- Email: [email protected]
Carinal Resection Requiring Cardiopulmonary Bypass in a Pregnant Patient
Ann Thorac Surg 2013;96:1085–7
CASE REPORT FITZSIMONS ET AL CARINAL RESECTION, BYPASS, AND PREGNANCY
1085
Fig 4. In the microscopic evaluation with hematoxylin and eosin staining, (A) areas of thymomas subtypes B1 and B2 showed some lymphocytes with mild atypia (thin arrow) and the proliferation of epithelioid cells (thick arrow), and the (B) areas of thymoma subtype B3 showed cells with mitosis and atypical proliferation of epithelioid cells (thin arrow). (Original magnification, (A) ⫻200; (B) ⫻400).
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
References 1. Benveniste MF, Rosado-de-Christenson ML, Sabloff BS, Moran CA, Swisher SG, Marom EM. Role of imaging in the diagnosis, staging, and treatment of thymoma. Radiographics 2011;31:1847– 61. 2. Rosado-de-Christenson ML, Pugatch RD, Moran CA, Galobardes J. Thymolipoma: analysis of 27 cases. Radiology 1994; 193:121– 6. 3. Toyama T, Mizuno T, Masako A, et al. Pathogenesis of thymolipoma: report of 3 cases. Surg Today 1995;25:86 – 8. 4. Damadoglu E, Salturk C, Takir HB, et al. Mediastinal thymolipoma: an analysis of 10 cases. Respirology 2007;12: 924 –7. 5. Argani P, de Chiocca IC, Rosai J. Thymoma arising with a thymolipoma. Histopathology 1998;32:573– 4. 6. Haddad H, Joudeh A, El-Taani H, et al. Thymoma and thymic carcinoma arising in a thymolipoma: report of a unique case. Int J Surg Pathol 2009;17:55–9. 7. Restrepo CS, Pandit M, Rojas IC, et al. Imaging findings of expansile lesions of the thymus. Curr Probl Diagn Radiol 2005;34:22–34. 8. Tomiyama N, Honda O, Tsubamoto M, et al. Anterior mediastinal tumors: diagnostic accuracy of CT and MRI. Eur J Radiol 2009;69:280 – 8.
Carinal Resection Requiring Cardiopulmonary Bypass in a Pregnant Patient Michael G. Fitzsimons, MD, Joshua Ng, MD, Cameron Wright, MD, Douglas Mathisen, MD, Gus Vlahakes, MD, and Meredith Albrecht, MD Department of Anesthesia, Critical Care, and Pain Medicine, Department of Surgery, Thoracic Surgery Division, and Department of Surgery, Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts
A 35-year-old woman at 13 weeks gestation presented with adenoid cystic carcinoma of the distal left mainstem bronchus with chronic collapse of the left lung requiring carinal pneumonectomy. The extent of the tumor and need for significant retraction during dissection and pneumonectomy resulted in the need for cardiopulmonary bypass. The patient underwent successful left carinal Accepted for publication Dec 10, 2012. Address correspondence to Dr Fitzsimons, Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.12.048
FEATURE ARTICLES
to extrinsic compression of the adjacent thoracic structures, including cough, dyspnea, hemoptysis, chest pain, hoarseness, or paroxysmal atrial tachycardia. Less frequently, autoimmune manifestations may be present, usually myasthenia gravis, or rarely, Grave disease, aplastic anemia, and hypogammaglobulinemia [4]. The diagnosis of thymolipoma should be considered in a patient presenting with an anterior mediastinal fatty mass [2]. The presence of soft tissue within the lesion should always be assessed carefully because it can correspond to benign or malignant components. The differential diagnosis includes lipoma, prominent epicardial fat pad, congenital diaphragmatic hernia, teratoma, thymohemangiolipoma, liposarcoma, thymoma, thymic carcinoma, and other primary thymic malignancies [4]. The literature contains few case reports of thymomas originating from a thymolipoma. Argani and colleagues [5] reported a 67-year-old woman with a thymoma within a thymolipoma that was treated with tumor resection and monitored for up to 10 years, with no evidence of recurrence. Thymic carcinoma arising within a thymolipoma has also been reported [6]. To our knowledge our report is the first case of thymoma containing three histologic subtypes (B1, B2, and B3) simultaneously seen in the same