CASE PRESENTATION

Clerk
Department of Surgery
GENERAL DATA


BA
28 years old Male
Roman Catholic
Surigao City
CHIEF COMPLAINT


Hemoptysis
HISTORY OF PRESENT ILLNESS
7 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
anorexia
night sweats
Weight loss
Vomiting



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 ILLNESS
1 year PTA
Persistence of signs and symptoms
Consultation was done for PE of employment

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

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

1 day PTA
Massive bouts of hemoptysis
Dyspnea on mild physical activity
Back 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 years
Alcoholic beverage drinker- >20 years
Businessman by profession
Athletic
PAST ILLNESSES

No known food and drug allergies
No exposure to PTB from family
(-) PTB
(-) Heart Disease
(-) HPN
(-) BA
(-) CA
(-) DM
No past history of hospitalizations
REVIEW OF SYSTEMS
HEENT:
(-) headache
good vision
good hearing
(-) sore throat
Neck:
(-) dysphagia
(-) tender lymph nodes
CVS:
(-) chest pain
(-) no palpitations
(-) orthopnea


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

GUT:
anuria
Hematuria
(-) dysuria

REVIEW OF SYSTEMS
Muskuloskeletal:
(-) pruritus
(-) weakness
(-) numbness

PHYSICAL EXAMINATION
Awake, afebrile and not in cardiorespiratory distress

Vital Signs
Cardiac Rate- 89bpm
Respiratory Rate- 20cpm
Blood Pressure- 130/90 mmHg
Temperature- 36.3 C



PHYSICAL EXAMINATION
Head and Neck
Anicteric Sclerae
Pink palpebral conjunctiva
(-) Periorbital edema

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

PHYSICAL EXAMINATION
HEENT
(-) ear discharges
Intact tympanic membrane

(-) circumoral cyanosis
Tonsils are were not enlarged
PHYSICAL EXAMINATION
Neck
Trachea was midline upon palpation
No cervivcal lymphadenopathy
No neck vein engorgement
Non palpable thyroid gland
No masses and no tenderness palpated

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

Palpation
Equal Chest expansion
Equal Tactile fremitus

PHYSICAL EXAMINATION
Chest and Lungs

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

Auscultation:
(+) wheezing
(+) Crackles on all lung fields
PHYSICAL EXAMINATION
Cardiovascular

Inspection:
Adynamic precordium
JVP- 5cm

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

PHYSICAL EXAMINATION
Cardiovascular
Percussion
Dullness heard at:
Right 2
nd
ICS midclavicular line
Left 2
nd
ICS midlcavicular line
3
rd
ICS left
Auscultation
Good S1 and S2
(-) murmurs heard at:
right 2
nd
ICS
Left 2
nd
ICS
Lower left side of the sternum
5
th
ICS midclavicular line


PHYSICAL EXAMINATION
Abdominal exam

Inspection:
(-) skin lesions
Flat abdomen
No dilated veins

Auscultation:
Normoactive bowel sounds
PHYSICAL EXAMINATION
Abdominal examination

Percussion
Typmanytic on LUQ, LLQ, RLQ
Liver span:
7 cm miclavicular

Palpation
No masses
No tenderness
No organomegaly
PHYSICAL EXAMINATION
Musculoskeletal
(-) tenderness
(-) edema
(-) cyanosis
(-) clubbing
Good range of motion
PHYSICAL EXAMINATION
Neurologic exam
MSE: Oriented to person place and time
Cranial nerves
CN II- direct and consensual reflex noted
CN 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
deficits
CN VIII- good hearing acuity
CN IX,X- (+)gag reflex
CN XI- (+) shrug shoulders
CN XII- (-) tongue deviation







+2 +2 +2 +2

+2 +2

+2 +2



+2 +2





R L
Upper
extremities:
5/5 5/5
Lower
extremities
5/5 5/5
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
Cerebellar:
(-)nystagmus
(-) rombergs test
Normal gait
(+) RAM
(+) point nose to finger

