u00e1tky per os lze diagnostikovat perforaci j\u00edcnu, p\u0159i podez\u0159en\u00ed na tuto komplikaci lze tak\u00e9 indikovat klasick\u00fd ezofagogram vodnou kontrastn\u00ed l\u00e1tkou (obr. 2).<\/p>\n\n\n\n\n
\n

\"Obr.<\/a>

Obr. 2
3D rekonstrukce trachey utla\u010den\u00e9 dystopickou strumou<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 3
Paravertebr\u00e1ln\u00ed neurinom bez intraspin\u00e1ln\u00ed propagace<\/p><\/div><\/td>\n<\/tr>\n

\n

\"Obr.<\/a>

Obr. 4
Hyperakumulace 6FDG v germin\u00e1ln\u00edm tumoru mediastina<\/p><\/div><\/td>\n

<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Magnetick\u00e1 rezonance (magnetic resonance imaging, MRI) nep\u0159in\u00e1\u0161\u00ed z\u00e1sadn\u011bj\u0161\u00ed zm\u011bnu kvality informace, m\u00e1 ale nulovou radia\u010dn\u00ed z\u00e1t\u011b\u017e. Jednozna\u010dnou p\u0159ednost p\u0159ed CT m\u00e1 MRI u posuzov\u00e1n\u00ed invaze do skeletu, obratl\u016f, nervov\u00fdch struktur \u010di p\u0159\u00edpadn\u00e9 intraspin\u00e1ln\u00ed propagace u n\u00e1dor\u016f zadn\u00edho mediastina (obr. 3).<\/p>\n

Pozitronov\u00e1 emisn\u00ed tomografie (PET): jde o kombinaci morfologick\u00e9ho a funk\u010dn\u00edho vy\u0161et\u0159en\u00ed, kter\u00e1 vyu\u017e\u00edv\u00e1 principu zv\u00fd\u0161en\u00e9ho metabolizmu gluk\u00f3zy n\u00e1dorovou tk\u00e1n\u00ed. PET vykazuje uspokojivou spolehlivost v diferenci\u00e1ln\u00ed diagnostice fok\u00e1ln\u00edch l\u00e9z\u00ed mediastina o pr\u016fm\u011bru v\u011bt\u0161\u00edm ne\u017e 10mm a v hodnocen\u00ed malign\u00ed mediastin\u00e1ln\u00ed lymfadenopatie (obr. 4). Jednozna\u010dn\u00fdm benefitem PET je mo\u017enost vylou\u010dit vzd\u00e1len\u00e9 metast\u00e1zy v jedn\u00e9 dob\u011b.<\/p>\n

Endoskopie<\/h5>\n

Endoskopick\u00e9 metody (bronchoskopie, ezofagogastroskopie) maj\u00ed u mediastin\u00e1ln\u00edch afekc\u00ed v\u00fdznam limitovan\u00fd v\u00edcem\u00e9n\u011b na vylou\u010den\u00ed \u010di potvrzen\u00ed invaze tumor\u016f mediastina do tracheobronchi\u00e1ln\u00edho stromu \u010di j\u00edcnu. V\u00fdte\u010dn\u00fdm pomocn\u00edkem jsou p\u0159i diagnostice a pl\u00e1nov\u00e1n\u00ed intervence u ezofagotrache\u00e1ln\u00edch sten\u00f3z a p\u00ed\u0161t\u011bl\u00ed. N\u011bkter\u00e9 p\u00ed\u0161t\u011ble lze \u00fasp\u011b\u0161n\u011b l\u00e9\u010dit plnost\u011bnn\u00fdmi nebo obdukovan\u00fdmi stenty. Pomoc\u00ed endoskopie lze z\u00edskat materi\u00e1l k cytologick\u00e9mu \u010di histologick\u00e9mu vy\u0161et\u0159en\u00ed. Endoskopick\u00e1 ultrasonografie si vydobyla svou pozici v kardiologii jako endoezofage\u00e1ln\u00ed ultrasonografie (EEUS), v hrudn\u00ed chirurgii lze tuto cestu vyu\u017e\u00edt k diagnostice l\u00e9z\u00ed j\u00edcnu a v jeho t\u011bsn\u00e9m okol\u00ed, nap\u0159\u00edklad k diagnostice mediastin\u00e1ln\u00ed lymfadenopatie. Endobronchi\u00e1ln\u00ed ultrasonografie (EBUS) analogicky dovoluje diagnostiku afekc\u00ed tracheobronchi\u00e1ln\u00edho stromu a lo\u017eisek v jeho bl\u00edzkosti, tedy jak v pl\u00edci, tak v mediastinu. Pokud je vy\u0161et\u0159en\u00ed prov\u00e1d\u011bno radi\u00e1ln\u00ed sondou, zobrazuje v \u0159ezu jednotliv\u00e9 vrstvy st\u011bny vy\u0161et\u0159ovan\u00e9 trubice (j\u00edcnu \u010di pr\u016fdu\u0161ky) a sousedn\u00ed struktury. Za pou\u017eit\u00ed line\u00e1rn\u00ed sondy v realtime modu lze za kontroly obrazu prov\u00e1d\u011bt navigovan\u00e9 biopsie sporn\u00fdch l\u00e9z\u00ed. EEUS a EBUS byly v hrudn\u00ed chirurgii zpopularizov\u00e1ny jako komplement\u00e1rn\u00ed postupy k mediastinoskopii pro invazivn\u00ed staging mediastina u karcinomu plic.<\/p>\n