lesion arising within a thymolipoma. Although the diagnosis of a thymic tumor may be suggested by CT findings, it is usually not possible to differentiate a benign from a malignant lesion with CT scan alone [7]. Surgical excision should be considered for patients with a gigantic intrathoracic lipomatous mass on CT, as seen in our patient. The use of magnetic resonance imaging for the evaluation of anterior mediastinal lesions has several advantages, including excellent spatial resolution, lack of ionizing radiation, and lack of iodinated contrast [8]. The advent of functional methods, such as diffusion-weighted images, can be used to assess tumor activity and recognize areas suggestive of malignancy. Fat-suppression techniques may be useful in differentiating surrounding fat from solid areas that would represent a thymoma or thymic carcinoma. Heterogeneous signal intensity is present in tumors with necrosis, hemorrhage, or cystic change. In conclusion, we documented and discussed the occurrence of an atypical variant of thymolipoma containing three histologic subtypes of thymomas inside. To our knowledge this is the first case reported with these characteristics.
1086
CASE REPORT FITZSIMONS ET AL CARINAL RESECTION, BYPASS, AND PREGNANCY
pneumonectomy and subsequently delivered a healthy baby. (Ann Thorac Surg 2013;96:1085–7) © 2013 by The Society of Thoracic Surgeons
C
arinal pneumonectomy for adenoid cystic carcinoma of the bronchus can generally be accomplished with selective one-lung ventilation. More extensive surgical resection requiring manipulation and dissection may require the use of cardiopulmonary bypass and heparin administration. Cardiopulmonary bypass during pregnancy may place the health of the fetus in jeopardy. The development of an appropriate perioperative plan by a multidisciplinary team is necessary to assure a satisfactory outcome in such a situation.
FEATURE ARTICLES
A 35-year-old woman in her 13th week of pregnancy presented with adenoid cystic carcinoma of the left main bronchus for surgical resection. She had had stridor and dyspnea 9 months before presentation. She experienced intermittent chest pressure and tightness but denied any pain or voice changes. Over the subsequent months, she had progressive shortness of breath with minimal exertion. A computed tomography scan of the chest was performed and revealed a markedly hyperinflated right lung with herniation into the left hemithorax. There was complete occlusion of the left main bronchus at the carina with extension into the parenchyma and complete collapse of the lung. The mass extensively abutted the aortopulmonary window. Broad contact was noted with the right and left main pulmonary arteries. The mass extended posteriorally, abutting the descending thoracic aorta, and there were two small indeterminate lung nodules visualized on computed tomography scan. Preoperative evaluation revealed a pleasant and healthy-appearing woman. Her medical history was significant for asthma, bilateral spontaneous pneumothorax, and hemorrhoids. She had never been a smoker. Blood pressure was 99/53 mm Hg. She was 67 inches in height and 63 kilograms in weight. She confirmed that she was 12 weeks pregnant and that her pregnancy was uneventful. Preoperative laboratory analysis was unremarkable. Preoperative discussion included an estimated risk of loss of pregnancy at 15% to 30%. The anesthetic plan included a check of fetal heart tones before surgery, avoidance of teratogenic medications, maintenance of maternal oxygenation, higher flow rates, and maintenance of normothermia. The obstetric service was consulted and noted that that the risks of general anesthesia and the likelihood of birth defects due to anesthesia are low. Fetal heart tones would be checked before and after surgery but not continually monitored during the period of the procedure and anesthesia. A bronchoscopy performed under local anesthesia and sedation revealed limited involvement of the distal trachea. The right mainstem bronchus had some involvement down to the level of the takeoff of the right upper lobe medially. The mucosa on the bronchus intermedius
