ASSISTANT:
ANESTHESIOLOGIST:
Leslie A. Sullivan, M.D.
Mark Kenter, M.D.
OPERATION:
1.
Fiberoptic bronchoscopy.
2.
Esophagoscopy.
3.
Left thoracotomy and lung resection with resection of
the superior segment of the left upper lobe.
4.
Lymphadenectomy.
5.
Pleurectomy.
6.
Biopsy of the aorta.
PREOPERATIVE DIAGNOSES:
1.
Esophageal carcinoma.
2.
Anemia.
3.
Dehydration.
POSTOPERATIVE DIAGNOSES:
1.
Esophageal carcinoma.
2.
Dehydration.
3.
Anemia.
4.
Left lower lobe lesion of abdominal aortic wall.
5.
Pleurisy.
ANESTHESIA: General endotracheal with Dr. Kenter with a
thoracic epidural.
INDICATIONS: The patient is a 72-year-old male with
esophageal cancer whose work up was outlined in his history
and physical and comes in now for resection.
FINDINGS: The patient indeed was found to have marked
adhesion of the left lung up to the pleural area and this
was all taken down. As it was resected, the left lung was
found to be a superior segment of the left lower lobe
markedly adherent to the aorta. The esophagus itself had a
lot of reaction around it but not extending beyond the
pleural borders. There were two large 1.5- to 2-cm lymph
nodes on top of it, these were excised and on frozen
section did not show any gross tumor. Lymph nodes were
also taken from the superior mediastinum as well.
The lesion in the lung was sent for multiple biopsies and
frozen section because of question about metastatic disease
versus a primary lung or other disease, and a definitive
diagnosis could not be made and, therefore, it was elected
not to proceed with the esophagectomy. The lesion was
growing into the aortic wall and on the adventitia there
was about a 4.5 x 5-cm area of the adventitia that was
involved. Care was taken not to disturb this and several
biopsies were taken around the edges of it and some sent
for cultures as well as for final pathology. After the
lung was resected, there was no significant air leak.
On the esophagoscopy the patient did have a tumor that was
extruding into the lumen at 34 cm, though some of it,
however, did not show any obvious abnormalities.
At the end of the procedure, the patient was able to be
awakened and extubated and taken to the postoperative
anesthesia recovery room in stable condition.
PROCEDURE: The patient was placed on the table in the
supine position and after placement of an IV, arterial
line, Foley catheter, general endotracheal anesthesia was
induced. A thoracic epidural had previously been placed.
The fiberoptic bronchoscope was passed and there was no
evidence of any endobronchial lesions. The scope was
removed, esophagoscope was passed with the findings as
noted above. The scope was then removed and the patient
was then placed in the right lateral decubitus position,
the left chest prepped and draped in the usual sterile
fashion.
A left lateral thoracotomy was performed sparing the
latissimus dorsi going into the 6th intercostal space. The
esophagus was found as noted; however, the lung was
markedly adherent to the whole area of the posterior chest
wall around the spine and this was carefully freed up and a
pleurectomy was done. Then it was found that the left
lower lobe, as we went through the fissure, separated that
with the GIA stapler, was markedly adherent to the aorta.
After this was freed up and dissected out, the aorta could
be seen more medially and this was freed up and indeed
there was marked reaction around the pleura but there was
no evidence of tumor spreading beyond the pleural surface.
There were two several large lymph nodes about 1.5 to 2 cm
on the superior surface of the aorta as noted on the
ultrasound and these were both resected and biopsied.
There were also nodes up along the superior mediastinum
which were dissected off and indeed on frozen section
showed no cancer.
Returning attention then to the lung, it became apparent
that there was a lesion in the superior segment of the left
upper lobe, it was about 4.5 to 5 cm, that was adherent to
the aorta. It was, therefore, elected to carefully resect
the lung around where they entered through the pleura and
then a space was able to be made and a segmental resection
was done of the left lower lobe superior segment and
leaving it adherent to the aorta. After this was freed up,
it became apparent there were no other nodes around in the
hilum to suggest it was small metastatic disease, it was
then carefully freed up and it was found to be adherent to
the adventitia. This was taken off and indeed there was a
space left that was about 4.5 x 5 cm in the adventitia to
the aorta. Several biopsies were taken around the edge of
this and again on frozen could not be sure there was
metastatic disease and some was sent for final pathology.
A portion also was sent for cultures as well.
After this was freed up, the remainder of the lung expanded
well. This whole segment was abnormal but the remainder of
the left lower lobe did not have any obvious abnormalities
and any evidence of metastatic disease. The inferior
pulmonary ligament was freed up from the inferior pulmonary
vein. Not being sure whether this was metastatic disease,
infection or what the inflammation was and knowing that we
would not necessarily want an esophagogastrectomy in the
area if indeed anything needed to be done to the aorta such
as putting a graft in, it was elected not to proceed with
esophageal resection and attention was turned to closure.
The area of the segment of resection was oversewn with
interlocking #3-0 chromic suture and right angle and
straight #36 French chest tubes were placed through stab
wounds and secured with #0 silk suture. Attention was
turned to closure. Double pericostals were placed and the
muscles were reapproximated with #0 Vicryl suture. The
subcutaneous tissue was closed with continuous suture of
#2-0 Vicryl and the skin was approximated with subcuticular
stitch of #3-0 Vicryl. At the end of the procedure, the
sponge, needle and instrument counts were correct.
ESTIMATED BLOOD LOSS:
500 mL through pleurectomy.
REPLACEMENT: Two (2) units of packed cells, 500 mL of
albumin and 800 mL of crystalloid.
DRAINS:
Two #36 French chest tubes.
The patient's wound was dressed, he was placed in the
supine position, was extubated and taken to the
postoperative anesthesia recovery room in stable condition.
The patient had minimal air leak and on the chest x-ray
showed good expansion of the left lung. He was awake and
moving all extremities well and alert and conscious.