Transpariet\u00e1ln\u00ed biopsie<\/h6>\n

T\u00edmto zp\u016fsobem lze ov\u011b\u0159it dosa\u017eiteln\u00e9 mediastin\u00e1ln\u00ed l\u00e9ze stejn\u011b jako lo\u017eiska vych\u00e1zej\u00edc\u00ed z pleury \u010di hrudn\u00ed st\u011bny. K punkci se pou\u017e\u00edvaj\u00ed tenk\u00e9 jehly (Silverman), trucut jehlami lze z\u00edskat v\u00e1le\u010dek tk\u00e1n\u011b k histologick\u00e9mu vy\u0161et\u0159en\u00ed. Zaveden\u00ed jehly je mo\u017en\u00e9 c\u00edlit sonograficky, skiaskopicky \u010di pomoc\u00ed CT.<\/p>\n

Biopsie supraklavikul\u00e1rn\u00edch uzlin\u00a0(Danielsova biopsie)<\/h6>\n

Jedn\u00e1 se o 3-5 centimetrovou incizi nad medi\u00e1ln\u00edm koncem kl\u00ed\u010dku, kter\u00e1 exponuje preskalenickou tukov\u011blymfatickou tk\u00e1\u0148 p\u0159i \u00faponu m. scalenus anterior. P\u0159i preparaci mus\u00ed b\u00fdt \u0161et\u0159en n. phrenicus, prob\u00edhaj\u00edc\u00ed po p\u0159edn\u00ed plo\u0161e tohoto svalu. Pot\u0159eba explorovat supraklavikul\u00e1rn\u00ed uzliny je pov\u011bt\u0161inou d\u00e1na pozitivn\u00edm n\u00e1lezem zobrazovac\u00edch metod (USG, CT, PET). V p\u0159\u00edpad\u011b hmatn\u00e9 uzliny nad kl\u00ed\u010dkem je v\u011bt\u0161inou dostate\u010dn\u00e1 punk\u010dn\u00ed biopsie, negativn\u00ed histopatologick\u00fd n\u00e1lez indikuje biopsii chirurgickou.<\/p>\n

