CASE PRESENTATION

ClerkDepartment of Surgery

GENERAL DATA

BA28 years old MaleRoman CatholicSurigao City

CHIEF COMPLAINT

Hemoptysis

HISTORY OF PRESENT ILLNESS7 years PTA:

Occasional back pains with associated cough and dyspnea on heavy physical activities

Condition was tolerated, no consultation done

Claimed to have been relieved by herbal ointments

HISTORY OF PRESENT ILLNESS

6 years PTA

Persistence of signs and symptoms

Onset of hemoptysis at approx 1 tbsp

Patient noted some fats and white hair on sputum

No associated anorexianight sweatsWeight lossVomiting

HISTORY OF PRESENT ILLNESS

6 years PTA

Consultation was done:Treated for pneumonia with unrecalled antibiotics for 1 week, no relief

X-ray was done results suggested for CT scan

Patient did not comply due to financial reasons

Condition was tolerated and self medicated with antibiotics and herbal capsules

Patient noted that signs and symptoms are waxing and waning

HISTORY OF PRESENT ILLNESS1 year PTAPersistence of signs and symptomsConsultation was done for PE of employment

X-ray done: Paracardiac density in the Right lower and middle lung lobes, advised for CT scanCT scan done:Complex mass on anterior mediastinum, consider a mediastinal teratoma with enlarged mediastinal nodeSought consult to a pulmonologist and advised for surgery

1 week PTAIncrease frequency of hemoptysis Dyspnea on mild physical activity Condition was tolerated

1 day PTAMassive bouts of hemoptysisDyspnea on mild physical activityBack pains Patient prompted for consultation and was admitted HISTORY OF PRESENT ILLNESS

FAMILY HISTORY

(+) CA- paternal side(-) Heart Disease(-) HPN (-) BA(-) PTB(-) DM

PERSONAL AND SOCIAL HISTORY

Smoker- 15 pack yearsAlcoholic beverage drinker- >20 yearsBusinessman by professionAthletic

PAST ILLNESSES

No known food and drug allergiesNo exposure to PTB from family (-) PTB(-) Heart Disease(-) HPN (-) BA (-) CA (-) DMNo past history of hospitalizations

REVIEW OF SYSTEMSHEENT: (-) headachegood vision good hearing(-) sore throatNeck: (-) dysphagia(-) tender lymph nodesCVS: (-) chest pain (-) no palpitations (-) orthopnea

REVIEW OF SYSTEMSGastrointestinal: (-) nausea(-) lower back pain(-) abdominal pain(-) diarrhea (-) vomiting

GUT: anuriaHematuria(-) dysuria

REVIEW OF SYSTEMSMuskuloskeletal:(-) pruritus(-) weakness(-) numbness

PHYSICAL EXAMINATIONAwake, afebrile and not in cardiorespiratory distress

Vital SignsCardiac Rate- 89bpmRespiratory Rate- 20cpmBlood Pressure- 130/90 mmHgTemperature- 36.3 C

PHYSICAL EXAMINATIONHead and NeckAnicteric ScleraePink palpebral conjunctiva(-) Periorbital edema

nasal septum midline upon inspection(-) nasal discharges(-) nasal congestion(-) epistaxis(-) sinus tenderness

PHYSICAL EXAMINATIONHEENT(-) ear discharges Intact tympanic membrane

(-) circumoral cyanosisTonsils are were not enlarged

PHYSICAL EXAMINATIONNeckTrachea was midline upon palpationNo cervivcal lymphadenopathyNo neck vein engorgement Non palpable thyroid glandNo masses and no tenderness palpated

PHYSICAL EXAMINATIONChest and Lungs Inspection(-) accessory muscles of respiration(-) Intercostal retractions(-) hoovers sign

Palpation Equal Chest expansion Equal Tactile fremitus

PHYSICAL EXAMINATIONChest and Lungs

Percussion:Poor diaphragmatic excursion Mild dullness heard on bilateral lung fields