Ann Thorac Surg 2013;96:1085–7
appeared normal. General anesthesia was induced with propofol, fentanyl, and vecuronium. Mask ventilation was easy, as was intubation. General anesthesia was maintained with continuous infusions of remifentanil and propofol. The patient underwent a median sternotomy. Examination revealed near-complete herniation of the right lung into the left lateral pleural space. The left lung was chronically deflated. It was considered that the degree of retraction necessary to complete the left pneumonectomy would result in significant hemodynamic instability. An activated clotting time of 499 s was established (goal 480 s). Cardiopulmonary bypass with a heparin-bonded circuit was initiated with aortic arterial cannulation and placement of a two-stage cannula in the right atrial appendage. Normothermia was maintained as well as a beating heart to allow pulsatility. Flows were maintained above 2.5 L · min⫺1 · m⫺2. She underwent a left carinal pneumonectomy with reimplantation of the right mainstem bronchus to the trachea (tracheal sleeve pneumonectomy), excision of the left atrial appendage to avoid coumadin in case of atrial fibrillation, and excision of the right middle and lower lobe lung nodules. Pathology revealed stage IV metastatic adenoid cystic carcinoma. The patient demonstrated adequate muscle strength after muscle relaxant reversal. She was extubated at the end of the procedure, and dyspnea developed. She was reintubated and transported to the intensive care unit where she was extubated the following morning. She was found to have left vocal cord immobility requiring bedside laryngoplasty and injection with Restylane (Q-Med, a Galderma Division, Uppsala, Sweden). Postoperative flexible bronchoscopy revealed a viable, completely intact anastomosis. She was discharged on postoperative day 9. The remainder of her pregnancy was uneventful, and she delivered a healthy baby girl slightly after term. She is now 24 months postoperative; metastasis to her remaining lung developed, and she is undergoing chemotherapy.
Comment The most common indications for tracheal resection and reconstruction are postintubation stenosis and tumors. Primary malignant tumors such as adenoid cystic carcinoma and squamous cell carcinoma are rare [1]. Symptoms are nonspecific and may include progressive exercise intolerance, hemoptysis, exercise-induced stridor, and stridor at rest. The diagnosis of “adult onset” asthma is often a mistaken diagnosis in patients with tracheal pathology. The major concern of the anesthesiologist is management of the airway during induction of anesthesia and management of the airway during tracheal surgery. Spontaneous ventilation during induction of anesthesia with a volatile agent allows one to carefully assess the ability to ventilate with positive pressure [2]. The airway must be shared with the surgeon during surgery. The position of the tumor and site of resection may make ventilation and oxygenation difficult or impossible.
Ann Thorac Surg 2013;96:1087–9
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
1087
performed later in pregnancy, ␣-stat blood gas management, and pulsatile perfusion during bypass. The authors would like to thank Erin Lacey for her assistance with the preparation and submission of this manuscript.
References 1. Grillo HC. The history of tracheal surgery. Chest Surg Clin North Am 2003;175– 89. 2. Furimsky M, Aronson S, Ovassapian A. Perioperative anesthesia management of a patient presenting for resection of a tracheal mass. J Cardiothorac Vasc Anesth 1998;12:701– 4. 3. Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth 1999;46:439 –55. 4. Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2002;97:1582–90. 5. Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg 2009;108:777– 85.