Mediastinoskopie<\/h6>\n
\"Obr.<\/a>

Obr. 5
P\u0159edn\u00ed mediastinoskopie<\/p><\/div>\n

Kr\u010dn\u00ed mediastinoskopie<\/strong><\/p>\n

Ko\u017en\u00ed \u0159ez je veden 2 cm nad jugulem v ko\u017en\u00ed \u0159ase.Po rozhrnut\u00ed infrahyoidn\u00edch sval\u016f se odhrne pretrache\u00e1ln\u00ed tuk a pronikne se k pretrache\u00e1ln\u00ed fascii.Levou brachiocephalickou \u017e\u00edlu, a. anonymu a dist\u00e1ln\u011bji oblouk aorty je nutn\u00e9 odtla\u010dit prstem od pr\u016fdu\u0161nice ventr\u00e1ln\u011b. Po zaveden\u00ed mediastinoskopu lzebioptovat uzliny horn\u00edho mediastina nebo odebratbiopsii z tumoru ulo\u017een\u00e9ho v p\u0159edn\u00edm mediastin\u00e1ln\u00edm kompartmentu. Diagnostick\u00e1 v\u00fdt\u011b\u017enost mediastinoskopie je limitov\u00e1na t\u00edm, \u017ee lze explorovat pouze prea paratrache\u00e1ln\u00ed prostor do \u00farovn\u011b bifurkace trachey. P\u0159i roz\u0161\u00ed\u0159en\u00e9 mediastinoskopii se po dokon\u010den\u00ed mediastinoskopie typick\u00e9 p\u0159esune p\u0159\u00edstroj do tunelu vytvo\u0159en\u00e9ho tupou preparac\u00ed nad obloukem aorty mezi truncus brachiocephalicus a levou karotickou tepnou. Takto lze bioptovat l\u00e9ze vlevo later\u00e1ln\u011b od oblouku aorty. Interkost\u00e1ln\u00edm p\u0159\u00edstupem lze zav\u00e9st mediastinoskop a odebrat biopsii pod kontrolou optiky. Lze volit mezi\u017eeb\u0159\u00ed nad nejv\u011bt\u0161\u00ed masou tumoru. Ko\u017en\u00ed \u0159ez je orientov\u00e1n p\u0159\u00ed\u010dn\u011b, svalov\u00e1 vl\u00e1kna m. pectoralis jsou tup\u011b rozhrnuta. Tupou preparac\u00ed se vyhled\u00e1 mamm\u00e1rn\u00ed c\u00e9vn\u00ed svazek, odsune (v\u00fdjime\u010dn\u011b se liguje) a pronikne se do mediastina. Do t\u00e9to incize se zavede mediastinoskop. Ten lze zav\u00e9st i intrapleur\u00e1ln\u011b, pokud je nezbytn\u00e9 ov\u011b\u0159it nap\u0159\u00edklad hilov\u00e9 uzliny nebo infiltraci tumoru do mediastin\u00e1ln\u00edch struktur. Tento postup ozna\u010dujeme jako p\u0159edn\u00ed mediastinoskopii (obr. 5).<\/p>\n

Mediastinotomie<\/h6>\n

P\u0159edn\u00ed mediastinotomie se naz\u00fdv\u00e1 tak\u00e9 Chamberlainova operace. Jedn\u00e1 se o n\u011bkolikacentimetrovou incizi nad chrupav\u010ditou \u010d\u00e1st\u00ed 2. \u017eebra, po jej\u00ed resekci se obvykle liguje mamm\u00e1rn\u00ed c\u00e9vn\u00ed svazek, pak lze proniknout extrapleur\u00e1ln\u011b do mediastina. Tento p\u0159\u00edstup slou\u017eil v d\u0159\u00edv\u011bj\u0161\u00ed dob\u011b k ov\u011b\u0159en\u00ed malign\u00ed mediastin\u00e1ln\u00ed lymfadenopatie nebo k biopsii tumor\u016f mediastina. Dnes tento p\u0159\u00edstup obvykle supluj\u00ed miniinvazivn\u00ed postupy (transpariet\u00e1ln\u00ed biopsie, videotorakoskopie). Paravertebr\u00e1ln\u00ed p\u0159\u00edstup do zadn\u00edho mediastina podle Nasiloffa dovoluje extrapleur\u00e1ln\u00ed dren\u00e1\u017e hnisav\u00fdch proces\u016f cestou resekce paravertebr\u00e1ln\u00edch \u00fasek\u016f \u017eeber a p\u0159\u00ed\u010dn\u00fdch v\u00fdb\u011b\u017ek\u016f hrudn\u00edch obratl\u016f. Dnes se u\u017e\u00edv\u00e1 naprosto raritn\u011b.<\/p>\n