Auscultation:(+) wheezing(+) Crackles on all lung fields

PHYSICAL EXAMINATIONCardiovascular

Inspection:Adynamic precordiumJVP- 5cm

PalpationBrisk carotid pulses Brisk peripheal pulses PMI- 5th ICS Midclavicular line (-) Hepatojugular reflux(-)heaves, (-)thrills

PHYSICAL EXAMINATIONCardiovascularPercussionDullness heard at:Right 2nd ICS midclavicular lineLeft 2nd ICS midlcavicular line3rd ICS leftAuscultationGood S1 and S2(-) murmurs heard at:right 2nd ICSLeft 2nd ICSLower left side of the sternum 5th ICS midclavicular line

PHYSICAL EXAMINATIONAbdominal exam

Inspection:(-) skin lesions Flat abdomenNo dilated veins

Auscultation:Normoactive bowel sounds

PHYSICAL EXAMINATIONAbdominal examination

PercussionTypmanytic on LUQ, LLQ, RLQLiver span:7 cm miclavicular

PalpationNo massesNo tendernessNo organomegaly

PHYSICAL EXAMINATIONMusculoskeletal (-) tenderness (-) edema(-) cyanosis(-) clubbingGood range of motion

PHYSICAL EXAMINATIONNeurologic examMSE: Oriented to person place and timeCranial nervesCN II- direct and consensual reflex notedCN III, IV, VI- intact extra-occular movements CN V- intact muscles of mastication, no sensory deficits CN VII- intact muscles of facial expression, no sensory deficitsCN VIII- good hearing acuityCN IX,X- (+)gag reflexCN XI- (+) shrug shouldersCN XII- (-) tongue deviation

+2 +2 +2 +2 +2 +2 +2 +2

+2 +2

PHYSICAL EXAMINATION

RLUpper extremities: 5/55/5Lower extremities 5/55/5

PHYSICAL EXAMINATIONCerebellar:(-)nystagmus(-) rombergs testNormal gait(+) RAM(+) point nose to finger

No sensory deficits No pathologic Reflexes

ADMITTING IMPRESSION

Mediastinal Mass T/C Teratoma

SALIENT FEATURES 28 years oldWaxing and waning of signs and symptomsDyspneaHemoptysisCT findings of its location in the anterior mediastinumSmoker for 15 pack yearsAlcoholic beverage drinker for 20 years(+)FHx of CancerNo constitutional signs and symptoms

DIFFERENTIAL DIAGNOSIS

Pulmonary TuberculosisRuptured Esophageal VaricesThymomaLung Carcinoma

DIFFERENTIAL DIAGNOSISPulmonary TubercolosisRule in(+) HemoptysisDyspneaCough and back pains not relieved with antibioticsRule out:(-) weight loss(-) night sweats(-) anorexia, vomiting No exposure to PTB patients as claimed

Ruptured Esophageal VaricesRule inAlcoholic beverage drinker for 20 yearsRule out:Anicetric sclerae, (-) jaundice(-) superficial dilated veins on abdomen(-) spider angiomata(-) hepatosplenomegaly(-) ascitis Intact sensorium

DIFFERENTIAL DIAGNOSIS

ThymomaRule in:DyspneaHemoptysisCT findings of its location in the anterior mediastinumRule out:No diplopia, Ptosis No hx of constant muscle weakness that improves after restNo muscle weakness on PE DIFFERENTIAL DIAGNOSIS

Lung CARule in:Smoker 15 pack yearsHemoptysis Dyspnea FHx of CancerRule out:No weight lossNo anorexia, no vomiting, night sweats