Preoperative Computed Tomography-Guided Localization of Ground-Glass Opacities With Metallic Clip Chiang J. Tyng, MD, Marcus V.B. Baranauskas, MD, Almir G.V. Bitencourt, MD, Maria Fernanda A. Almeida, MD, João Paulo K. Matsushita, Jr, MD, Paula N.V. Barbosa, MD, Marcos D. Guimarães, MD, and Rubens Chojniak, PhD Department of Imaging and Department of Thoracic Surgery, Hospital AC Camargo, São Paulo, Brazil
Intraoperative localization of ground-glass opacities is difficult because they are not easy to palpate and may be invisible at radioscopy. Therefore, various techniques have been developed to improve intraoperative localization of these lesions, allowing an adequate surgical resection. The aim of this study is to report two cases of preoperative localization of ground-glass opacities through computed tomography– guided placement of a metallic clip inside the lesion and to discuss this new technique in comparison with those previously described. (Ann Thorac Surg 2013;96:1087–9) © 2013 by The Society of Thoracic Surgeons
G
round-glass opacities (GGO) are a nonspecific radiologic finding, which may be associated with various benign and malignant diseases. In patients with lung cancer or other malignancies, these lesions are known to exhibit high malignancy potential and therefore require tissue confirmation for proper treatment planning [1].
Accepted for publication Jan 4, 2013. Address correspondence to Dr Tyng, Rua Prof. Antônio Prudente, 211, 01509-010, São Paulo-SP, Brazil; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.028
FEATURE ARTICLES
Advancing an endotracheal tube into a main bronchus for such procedures essentially may allow one-lung ventilation. The use of cardiopulmonary bypass for tracheal resection and reconstruction was popular in the 1960s [3]. Systemic anticoagulation therapy associated with cardiopulmonary bypass risks lung hemorrhage with dissection. Improvements in surgical management at specialized centers subsequently decreased the need for bypass. The need for cardiopulmonary bypass was anticipated well in advance of the procedure, and confirmed when the degree of tracheal and mainstem involvement was noted on computed tomography scan and preoperative bronchoscopy. Standard single-lumen endotracheal intubation of the right mainstem bronchus would have potentially ventilated only the right middle and lower lobes during resection and reconstruction. Manipulation of the tumor because of its size combined with possible lack of ventilation of right upper lobe would have resulted in inadequate gas exchange for the patient and fetus. Concern in the past existed about full heparinization, manipulation of lung, and risk of pulmonary hemorrhage. Lung transplant on cardiopulmonary bypass has proved this can be done safely if care is taken. There was no pulmonary hemorrhage in this case, despite wedge resections of two lung nodules. There are two primary aims in the anesthetic management of patients undergoing cardiopulmonary bypass: avoidance of teratogenic agents and minimizing effects of cardiopulmonary bypass that may induce premature labor. The safety of most drugs in the perioperative period is unclear. The most critical time for teratogenic effects is in early gestation. Diazepam is associated with the development of cleft palate, etomidate is embryocidal, and coumadin is associated with congenital malformations. The use of ketamine is not recommended in the first trimester. Neuromuscular-blocking agents and heparin do not cross the blood-brain barrier and are considered safe. The effects of vasopressors such as epinephrine and dopamine are unknown. The use of phenylephrine and ephedrine is considered acceptable for treatment of hypotension. Recent evidence suggests phenylephrine is associated with higher fetal pH [4]. Propofol is considered a safe induction agent, although hypotension may compromise uterine perfusion. Premature onset of labor is the major concern with the conduction of cardiopulmonary bypass. Uteroplacental blood flow may be compromised by nonpulsatile blood flow, hypotension, hypothermia, and the inflammatory state associated with bypass [5]. Low uteroplacental blood flow, hypothermia, hemodilution, embolization, prolonged bypass, and obstruction of vena cava blood return may induce fetal asphyxia [5]. Chandrasekhar and associates [5] recommend several strategies for the safe management of cardiopulmonary bypass in the parturient, including 15 degrees of lateral tilt, perfusion pressure greater than 70 mm Hg, higher bypass flow rates (⬎2.5 L · min⫺1 · m⫺2), minimization of bypass times, normothermia, and maintenance of arterial oxygenation. The team may consider tocolytic therapy for procedures
CASE REPORT TYNG ET AL PREOPERATIVE METALLIC CLIP LOCALIZATION
CASE REPORT FITZSIMONS ET AL CARINAL RESECTION, BYPASS, AND PREGNANCY
1085
Fig 4. In the microscopic evaluation with hematoxylin and eosin staining, (A) areas of thymomas subtypes B1 and B2 showed some lymphocytes with mild atypia (thin arrow) and the proliferation of epithelioid cells (thick arrow), and the (B) areas of thymoma subtype B3 showed cells with mitosis and atypical proliferation of epithelioid cells (thin arrow). (Original magnification, (A) ⫻200; (B) ⫻400).