Torakoskopie a videotorakoskopie<\/h6>\n

Videotorakoskopie (VTS) v posledn\u00ed dob\u011b nahradila jednostrann\u00e9 postupy (p\u0159edn\u00ed mediastinotomii, p\u0159edn\u00ed mediastinoskopii) a v n\u011bkter\u00fdch indikac\u00edch i klasickou cervik\u00e1ln\u00ed mediastinoskopii (obr. 9). L\u00e9ze p\u0159edn\u00edho a st\u0159edn\u00edho mediastina lze v\u011bt\u0161inou bioptovat v poloze na z\u00e1dech s podlo\u017een\u00edm operovan\u00e9ho hemitoraxu do t\u0159icetistup\u0148ov\u00e9ho \u00fahlu, procesy v zadn\u00edm mediastinu jsou p\u0159\u00edstupn\u011bj\u0161\u00ed v later\u00e1ln\u00ed poloze sklon\u011bn\u00e9 t\u00e9m\u011b\u0159 na b\u0159icho. V\u00fdhodou VTS je dobr\u00fd p\u0159ehled p\u0159i zv\u011bt\u0161en\u00ed na monitoru, drobn\u00e9 a benign\u00ed l\u00e9ze mohou b\u00fdt takto definitivn\u011b odstran\u011bny. Rizika jsou v\u00e1z\u00e1na na zp\u016fsob operace: nutnost selektivn\u00ed ventilace a kolapsu pl\u00edce, nebezpe\u010d\u00ed intrapleur\u00e1ln\u00ed diseminace b\u011bhem diagnostick\u00e9ho v\u00fdkonu, chyb\u011bn\u00ed taktiln\u00edho vjemu, instrumentace v nebezpe\u010dn\u00e9m ter\u00e9nu atd. Obvykle se zav\u00e1d\u011bj\u00ed dva 10milimetrov\u00e9 pracovn\u00ed kan\u00e1ly, jeden pro optiku a druh\u00fd pro pracovn\u00ed n\u00e1stroj. P\u0159i pot\u0159eb\u011b adheziol\u00fdzy, preparace \u010di manipulace s pl\u00edc\u00ed je nutn\u00e9 zav\u00e9st dal\u0161\u00ed porty, obvykle men\u0161\u00edho pr\u016fsvitu. Po videotorakoskopii se obvykle dr\u00e9nuje pohrudni\u010dn\u00ed dutina (obr. 6).<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 6
Sestava n\u00e1stroj\u016f pro videotorakoskopii<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 7
Sternotorakotomie typu otev\u0159en\u00fdch dv\u00ed\u0159ek (open door thoracotomy)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Sternotomie, torakotomie<\/h6>\n

Typick\u00fdm p\u0159\u00edstupem do mediastina je sternotomie, podle rozsahu operace \u010d\u00e1ste\u010dn\u00e1, \u00fapln\u00e1, pod\u00e9ln\u00e1 \u010di p\u0159\u00ed\u010dn\u00e1. L\u00e9ze v horn\u00edm mediastinu n\u011bkdy vy\u017eaduj\u00ed incizi typu padac\u00edch dv\u00ed\u0159ek, n\u00e1dory viscer\u00e1ln\u00edho a zadn\u00edho kompartmentu jsou l\u00e9pe p\u0159\u00edstupn\u00e9 z torakotomie (later\u00e1ln\u00ed, posterolater\u00e1ln\u00ed) (obr. 7). Detailn\u00ed popis je ve speci\u00e1ln\u00ed stati (2.3 Opera\u010dn\u00ed p\u0159\u00edstupy do hrudn\u00edku).<\/p>\n

4.3 Z\u00e1n\u011btliv\u00e1 onemocn\u011bn\u00ed mediastina<\/h3>\n

Akutn\u00ed mediastinitida<\/p>\n

Je n\u00e1hl\u00e1 z\u00e1n\u011btliv\u00e1 hrudn\u011bchirurgick\u00e1 p\u0159\u00edhoda s rychl\u00fdm pr\u016fb\u011bhem. Vyskytuje se a\u017e 6\u00d7 \u010dast\u011bji u mu\u017e\u016f, obvykle mezi 30-50. rokem. P\u0159es ve\u0161ker\u00e9 pokroky modern\u00ed medic\u00edny m\u00e1 d\u00edky chyb\u011bn\u00ed p\u0159irozen\u00fdch anatomick\u00fdch hranic v mediastinu, obvykl\u00e9 polymikrobi\u00e1ln\u00ed etiologii a v\u011bt\u0161inou komplikovan\u00e9mu pr\u016fb\u011bhu st\u00e1le vysokou mortalitu.<\/p>\n

