Surgical Approaches and Perioperative Outcomes in Mediastinal Paragangliomas: A 20-Year Comprehensive Systematic Review

Background: Mediastinal paragangliomas (MPs) are rare, highly vascular neuroendocrine tumors whose surgical resection is the gold standard but carries a high risk of perioperative complications due to the MPs’ proximity to major cardiovascular structures with potential life-threatening hemorrhage. Due to their rarity, the literature consists primarily of case reports. Our systematic review aims to synthesize the evidence from the last two decades to propose a standardized, multidisciplinary approach to the diagnosis and surgical man- agement of MPs. Methods: A systematic literature review was conducted from 2005 to 2025. Studies reporting on surgically resected adult mediastinal paragangliomas were included. Patient demographic data, diagnostic workup, surgical approaches, and outcomes were ex- tracted and analyzed descriptively. Results: Analysis of 79 patients from 75 papers revealed a median age of 50 years (female predominance of 62%). Most tumors were in the middle mediastinum (51.9%). Sternotomy was the most common surgical approach (44.3%), with cardiopulmonary bypass utilized in 27.8% of cases. Postoperative complications occurred in 28% of patients, with left vocal cord palsy (12.7%) being most frequent. The median follow-up was 12 months. All percentages refer to the number of patients. Conclusions: Surgical removal is the standard of care for curative treatment of MPs. However, surgical treatment requires meticulous planning within a multidisciplinary team to reduce the risk of perioperative complications. The choice of surgical approach—open, minimally invasive, or with circulatory support—depends on tumor site, size, and vascular involvement. This review consolidates existing evidence of MPs’ surgical management, aiming to mitigate the significant risks associated with surgery. Lifelong follow-up is essential due to the potential for recurrence.