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
References 1. Benveniste MF, Rosado-de-Christenson ML, Sabloff BS, Moran CA, Swisher SG, Marom EM. Role of imaging in the diagnosis, staging, and treatment of thymoma. Radiographics 2011;31:1847– 61. 2. Rosado-de-Christenson ML, Pugatch RD, Moran CA, Galobardes J. Thymolipoma: analysis of 27 cases. Radiology 1994; 193:121– 6. 3. Toyama T, Mizuno T, Masako A, et al. Pathogenesis of thymolipoma: report of 3 cases. Surg Today 1995;25:86 – 8. 4. Damadoglu E, Salturk C, Takir HB, et al. Mediastinal thymolipoma: an analysis of 10 cases. Respirology 2007;12: 924 –7. 5. Argani P, de Chiocca IC, Rosai J. Thymoma arising with a thymolipoma. Histopathology 1998;32:573– 4. 6. Haddad H, Joudeh A, El-Taani H, et al. Thymoma and thymic carcinoma arising in a thymolipoma: report of a unique case. Int J Surg Pathol 2009;17:55–9. 7. Restrepo CS, Pandit M, Rojas IC, et al. Imaging findings of expansile lesions of the thymus. Curr Probl Diagn Radiol 2005;34:22–34. 8. Tomiyama N, Honda O, Tsubamoto M, et al. Anterior mediastinal tumors: diagnostic accuracy of CT and MRI. Eur J Radiol 2009;69:280 – 8.
Carinal Resection Requiring Cardiopulmonary Bypass in a Pregnant Patient Michael G. Fitzsimons, MD, Joshua Ng, MD, Cameron Wright, MD, Douglas Mathisen, MD, Gus Vlahakes, MD, and Meredith Albrecht, MD Department of Anesthesia, Critical Care, and Pain Medicine, Department of Surgery, Thoracic Surgery Division, and Department of Surgery, Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts
A 35-year-old woman at 13 weeks gestation presented with adenoid cystic carcinoma of the distal left mainstem bronchus with chronic collapse of the left lung requiring carinal pneumonectomy. The extent of the tumor and need for significant retraction during dissection and pneumonectomy resulted in the need for cardiopulmonary bypass. The patient underwent successful left carinal Accepted for publication Dec 10, 2012. Address correspondence to Dr Fitzsimons, Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.12.048
FEATURE ARTICLES
to extrinsic compression of the adjacent thoracic structures, including cough, dyspnea, hemoptysis, chest pain, hoarseness, or paroxysmal atrial tachycardia. Less frequently, autoimmune manifestations may be present, usually myasthenia gravis, or rarely, Grave disease, aplastic anemia, and hypogammaglobulinemia [4]. The diagnosis of thymolipoma should be considered in a patient presenting with an anterior mediastinal fatty mass [2]. The presence of soft tissue within the lesion should always be assessed carefully because it can correspond to benign or malignant components. The differential diagnosis includes lipoma, prominent epicardial fat pad, congenital diaphragmatic hernia, teratoma, thymohemangiolipoma, liposarcoma, thymoma, thymic carcinoma, and other primary thymic malignancies [4]. The literature contains few case reports of thymomas originating from a thymolipoma. Argani and colleagues [5] reported a 67-year-old woman with a thymoma within a thymolipoma that was treated with tumor resection and monitored for up to 10 years, with no evidence of recurrence. Thymic carcinoma arising within a thymolipoma has also been reported [6]. To our knowledge our report is the first case of thymoma containing three histologic subtypes (B1, B2, and B3) simultaneously seen in the same lesion arising within a thymolipoma. Although the diagnosis of a thymic tumor may be suggested by CT findings, it is usually not possible to differentiate a benign from a malignant lesion with CT scan alone [7]. Surgical excision should be considered for patients with a gigantic intrathoracic lipomatous mass on CT, as seen in our patient. The use of magnetic resonance imaging for the evaluation of anterior