Intraoperative Catastrophe during Benign Mediastinal Tumor Mass Excision: A Case Report

Abstract

Mature teratoma of the mediastinum poses a significant surgical challenge due to close vicinity to vital structures causing respiratory insufficiency or hemodynamic compromise. While the malignant variety of germ cell tumors (GCT) generally present with florid symptoms, benign teratomas are detected incidentally on imaging. Large teratomas presenting as mediastinal mass syndrome have additional difficulty in airway access. Herein, we report a case of a 40-year-old-female with no significant comorbidities presenting with rapidly progressing symptoms of chest pain, dyspnea, and superior vena cava (SVC) compression. Computed tomography (CT) scan of the neck and chest confirmed a large cystic lesion with marked compression of the great veins in the neck, arch of aorta, trachea, and proximal bronchial divisions. Airway access intraoperatively was done by awake fiberoptic bronchoscopy. However, sudden hypoxia and hemodynamic deterioration warranted emergency sternotomy. Adequate preoperative preparation, as well as standby extracorporeal circulatory support, led to successful and complete excision of the tumor. The patient had an uneventful recovery and extubated in the intensive care unit (ICU) the next day. Histopathology of the mass confirmed to be mature benign cystic teratoma. At six-month follow-up, the patient was completely asymptomatic without any complications. The impact of intraoperative catastrophe on the healthcare team can be immense. Inability to achieve a secure airway and the resultant hypoxia can result in permanent neurological damage. A multidisciplinary approach leading to adequate preoperative assessment, intraoperative preparedness for an emergency sternotomy with standby extracorporeal circulatory support due to the risk of mediastinal mass syndrome, were key features in the successful management of the patient.

Single-Center Experience of Management of Mediastinal Cyst—A Case Series

“…Some cysts are known to cause specific symptoms related to their structure, location, and formation mechanisms. 4 Our patients also had pressure on some mediastinal organs and related symptoms. Seven of our patients had trachea compression and associated cough and shortness of breath.…”

Rescue computed tomography-guided drainage of a giant mediastinal mature teratoma causing airway obstruction prior to surgical resection: a case report

“…General anesthetics and muscle relaxants decrease chest wall muscle tone, elevate the diaphragm, change the position of the tumor, and increase the risk of pressure obstruction of the airways and great blood vessels [1]. Furthermore, increased intrathoracic pressure due to positive pressure ventilation after intubation may worsen airway obstruction, resulting in further respiratory failure and circulatory collapse [2,3]. In such cases, extracorporeal membrane oxygenation (ECMO) should be provided in conjunction with general anesthesia [4,5].…”

Presenting Symptomatology of Mediastinal Masses and Its Effect on Surgical Outcomes

“…Previous studies have shown that the proximity of a mediastinal mass to vital structures in the mediastinum can make the operation and anesthesia considerations more technically challenging. 2,13 If a mass is larger, it is more likely to be abutting major structures and thus causing symptoms (for example, a mass compressing the lung causing shortness of breath or a mass abutting the esophagus causing dysphagia). Larger mediastinal masses may be more technically challenging to resect, thus leading to a longer postoperative length of stay.…”