Excision of Large Left Chest Chondrosarcoma in Rural West Africa

Abstract

In 2015, the Lancet commission published its report increasing awareness about the global burden of surgical disease. Our case illustrates this burden and brings to light considerations for thoracic surgical care in rural, underserved areas. CASE PRESENTATION:A seven-year old male presented to the Hospital of Hope in Mango, Togo with a three-year history of a slowly growing chest mass. Physical exam showed a large, left chest wall mass suspicious for chest wall sarcoma. He was positioned in the right lateral decubitus position. Care was taken to preserve the latissiumus dorsi, serratus anterior, and pectoralis major as muscle coverage for closure. We dissected around the mass and entered the left chest cavity. There was involvement of the pericardium, mass effect on the heart, and the left lung was atrophic due to tumor mass effect. Intraoperative cardiac arrest occurred five times and formal paddles were not available but electrical activity returned following cardiac massage and by filling the chest cavity with saline and using external cardioversion. During the resection, due to the proximity of the left lung hilum and pericardium to the tumor, we performed a left pneumonectomy and pericardiectomy in addition to resection of left ribs four through eight. Ultimately, the tumor extended posteriorly to the border of the spine limiting ability to achieve grossly negative margins. Serratus anterior, latissiumus dorsi, and pectoralis major were used for primary closure. The size of the tumor was 15 x 13 x 13 cm. The patient was successfully extubated, had an uneventful recovery, and returned home with his parents. Unfortunately, the patient expired six months after surgery due to tumor recurrence. DISCUSSION:In rural, international settings thoracic pathology is often advanced far beyond what is seen in countries with more developed medical infrastructure leading to significant difficulties in all aspects of thoracic surgical care. Specifically, standard intraoperative tools as well as routine parts of postoperative care are commonly not available. Due to this both creative thinking as well as careful operative planning are essential in providing care for patients.CONCLUSIONS: Short-term service trips by thoracic surgeons are essential to alleviating the immediate burden of thoracic surgical disease. However, educating native surgeons and investments in healthcare infrastructure are the best long-term solutions for addressing thoracic pathology in the developing world.