DIFFERENTIAL DIAGNOSIS

LABORATORY

ABGpH- 7.3 PCO2- 33.4PO2- 80HCO3- 20.2O2 sat- 96%

CBCHgb- 139Hct- 0.43WBC- 12.1Seg- 0.52Lymph- 0.41Monocyte- 0.05Eosinophil- 0.02Plt count- 270PT- 13.3 secAPTT- 45.5BT- 1 min and 15 secCT- 4 minsLABORATORY

XRAYThere are confluent hazy densities in the Right lower and middle lung fields. The left lung is clear and well expanded. Heart is normal in size

Imp: Consolidated Pneumonia on Right Lower and Middle Lung

CT-SCAN

Right middle lobe pulmonary mass with ipsilateral diffuse lung involvement and bilateral mediastinal lymphadenopathy. Bronchioalveolar carcinoma is a differentail

OR DONE (03/04/10)

Open thoracotomy (Right); Bilobectomy (RUL & RML) & excision of mediastinal tumor (partial)

SURGICAL TECHNIQUE Patient placed in left lateral decubitus position. R side under GA using double lumen ETAsepsis/anti-sepsisSterile drapes placed5th ICS entered(+) mediastinal mass encroaching the upper and middle lobes, w/c is adherent to the SVC & pericardiumBilobectomy (RUL & RML) donePartial excision of mediastinal tumor doneHemostasis CTT R closureDressing Px tolerated the procedure wellSpecimen sent to histopath for biopsy

COURSE IN THE WARD8TH HOSPITAL DAY7TH POST-OP DAY

Subjective:Mild difficulty in deep inspirationPain scale of 4/10 at surgical siteWeakness of lower extremitiesMild coughHad episodes of having blood streaked sputum during expectoration

ObjectiveAwake, afebrile, NCRDS120/90, 90bpm, 19cpm, 36.8C/L:I- Posterolateral surgical scar on the RPal- equal chest expantion - equal tactile fremitus Per resonant on LUL, LLL, RLFAus- mild crackles on right lung field

COURSE IN THE WARD8TH HOSPITAL DAY7TH POST-OP DAY

Assessment:S/P open thoracotomy (Right); Bilobectomy (RUL & RML) & excision of mediastinal tumor

Plan:Daily dressingContinue respiratory exercise Continue medications

COURSE IN THE WARD8TH HOSPITAL DAY7TH POST-OP DAY

Subjective:Mild difficulty in deep inspirationPain scale of 2/10 at surgical siteWeakness of lower extremitiesMild cough with clear sputumHad episodes of having blood streaked sputum during expectoration

COURSE IN THE WARD9TH HOSPITAL DAY8TH POST-OP DAY

ObjectiveAwake, afebrile, NCRDS120/90, 90bpm, 19cpm, 36.8CTT removedC/L:I- Posterolateral surgical scar on the RPal- equal chest expantion - equal fremitus Per resonant on LUL, LLL, RLL fieldsAus- (-) crackles, (-)wheezing

COURSE IN THE WARD9TH HOSPITAL DAY8TH POST-OP DAY

Assessment:S/P open thoracotomy (Right); Bilobectomy (RUL & RML) & excision of mediastinal tumor

Plan:Daily dressingContinue respiratory exercise Continue medicationsFor Bronchoscopy this (03/13/10)

COURSE IN THE WARD9TH HOSPITAL DAY8TH POST-OP DAY

COURSE IN THE WARD10TH HOSPITAL DAY9TH POST-OP DAY

Subjective:Mild difficulty in deep inspirationPain scale of 2/10 at surgical siteMild cough with clear sputumno episode of having blood streaked sputum during expectoration

COURSE IN THE WARD10TH HOSPITAL DAY9TH POST-OP DAY

ObjectiveAwake, afebrile, NCRDS120/90, 90bpm, 19cpm, 36.8C/L:I- Posterolateral surgical scar on the RPal- equal chest expantion - equal fremitus Per resonant on LUL, LLL, RLL fieldsAus- (-) crackles, (-)wheezing

Assessment:S/P open thoracotomy (Right); Bilobectomy (RUL & RML) & excision of mediastinal tumor

Plan:Daily dressingContinue respiratory exercise Continue medicationsBronchoscopy done

COURSE IN THE WARD10TH HOSPITAL DAY9TH POST-OP DAY

BRONCHOSCOPY REPORT

Vocal cords are well coaptated. The trachea is at midline. The carina is sharp. The Left bronchial tree is normal. The stumps of the R upper & middle lobes are clean& slightly hyperemic. The lobe is normal. Secretions are minimal.