Etiopatogeneze<\/h6>\n

Z\u00e1n\u011bt mediastina m\u016f\u017ee m\u00edt p\u016fvod ve struktur\u00e1ch mediastina, v okoln\u00edch tk\u00e1n\u00edch a skeletu, m\u016f\u017ee sestoupit z orofarynge\u00e1ln\u00ed oblasti, ascendentn\u00ed cesta z b\u0159icha \u010di retroperitonea je tak\u00e9 mo\u017en\u00e1. Metastatick\u00e1 hematogenn\u00ed geneze je vz\u00e1cn\u00e1. Nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou akutn\u00ed mediastinitidy je v dne\u0161n\u00ed dob\u011b perforace j\u00edcnu (85\u201390 % p\u0159\u00edpad\u016f). V d\u0159\u00edv\u011bj\u0161\u00edch dob\u00e1ch byla \u010dast\u011bj\u0161\u00ed poran\u011bn\u00ed kr\u010dn\u00edho j\u00edcnu v oblasti Kili\u00e1nova sv\u011bra\u010de a pyriformn\u00edch reces\u016f v souvislosti s rigidn\u00ed ezofagoskopi\u00ed \u010di dilata\u010dn\u00ed terapi\u00ed striktur j\u00edcnu bez kontroly zraku. V \u00e9\u0159e flexibiln\u00ed endoskopie se pom\u011br poran\u011bn\u00ed or\u00e1ln\u00edho i abor\u00e1ln\u00edho j\u00edcnu vyrovnal d\u00edky instrumentac\u00edm v cel\u00e9m pr\u016fb\u011bhu j\u00edcnu a tak\u00e9 v d\u016fsledku sklerotizac\u00ed a ligac\u00ed ezofage\u00e1ln\u00edch varix\u016f. Krom\u011b iatrogenn\u00edch perforac\u00ed m\u016f\u017ee b\u00fdt j\u00edcen poran\u011bn v r\u00e1mci vysokoenergetick\u00fdch polytraumat, vz\u00e1cn\u00e9 jsou spont\u00e1nn\u00ed ruptury termin\u00e1ln\u00edho j\u00edcnu (Boerhaave). Mediastinitida je typickou komplikac\u00ed kardiochirurgie (v r\u00e1mci komplikovan\u00e9ho hojen\u00ed sternotomie), m\u016f\u017ee b\u00fdt d\u016fsledkem z\u00e1n\u011btliv\u00fdch onemocn\u011bn\u00ed hrudn\u00ed st\u011bny (sternoklavikul\u00e1rn\u00ed osteoartritida). Z\u00e1n\u011bt m\u016f\u017ee do mediastina p\u0159estoupit ze septick\u00fdch proces\u016f plicn\u00edch \u010di z infikovan\u00fdch mediastin\u00e1ln\u00edch uzlin. Tak\u00e9 hrudn\u00ed \u010di abdomin\u00e1ln\u00ed chirurgie m\u016f\u017ee b\u00fdt na po\u010d\u00e1tku t\u00e9to v\u00e1\u017en\u00e9 komplikace (trache\u00e1ln\u00ed chirurgie, mediastinoskopie, antirefluxn\u00ed v\u00fdkony). Poran\u011bn\u00ed kontinuity trachey a velk\u00fdch bronch\u016f, traumatick\u00e1 i iatrogenn\u00ed, mohou m\u00edt podobn\u00fd dopad.<\/p>\n

Infekce se pak rychle \u0161\u00ed\u0159\u00ed v \u0159\u00eddk\u00e9 pojivov\u00e9 tk\u00e1ni od m\u00edsta prvotn\u00edho poru\u0161en\u00ed celistvosti dut\u00fdch org\u00e1n\u016f \u010di od lo\u017eiska traumatick\u00e9 (iatrogenn\u00ed) inokulace. V \u00e9\u0159e antibiotik postupn\u011b kles\u00e1 incidence ob\u00e1van\u00e9 descendentn\u00ed nekrotizuj\u00edc\u00ed mediastinitidy, kter\u00e1 m\u00e1 sv\u016fj p\u016fvod v hlubok\u00fdch kr\u010dn\u00edch fasci\u00e1ln\u00edch prostorech. Tyto infekce maj\u00ed nej\u010dast\u011bji odontogenn\u00ed, p\u0159\u00edpadn\u011b parafarynge\u00e1ln\u00ed p\u016fvod a za chyb\u011bn\u00ed p\u0159irozen\u00fdch cervikomediastin\u00e1ln\u00edch bari\u00e9r sestupuj\u00ed prevertebr\u00e1ln\u011b \u010di pod\u00e9l karotick\u00fdch svazk\u016f nebo nej\u010dast\u011bji z retrofarynge\u00e1ln\u00edho prostoru pod\u00e9l j\u00edcnu do viscer\u00e1ln\u00edho kompartmentu mediastina. Komorbidity (DM, malnutrice) zvy\u0161uj\u00ed riziko vzniku a v\u00fdznamn\u011b zhor\u0161uj\u00ed pr\u016fb\u011bh. Nej\u010dast\u011bj\u0161\u00edmi patogeny, prok\u00e1zan\u00fdmi v r\u00e1mci akutn\u00ed mediastinitidy, jsou Staph. aureus, Strept. pyogenes, Staph. pneumoniae, Strept. species, Klebsiella sp., Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Enterobacter, Bacteroides, Peptococcus, Peptostreptococcus, Fusobacterium<\/i>, v\u011bt\u0161inou v kombinaci. Diagnostika se op\u00edr\u00e1 o typick\u00e9 symptomy: febrilie, ka\u0161el, bolest retrostern\u00e1ln\u011b, p\u0159\u00edpadn\u011b v epigastriu a na krku, zv\u00fd\u0161en\u00e1 salivace, odynofagie, dysfagie, n\u011bkdy zvracen\u00ed. Postupn\u011b se m\u016f\u017ee p\u0159idat du\u0161nost a pleur\u00e1ln\u00ed p\u0159\u00edznaky.<\/p>\n