No sensory deficits
No pathologic Reflexes


ADMITTING IMPRESSION



Mediastinal Mass T/C Teratoma
SALIENT FEATURES
28 years old
Waxing and waning of signs and symptoms
Dyspnea
Hemoptysis
CT findings of its location in the anterior
mediastinum
Smoker for 15 pack years
Alcoholic beverage drinker for 20 years
(+)FHx of Cancer
No constitutional signs and symptoms





DIFFERENTIAL DIAGNOSIS

Pulmonary Tuberculosis
Ruptured Esophageal Varices
Thymoma
Lung Carcinoma

DIFFERENTIAL DIAGNOSIS
Pulmonary Tubercolosis
Rule in
(+) Hemoptysis
Dyspnea
Cough and back pains not relieved with antibiotics
Rule out:
(-) weight loss
(-) night sweats
(-) anorexia, vomiting
No exposure to PTB patients as claimed
Ruptured Esophageal Varices
Rule in
Alcoholic beverage drinker for 20 years
Rule out:
Anicetric sclerae, (-) jaundice
(-) superficial dilated veins on abdomen
(-) spider angiomata
(-) hepatosplenomegaly
(-) ascitis
Intact sensorium


DIFFERENTIAL DIAGNOSIS
Thymoma
Rule in:
Dyspnea
Hemoptysis
CT findings of its location in the anterior
mediastinum
Rule out:
No diplopia, Ptosis
No hx of constant muscle weakness that improves
after rest
No muscle weakness on PE

DIFFERENTIAL DIAGNOSIS
Lung CA
Rule in:
Smoker 15 pack years
Hemoptysis
Dyspnea
FHx of Cancer
Rule out:
No weight loss
No anorexia, no vomiting, night sweats


DIFFERENTIAL DIAGNOSIS
LABORATORY


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

CBC
Hgb- 139
Hct- 0.43
WBC- 12.1
Seg- 0.52
Lymph- 0.41
Monocyte- 0.05
Eosinophil- 0.02
Plt count- 270
PT- 13.3 sec
APTT- 45.5
BT- 1 min and 15 sec
CT- 4 mins
LABORATORY
XRAY
There 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 ET
Asepsis/anti-sepsis
Sterile drapes placed
5
th
ICS entered
(+) mediastinal mass encroaching the upper and middle lobes,
w/c is adherent to the SVC & pericardium
Bilobectomy (RUL & RML) done
Partial excision of mediastinal tumor done
Hemostasis
CTT R closure
Dressing
Px tolerated the procedure well
Specimen sent to histopath for biopsy

COURSE IN THE WARD
8
TH
HOSPITAL DAY
7
TH
POST-OP DAY


Subjective:
Mild difficulty in deep inspiration
Pain scale of 4/10 at surgical site
Weakness of lower extremities
Mild cough
Had episodes of having blood streaked sputum
during expectoration




Objective
Awake, afebrile, NCRDS
120/90, 90bpm, 19cpm, 36.8
C/L:
I- Posterolateral surgical scar on the R
Pal- equal chest expantion
- equal tactile fremitus
Per resonant on LUL, LLL, RLF
Aus- mild crackles on right lung field

COURSE IN THE WARD
8
TH
HOSPITAL DAY
7
TH
POST-OP DAY

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

Plan:
Daily dressing
Continue respiratory exercise
Continue medications

COURSE IN THE WARD
8
TH
HOSPITAL DAY
7
TH
POST-OP DAY

Subjective:
Mild difficulty in deep inspiration
Pain scale of 2/10 at surgical site
Weakness of lower extremities
Mild cough with clear sputum
Had episodes of having blood streaked sputum
during expectoration


COURSE IN THE WARD
9
TH
HOSPITAL DAY
8
TH
POST-OP DAY

Objective
Awake, afebrile, NCRDS
120/90, 90bpm, 19cpm, 36.8
CTT removed
C/L:
I- Posterolateral surgical scar on the R
Pal- equal chest expantion
- equal fremitus
Per resonant on LUL, LLL, RLL fields
Aus- (-) crackles, (-)wheezing