mediastinal lesions has several advantages, including excellent spatial resolution, lack of ionizing radiation, and lack of iodinated contrast [8]. The advent of functional methods, such as diffusion-weighted images, can be used to assess tumor activity and recognize areas suggestive of malignancy. Fat-suppression techniques may be useful in differentiating surrounding fat from solid areas that would represent a thymoma or thymic carcinoma. Heterogeneous signal intensity is present in tumors with necrosis, hemorrhage, or cystic change. In conclusion, we documented and discussed the occurrence of an atypical variant of thymolipoma containing three histologic subtypes of thymomas inside. To our knowledge this is the first case reported with these characteristics.
1086
CASE REPORT FITZSIMONS ET AL CARINAL RESECTION, BYPASS, AND PREGNANCY
pneumonectomy and subsequently delivered a healthy baby. (Ann Thorac Surg 2013;96:1085–7) © 2013 by The Society of Thoracic Surgeons
C
arinal pneumonectomy for adenoid cystic carcinoma of the bronchus can generally be accomplished with selective one-lung ventilation. More extensive surgical resection requiring manipulation and dissection may require the use of cardiopulmonary bypass and heparin administration. Cardiopulmonary bypass during pregnancy may place the health of the fetus in jeopardy. The development of an appropriate perioperative plan by a multidisciplinary team is necessary to assure a satisfactory outcome in such a situation.
FEATURE ARTICLES
A 35-year-old woman in her 13th week of pregnancy presented with adenoid cystic carcinoma of the left main bronchus for surgical resection. She had had stridor and dyspnea 9 months before presentation. She experienced intermittent chest pressure and tightness but denied any pain or voice changes. Over the subsequent months, she had progressive shortness of breath with minimal exertion. A computed tomography scan of the chest was performed and revealed a markedly hyperinflated right lung with herniation into the left hemithorax. There was complete occlusion of the left main bronchus at the carina with extension into the parenchyma and complete collapse of the lung. The mass extensively abutted the aortopulmonary window. Broad contact was noted with the right and left main pulmonary arteries. The mass extended posteriorally, abutting the descending thoracic aorta, and there were two small indeterminate lung nodules visualized on computed tomography scan. Preoperative evaluation revealed a pleasant and healthy-appearing woman. Her medical history was significant for asthma, bilateral spontaneous pneumothorax, and hemorrhoids. She had never been a smoker. Blood pressure was 99/53 mm Hg. She was 67 inches in height and 63 kilograms in weight. She confirmed that she was 12 weeks pregnant and that her pregnancy was uneventful. Preoperative laboratory analysis was unremarkable. Preoperative discussion included an estimated risk of loss of pregnancy at 15% to 30%. The anesthetic plan included a check of fetal heart tones before surgery, avoidance of teratogenic medications, maintenance of maternal oxygenation, higher flow rates, and maintenance of normothermia. The obstetric service was consulted and noted that that the risks of general anesthesia and the likelihood of birth defects due to anesthesia are low. Fetal heart tones would be checked before and after surgery but not continually monitored during the period of the procedure and anesthesia. A bronchoscopy performed under local anesthesia and sedation revealed limited involvement of the distal trachea. The right mainstem bronchus had some involvement down to the level of the takeoff of the right upper lobe medially. The mucosa on the bronchus intermedius
Ann Thorac Surg 2013;96:1085–7