\"Obr.<\/a>

Obr. 8
CT u mediastinitidy s bilater\u00e1ln\u00edm v\u00fdpotkem (ozna\u010deno \u0161ipkami)<\/p><\/div>\n

Diagnostika<\/h6>\n

Spr\u00e1vn\u011b odebran\u00e1 anamn\u00e9za dok\u00e1\u017ee sm\u011b\u0159ovat dal\u0161\u00ed diagnostick\u00e9 kroky. Je t\u0159eba p\u00e1trat po odontogenn\u00edch a ORL infekc\u00edch, poptat se po instrument\u00e1ln\u00edch intervenc\u00edch (bronchoskopie, gastroskopie, dilatace j\u00edcnu, intubace), zam\u011b\u0159it se na p\u0159edchoz\u00ed operace. D\u016fle\u017eit\u00e9 je p\u00e1tr\u00e1n\u00ed po komorbidit\u00e1ch. Laboratorn\u011b lze zaznamenat elevaci z\u00e1n\u011btliv\u00fdch marker\u016f (CRP, leukocyt\u00f3za), p\u0159i septick\u00fdch teplot\u00e1ch je vhodn\u00e9 odebrat hemokulturu.Skiagraficky lze zjistit roz\u0161\u00ed\u0159en\u00ed mediastina, zneost\u0159en\u00ed periviscer\u00e1ln\u00ed kresby, u perforac\u00ed mediastin\u00e1ln\u00ed p\u0159\u00edpadn\u011b podko\u017en\u00ed emfyz\u00e9m, pleur\u00e1ln\u00ed reakci, resp. v\u00fdpotek. N\u00e1sleduj\u00edc\u00edm krokem je oblig\u00e1tn\u011b CT krku, hrudn\u00edku, mediastina a podbr\u00e1ni\u010dn\u00edch prostor, dopln\u011bn\u00e9 o pod\u00e1n\u00ed kontrastn\u00ed l\u00e1tky intraven\u00f3zn\u011b nebo i per os (obr. 8).<\/p>\n

Perforaci trachey (bronchu) objasn\u00ed tracheobronchoskopie, p\u0159i poran\u011bn\u00ed j\u00edcnu vol\u00edme skiagram vodnou kontrastn\u00ed l\u00e1tkou, p\u0159\u00edpadn\u011b flexibiln\u00ed ezofagogastroskopii, pokud nebyla perforace j\u00edcnu pozn\u00e1na ji\u017e b\u011bhem samotn\u00e9ho vy\u0161et\u0159en\u00ed.<\/p>\n

Terapie<\/h6>\n

U\u017e v p\u0159\u00edpad\u011b podez\u0159en\u00ed na mediastinitidu je nutn\u00e9 zah\u00e1jit agresivn\u00ed antibiotickou terapii a soust\u0159edit se na prevenci septick\u00fdch komplikac\u00ed. D\u016fle\u017eit\u00e1 je volumoterapie a p\u00e9\u010de o dostate\u010dnou oxygenaci. Ihned po nezbytn\u00e9 p\u0159\u00edprav\u011b je nutn\u00e9 zrevidovat posti\u017een\u00e9 mediastin\u00e1ln\u00ed kompartmenty, pokusit se vy\u0159e\u0161it p\u0159\u00ed\u010dinu (sutura perforace, extrakce ciz\u00edho t\u011blesa) a prov\u00e9st \u0159\u00e1dn\u00fd debridement a dren\u00e1\u017e.<\/p>\n