COURSE IN THE WARD
9
TH
HOSPITAL DAY
8
TH
POST-OP DAY

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

Plan:
Daily dressing
Continue respiratory exercise
Continue medications
For Bronchoscopy this (03/13/10)


COURSE IN THE WARD
9
TH
HOSPITAL DAY
8
TH
POST-OP DAY


COURSE IN THE WARD
10
TH
HOSPITAL DAY
9
TH
POST-OP DAY

Subjective:
Mild difficulty in deep inspiration
Pain scale of 2/10 at surgical site
Mild cough with clear sputum
no episode of having blood streaked sputum during
expectoration


COURSE IN THE WARD
10
TH
HOSPITAL DAY
9
TH
POST-OP DAY

Objective
Awake, afebrile, NCRDS
120/90, 90bpm, 19cpm, 36.8
C/L:
I- Posterolateral surgical scar on the R
Pal- equal chest expantion
- equal fremitus
Per resonant on LUL, LLL, RLL fields
Aus- (-) crackles, (-)wheezing

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

Plan:
Daily dressing
Continue respiratory exercise
Continue medications
Bronchoscopy done


COURSE IN THE WARD
10
TH
HOSPITAL DAY
9
TH
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 WARD
11
TH
HOSPITAL DAY
10
TH
POST-OP DAY

Subjective:
Mild difficulty in deep inspiration
Pain scale of 2/10 at surgical site
Mild cough with clear sputum
no episode of having blood streaked sputum during
expectoration


COURSE IN THE WARD
11
TH
HOSPITAL DAY
10
TH
POST-OP DAY

Objective
Awake, afebrile, NCRDS
120/90, 90bpm, 19cpm, 36.8
C/L:
I- Posterolateral surgical scar on the R
Pal- equal chest expantion
- equal fremitus
Per resonant on LUL, LLL, RLL fields
Aus- (-) crackles, (-)wheezing

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

Plan:
Daily dressing
Continue respiratory exercise
Continue medications
Transfer of service to IM-Pulmo (AP)


COURSE IN THE WARD
10
TH
HOSPITAL DAY
9
TH
POST-OP DAY

FINAL DIAGNOSIS

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

ANATOMY
ANATOMY
ANATOMY
ANATOMY
ANATOMY
Superior Mediastinum
Thymus, large veins, large arteries, trachea,
esophagus and thoracic duct, and sympathetic
trunks

Inferior Mediastinum
Thymus,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
ANATOMY
Brochopulmonary
segment
Lung lobule
ANATOMY
Lymphatic Drainage
N1 (Pulmonary Lymph nodes)
Intrapulmonary or segmental nodes
Lobar nodes that lie along the upper-, middle-, and lower-lobe
bronchi
Interlobar nodes that are located in the angles formed by the
bifurcation of the main bronchi into the lobar bronchi
Hilar 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 sump
all of the pulmonary lobes of the corresponding lung drain into
this group of nodes
ANATOMY
lymphatic sump of Borrie


Lymphatic Drainage

N2 lymph nodes (Mediastinal)
Anterior mediastinal
Posterior mediastinal
Tracheobronchial
Paratracheal
ANATOMY

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
TERATOMA
60- 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
examination
TERATOMA


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

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
THORACOTOMY
The 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 retracted
THORACOTOMY
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 tube
THORACOTOMY
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 tendons
THORACOTOMY
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
induced
THORACOTOMY
POST-OPERATIVE CARE
Chest tube management
All 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
accumulation
To evacuate air if an air leak is present
Chest tube management
A 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 being
POST-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 control
POST-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 leak
Occur 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
powder
POST-OPERATIVE COMPLICATIONS
Bronchopleural fistula

Possible from the resected bronchial stump

Management options
Prolonged 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