appeared normal. General anesthesia was induced with propofol, fentanyl, and vecuronium. Mask ventilation was easy, as was intubation. General anesthesia was maintained with continuous infusions of remifentanil and propofol. The patient underwent a median sternotomy. Examination revealed near-complete herniation of the right lung into the left lateral pleural space. The left lung was chronically deflated. It was considered that the degree of retraction necessary to complete the left pneumonectomy would result in significant hemodynamic instability. An activated clotting time of 499 s was established (goal 480 s). Cardiopulmonary bypass with a heparin-bonded circuit was initiated with aortic arterial cannulation and placement of a two-stage cannula in the right atrial appendage. Normothermia was maintained as well as a beating heart to allow pulsatility. Flows were maintained above 2.5 L · min⫺1 · m⫺2. She underwent a left carinal pneumonectomy with reimplantation of the right mainstem bronchus to the trachea (tracheal sleeve pneumonectomy), excision of the left atrial appendage to avoid coumadin in case of atrial fibrillation, and excision of the right middle and lower lobe lung nodules. Pathology revealed stage IV metastatic adenoid cystic carcinoma. The patient demonstrated adequate muscle strength after muscle relaxant reversal. She was extubated at the end of the procedure, and dyspnea developed. She was reintubated and transported to the intensive care unit where she was extubated the following morning. She was found to have left vocal cord immobility requiring bedside laryngoplasty and injection with Restylane (Q-Med, a Galderma Division, Uppsala, Sweden). Postoperative flexible bronchoscopy revealed a viable, completely intact anastomosis. She was discharged on postoperative day 9. The remainder of her pregnancy was uneventful, and she delivered a healthy baby girl slightly after term. She is now 24 months postoperative; metastasis to her remaining lung developed, and she is undergoing chemotherapy.
Comment The most common indications for tracheal resection and reconstruction are postintubation stenosis and tumors. Primary malignant tumors such as adenoid cystic carcinoma and squamous cell carcinoma are rare [1]. Symptoms are nonspecific and may include progressive exercise intolerance, hemoptysis, exercise-induced stridor, and stridor at rest. The diagnosis of “adult onset” asthma is often a mistaken diagnosis in patients with tracheal pathology. The major concern of the anesthesiologist is management of the airway during induction of anesthesia and management of the airway during tracheal surgery. Spontaneous ventilation during induction of anesthesia with a volatile agent allows one to carefully assess the ability to ventilate with positive pressure [2]. The airway must be shared with the surgeon during surgery. The position of the tumor and site of resection may make ventilation and oxygenation difficult or impossible.
Ann Thorac Surg 2013;96:1087–9
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
1087
performed later in pregnancy, ␣-stat blood gas management, and pulsatile perfusion during bypass. The authors would like to thank Erin Lacey for her assistance with the preparation and submission of this manuscript.
References 1. Grillo HC. The history of tracheal surgery. Chest Surg Clin North Am 2003;175– 89. 2. Furimsky M, Aronson S, Ovassapian A. Perioperative anesthesia management of a patient presenting for resection of a tracheal mass. J Cardiothorac Vasc Anesth 1998;12:701– 4. 3. Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth 1999;46:439 –55. 4. Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2002;97:1582–90. 5. Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg 2009;108:777– 85.