Chirurgick\u00e1 l\u00e9\u010dba<\/h6>\n

Obvykl\u00fdm p\u0159\u00edstupem k dren\u00e1\u017ei horn\u00edch mediastin\u00e1ln\u00edch kompartment\u016f je incize pod\u00e9l k\u00fdva\u010de sb\u00edhaj\u00edc\u00ed do jugula nebo kol\u00e1rn\u00ed mediastinotomie. Mal\u00e9 perforace pr\u016fdu\u0161nice je mo\u017en\u00e9 \u0159e\u0161it konzervativn\u011b (tracheostomie), v\u011bt\u0161\u00ed lacerace vy\u017eaduj\u00ed reparaci (sutura, resekce a reanastom\u00f3za). Chirurgick\u00e9 o\u0161et\u0159en\u00ed poran\u011bn\u00ed or\u00e1ln\u00edho j\u00edcnu a dehiscence kr\u010dn\u00edch anastom\u00f3z u ezofagogastroplastik maj\u00ed malou \u0161anci na zhojen\u00ed, preferov\u00e1n je konzervativn\u00ed postup (vylou\u010den\u00ed p\u0159\u00edjmu per os, parenter\u00e1ln\u00ed re\u017eim, jejunostomie, p\u0159\u00edpadn\u011b vnit\u0159n\u00ed dren\u00e1\u017e j\u00edcnu). Nekr\u00f3za j\u00edcnu (nap\u0159. kaustick\u00e1) nebo transponovan\u00e9ho tubusu \u017ealudku n\u011bkdy vy\u017eaduje urgentn\u00ed exstirpaci, kr\u010dn\u00ed ezofagostomii a nutritivn\u00ed jejunostomii. Pokusy o akutn\u00ed n\u00e1hradu j\u00edcnu v jedn\u00e9 dob\u011b maj\u00ed jen st\u0159\u00eddav\u00fd \u00fasp\u011bch. Perforace abor\u00e1ln\u00edho j\u00edcnu je vhodn\u00e9 \u0159e\u0161it suturou a p\u0159\u00edpadn\u011b z\u00e1platou vit\u00e1ln\u00ed tk\u00e1n\u00ed (pleura, perikard, sval) do 24 hodin po poran\u011bn\u00ed, pozd\u011bj\u0161\u00ed pokusy o suturu jsou v\u011bt\u0161inou odsouzeny k ne\u00fasp\u011bchu. P\u0159\u00edstup do doln\u00edho a zadn\u00edho mediastina je obt\u00ed\u017en\u011bj\u0161\u00ed. Nejkrat\u0161\u00ed cestou je paravertebr\u00e1ln\u00ed p\u0159\u00edstup s resekc\u00ed kr\u010dku \u017eeber a p\u0159\u00ed\u010dn\u00fdch v\u00fdb\u011b\u017ek\u016f obratl\u016f podle Nasiloffa. O\u0161et\u0159ov\u00e1n\u00ed takov\u00e9 incize je obt\u00ed\u017en\u00e9, proto se dnes vol\u00ed v\u011bt\u0161inou transtorak\u00e1ln\u00ed p\u0159\u00edstup s vydatnou aktivn\u00ed dren\u00e1\u017e\u00ed, kter\u00fd je indikov\u00e1n zejm\u00e9na v p\u0159\u00edpad\u011b prok\u00e1zan\u00e9 pleur\u00e1ln\u00ed patologie.<\/p>\n

U mediastinitid po kardiovaskul\u00e1rn\u00edch v\u00fdkonech nab\u00fdv\u00e1 na v\u00fdznamu krom\u011b \u0159\u00e1dn\u00e9ho debridementu a r\u016fzn\u00fdch technik resutury\/stabilizace sterna tzv. vacuumclosed therapy (VAC system).<\/p>\n

Navzdory aktivn\u00ed a racion\u00e1ln\u00ed terapii se mediastinitida \u010dasto komplikuje, typicky rozvojem sepse, ARDS, multiorg\u00e1nov\u00fdm selh\u00e1v\u00e1n\u00edm, empy\u00e9mem, trombembolickou nemoc\u00ed a hemoragi\u00ed z aroze c\u00e9vn\u00edch struktur mediastina. Takov\u00fd pr\u016fb\u011bh i dnes nez\u0159\u00eddka kon\u010d\u00ed fat\u00e1ln\u011b.<\/p>\n