COURSE IN THE WARD11TH HOSPITAL DAY10TH POST-OP DAY

Subjective:Mild difficulty in deep inspirationPain scale of 2/10 at surgical siteMild cough with clear sputumno episode of having blood streaked sputum during expectoration

COURSE IN THE WARD11TH HOSPITAL DAY10TH POST-OP DAY

ObjectiveAwake, afebrile, NCRDS120/90, 90bpm, 19cpm, 36.8C/L:I- Posterolateral surgical scar on the RPal- equal chest expantion - equal fremitus Per resonant on LUL, LLL, RLL fieldsAus- (-) crackles, (-)wheezing

Assessment:S/P open thoracotomy (Right); Bilobectomy (RUL & RML) & excision of mediastinal tumor

Plan:Daily dressingContinue respiratory exercise Continue medicationsTransfer of service to IM-Pulmo (AP)

COURSE IN THE WARD10TH HOSPITAL DAY9TH POST-OP DAY

FINAL DIAGNOSIS

Mediastinal mass with Pulmonary Extension on both upper and middle Lobe Right T/C Teratoma

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMYSuperior MediastinumThymus, large veins, large arteries, trachea, esophagus and thoracic duct, and sympathetic trunks

Inferior MediastinumThymus,heart within the pericardium with the phrenic nerves on each side, esophagus and thoracic duct, descending aorta, and sympathetic trunks

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMYBrochopulmonary segmentLung lobule

ANATOMYLymphatic Drainage N1 (Pulmonary Lymph nodes)Intrapulmonary or segmental nodesLobar nodes that lie along the upper-, middle-, and lower-lobe bronchiInterlobar nodes that are located in the angles formed by the bifurcation of the main bronchi into the lobar bronchiHilar nodes that are located along the main bronchi

lymphatic sump of Borrie:Interlobar lymph nodes lie in the depths of the interlobar fissure on each side and constitute a lymphatic sumpall of the pulmonary lobes of the corresponding lung drain into this group of nodes

ANATOMYlymphatic sump of Borrie

Lymphatic Drainage

N2 lymph nodes (Mediastinal)Anterior mediastinalPosterior mediastinalTracheobronchialParatrachealANATOMY

Lymphatic drainage of the right lung is psilateral, except for occasional bilateral drainage to the superior mediastinum. Ipsilateral and contralateral drainage from the left lung to the superior mediastinum occur with the same frequency.ANATOMY

TUMORS OF THE MEDIASTINUM

TUMORS OF THE MEDIASTINUM

TUMORS OF THE MEDIASTINUM

TERATOMA

The most common type of mediastinal germ cell tumor

Germ cell tumors are benign and malignant neoplasms thought to originate from primordial germ cells that fail to complete the migration from the urogenital ridge and come to rest in the mediastinum

GERM CELL TUMORS

GERM CELL TUMORS

TERATOMA60- 70 % of germ cell tumors

They contain 2 to 3 embryonic layers that may include:Teeth, skin, hair (ectoderm)Cartilage and bone (mesodermal)Bronchial, intestinal, or pancreatic (endodermal)

TERATOMA

TERATOMA

The peak incidence is in the second and third decades of life

no gender predisposition

located most commonly in the anterosuperior mediastinum

Diagnosis can be made on routine chest radiography by the identification of well-formed teeth