Preoperative Computed Tomography-Guided Localization of Ground-Glass Opacities With Metallic Clip Chiang J. Tyng, MD, Marcus V.B. Baranauskas, MD, Almir G.V. Bitencourt, MD, Maria Fernanda A. Almeida, MD, João Paulo K. Matsushita, Jr, MD, Paula N.V. Barbosa, MD, Marcos D. Guimarães, MD, and Rubens Chojniak, PhD Department of Imaging and Department of Thoracic Surgery, Hospital AC Camargo, São Paulo, Brazil
Intraoperative localization of ground-glass opacities is difficult because they are not easy to palpate and may be invisible at radioscopy. Therefore, various techniques have been developed to improve intraoperative localization of these lesions, allowing an adequate surgical resection. The aim of this study is to report two cases of preoperative localization of ground-glass opacities through computed tomography– guided placement of a metallic clip inside the lesion and to discuss this new technique in comparison with those previously described. (Ann Thorac Surg 2013;96:1087–9) © 2013 by The Society of Thoracic Surgeons
G
round-glass opacities (GGO) are a nonspecific radiologic finding, which may be associated with various benign and malignant diseases. In patients with lung cancer or other malignancies, these lesions are known to exhibit high malignancy potential and therefore require tissue confirmation for proper treatment planning [1].
Accepted for publication Jan 4, 2013. Address correspondence to Dr Tyng, Rua Prof. Antônio Prudente, 211, 01509-010, São Paulo-SP, Brazil; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.028
FEATURE ARTICLES
Advancing an endotracheal tube into a main bronchus for such procedures essentially may allow one-lung ventilation. The use of cardiopulmonary bypass for tracheal resection and reconstruction was popular in the 1960s [3]. Systemic anticoagulation therapy associated with cardiopulmonary bypass risks lung hemorrhage with dissection. Improvements in surgical management at specialized centers subsequently decreased the need for bypass. The need for cardiopulmonary bypass was anticipated well in advance of the procedure, and confirmed when the degree of tracheal and mainstem involvement was noted on computed tomography scan and preoperative bronchoscopy. Standard single-lumen endotracheal intubation of the right mainstem bronchus would have potentially ventilated only the right middle and lower lobes during resection and reconstruction. Manipulation of the tumor because of its size combined with possible lack of ventilation of right upper lobe would have resulted in inadequate gas exchange for the patient and fetus. Concern in the past existed about full heparinization, manipulation of lung, and risk of pulmonary hemorrhage. Lung transplant on cardiopulmonary bypass has proved this can be done safely if care is taken. There was no pulmonary hemorrhage in this case, despite wedge resections of two lung nodules. There are two primary aims in the anesthetic management of patients undergoing cardiopulmonary bypass: avoidance of teratogenic agents and minimizing effects of cardiopulmonary bypass that may induce premature labor. The safety of most drugs in the perioperative period is unclear. The most critical time for teratogenic effects is in early gestation. Diazepam is associated with the development of cleft palate, etomidate is embryocidal, and coumadin is associated with congenital malformations. The use of ketamine is not recommended in the first trimester. Neuromuscular-blocking agents and heparin do not cross the blood-brain barrier and are considered safe. The effects of vasopressors such as epinephrine and dopamine are unknown. The use of phenylephrine and ephedrine is considered acceptable for treatment of hypotension. Recent evidence suggests phenylephrine is associated with higher fetal pH [4]. Propofol is considered a safe induction agent, although hypotension may compromise uterine perfusion. Premature onset of labor is the major concern with the conduction of cardiopulmonary bypass. Uteroplacental blood flow may be compromised by nonpulsatile blood flow, hypotension, hypothermia, and the inflammatory state associated with bypass [5]. Low uteroplacental blood flow, hypothermia, hemodilution, embolization, prolonged bypass, and obstruction of vena cava blood return may induce fetal asphyxia [5]. Chandrasekhar and associates [5] recommend several strategies for the safe management of cardiopulmonary bypass in the parturient, including 15 degrees of lateral tilt, perfusion pressure greater than 70 mm Hg, higher bypass flow rates (⬎2.5 L · min⫺1 · m⫺2), minimization of bypass times, normothermia, and maintenance of arterial oxygenation. The team may consider tocolytic therapy for procedures
CASE REPORT TYNG ET AL PREOPERATIVE METALLIC CLIP LOCALIZATION