Absces mediastina<\/h6>\n

Infekce se v mediastinu m\u016f\u017ee chovat difuzn\u011b nebo m\u00e1 tendenci k lokalizaci. Ohrani\u010denou kolekci hnisav\u00e9ho obsahu s nekrotickou tk\u00e1n\u00ed a s p\u0159\u00edm\u011bs\u00ed sekretu \u010di obsahu dut\u00fdch org\u00e1n\u016f pak naz\u00fdv\u00e1me absces mediastina. Ob\u011b formy infekce mohou koexistovat v mediastinu ka\u017ed\u00e1 zvl\u00e1\u0161\u0165 nebo jedna forma v druhou p\u0159ech\u00e1zet. \u010cast\u011bji vznik\u00e1 absces ohrani\u010den\u00edm mediastinitidy ve v\u00edcem\u00e9n\u011b preformovan\u00e9m prostoru (retrostern\u00e1ln\u011b, paravertebr\u00e1ln\u011b). Perforace abscesu (po instrumentaci, sb\u011bhl\u00e9ho z krku, abscedovan\u00e9 uzliny) m\u016f\u017ee vyvolat mediastinitidu. Diagnostika i terapie je podobn\u00e1 jako u nelokalizovan\u00e9 mediastinitidy, v\u011bt\u0161\u00edho v\u00fdznamu nab\u00fdv\u00e1 pouze navigovan\u00e1 dren\u00e1\u017e abscesov\u00e9ho lo\u017eiska, kter\u00e1 m\u016f\u017ee b\u00fdt prvn\u00edm krokem, ale z\u00e1rove\u0148 i definitivn\u00edm \u0159e\u0161en\u00edm supluj\u00edc\u00edm chirurgickou revizi (obr. 9). V\u00fdhodn\u00e1 je aplikace proplachov\u00e9 srkav\u00e9 dren\u00e1\u017ee.<\/p>\n

\"Obr.<\/a>

Obr. 9
Chirurgick\u00e1 dren\u00e1\u017e poststernotomick\u00e9ho abscesu (ozna\u010deno \u0161ipkou)<\/p><\/div>\n

Chronick\u00e1 fibrotizuj\u00edc\u00ed mediastinitida<\/h6>\n

B\u00fdv\u00e1 d\u00e1v\u00e1na do souvislosti se specifick\u00fdmi infekcemi a myk\u00f3zami (TBC, aktinomyk\u00f3za, histoplazm\u00f3za, blastomyk\u00f3za). Pokud neprok\u00e1\u017eeme vyvol\u00e1vaj\u00edc\u00ed agens a nejde o prok\u00e1zan\u00fd \u00fa\u010dinek zevn\u00edch p\u0159\u00ed\u010din (sarkoid\u00f3za, silik\u00f3za, stav po radioterapii), hovo\u0159\u00edme o idiopatick\u00e9 fibr\u00f3ze mediastina. Je vz\u00e1cn\u00e1, charakteristick\u00fdm znakem je excesivn\u00ed fibrotick\u00e1 reakce v p\u016fvodn\u011b \u0159\u00eddk\u00e9 mediastin\u00e1ln\u00ed pojivov\u00e9 tk\u00e1ni, kter\u00e1\u00a0vede k postupn\u011b se zhor\u0161uj\u00edc\u00edm p\u0159\u00edznak\u016fm z komprese mediastin\u00e1ln\u00edch struktur (ka\u0161el, stridor, zkr\u00e1cen\u00fd dech, syndrom horn\u00ed dut\u00e9 \u017e\u00edly). V\u00fdjime\u010dn\u011b se objevuj\u00ed bolesti na hrudi, hemopt\u00fdza, dal\u0161\u00ed p\u0159\u00edznaky jsou je\u0161t\u011b m\u00e9n\u011b specifick\u00e9.L\u00e9\u010dba je symptomatick\u00e1, v p\u0159\u00edpad\u011b specifick\u00fdch infekc\u00ed i kauz\u00e1ln\u00ed, n\u011bkdy mohou pomoci kortikoidy, chirurgick\u00e1 explorace je indikov\u00e1na jen z\u0159\u00eddka a jej\u00ed benefit je limitovan\u00fd.<\/p>\n

4.4 N\u00e1dory mediastina<\/h3>\n

N\u00e1dory mezihrud\u00ed nejsou \u010dast\u00e9, ve statistice \u010d\u00edtaj\u00ed asi1 % v\u0161ech novotvar\u016f, z\u00e1rove\u0148 v\u0161ak p\u0159edstavuj\u00ed asi 90% nemoc\u00ed mediastina. D\u00edky rozmanitosti tk\u00e1n\u00ed a struktur zde ulo\u017een\u00fdch nem\u016f\u017ee b\u00fdt jejich klasifikace jednoduch\u00e1 ani vy\u010derp\u00e1vaj\u00edc\u00ed, p\u0159edkl\u00e1d\u00e1me upravenou klasifikaci \u0160matovu (1986). Za prav\u00e9 n\u00e1dory mediastina pova\u017eujeme:<\/p>\n