CT findings of a predominantly fatty mass with a denser dependent portion containing globular calcifications, bone, or teeth and a solid protuberance into a cystic cavity are considered specific

diagnosis usually depends on microscopic examinationTERATOMA

Symptoms, when present, are related to mechanical effects and include chest pain, cough, dyspnea, or symptoms related to recurrent pneumonitisTERATOMA

Total surgical resection

Benign tumors of such large size or with involvement of adjacent mediastinal structures such that complete resection is impossible, partial resection has led to resolution of symptoms, frequently without relapse

TERATOMA

THORACOTOMYThe most frequently used incision for an open procedure in thoracic surgery is the posterolateral thoracotomy.

The posterolateral thoracotomy incision can be used for most pulmonary resections, esophageal operations, and for the approach to the posterior mediastinum and vertebral column

Incision typically starts at the anterior axillary line just below the nipple level and extends posteriorly below the tip of the scapula

THORACOTOMY

The incision then proceeds in a cranial direction halfway between the vertebral border of the scapula and the spinous processes of the vertebrae. The latissimus dorsi is divided and the serratus anterior is retractedTHORACOTOMY

Typically at the fifth interspace the intercostal muscles are divided using electrocautery above the sixth rib, and the pleural space is entered after confirming that the anesthesiologist has excluded ventilation to the operative lung by clamping the proper lumen of a double-lumen endotracheal tubeTHORACOTOMY

Cautery can then be used to perform an internal thoracotomy by continuing the division of the intercostal muscles more anteriorly (up to the level of the internal mammary artery) and posteriorly (up to the level of the paraspinous tendonsTHORACOTOMY

A pitfall of thoracic incisions in a lateral decubitus position is potential for injury to the brachial plexus and axillary vascular structures secondary to displacement of the shoulder. Therefore careful attention must be paid to positioning the patient on the operating table after anesthesia has been inducedTHORACOTOMY

POST-OPERATIVE CAREChest tube managementAll operations involving resection or manipulation of lung tissue, chest tubes are routinely placed into the pleural space

Purpose:To drain fluid, thereby preventing pleural fluid accumulationTo evacuate air if an air leak is present

Chest tube managementA drainage volume of 150 mL or less over 24 hours has been thought necessary in order to safely remove a chest tube

If the pleural space is altered (e.g., malignant pleural effusion, pleural space infections or inflammation, and pleurodesis), strict adherence to a volume requirement before tube removal is appropriate (typically 100 to 150 mL over 24 hours

POST-OPERATIVE CARE

Pain control

Good pain control after posterolateral thoracotomy is critical

Permits the patient to actively participate in breathing maneuvers designed to clear and manage secretions, and promotes ambulation and a feeling of well beingPOST-OPERATIVE CARE

Respiratory care

The best respiratory care is achieved when the patient is able to deliver an effective cough to clear secretions

Requires excellent pain controlPOST-OPERATIVE CARE

Pulmonary edema 1 to 5% of patients

Symptoms of respiratory distress manifest hours to days after surgery

Increase permeability and filtration pressure, and that decrease lymphatic drainage from the affected lung

Treatment consists of ventilatory support, fluid restriction, and diuretics.POST-OPERATIVE COMPLICATIONS

Post-operative air leakOccur more often and last longer in patients with emphysematous changes because the fibrotic changes and destroyed blood supply impairs healing of surface injuries

May be treated by diminishing or discontinuing suction (if used), by continuing chest drainage, or by instilling a pleurodesis agent, usually talcum powderPOST-OPERATIVE COMPLICATIONS

Bronchopleural fistula

Possible from the resected bronchial stump

Management optionsProlonged chest tube drainage Reoperation and reclosure (with stump reinforcement with intercostals or a serratus muscle pedicle flap)For fistulas less than 4 mm, bronchoscopic fibrin glue application Patients often have concomitant empyemas and open drainage may be necessary.POST-OPERATIVE COMPLICATIONS

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