Life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during the resection of a large mediastinal germ cell tumor: proposed safety measures in the absence of cardiovascular surgeons: a case report

Abstract

This report presents an unusual case of life-threatening massive bleeding in the pulmonary trunk adjacent to the right ventricular outflow tract during resection of a large primary mediastinal nonseminomatous germ cell tumor (PMNSGCT) in the absence of cardiovascular surgeons. The patient was a 21-year-old male whose large mediastinal tumor was diagnosed as an extragonadal PMNSGCT, which was a mixture of a yolk sac tumor and an immature teratoma. Generally, chemotherapy causes extensive peripheral tumor necrosis of PMNSGCTs, thus enabling their complete resection. In this case, surgeons considered the resection as possible by dissecting the peripheral necrotic tissue, and cardiovascular surgeons were thus not consulted. Enlarged modified left hemi-clamshell thoracotomy (HCST) was applied. While dissecting around the pulmonary trunk, the assistant-held forceps accidentally touched the tensed pulmonary trunk, which caused bleeding. We immediately contacted the collaborating cardiac surgery department at another hospital for assistance. Meanwhile, massive bleeding occurred, leading to hemorrhagic shock, and thus direct cardiac massage was required. Our team managed to establish a venoarterial (VA) extracorporeal membrane oxygenation (ECMO). After the arrival of cardiac surgeons, a suction circuit was added, and bleeding was stopped using sutures. Finally, complete resection of the tumor was achieved, and the patient awoke the following day without any brain dysfunction. After discussions with all the members involved in the surgery, we developed an in-hospital consensus on how to perform surgeries for large thoracic tumors safely at our cancer center without the cardiovascular surgery department. We herein present the case and consensus and discuss the relevant issues.

Primary mediastinal yolk sac tumor: A case report and literature review

“…Meanwhile, the VIP regimen, as another alternative of chemotherapy, was reported to have the similar efficacy to BEP, and it is more suitable for patients who are awaiting surgery because of the lower pulmonary toxicity. However, similar to the case in our report, some studies have showed that BEP and VIP have no significant effect on tumor size 6,15,19,20 . To date, opinions on the necessity of chemotherapy and the selection of chemotherapy scheme, still remains controversial.…”

“…Sakakura et al shared a case that the primary mediastinal nonseminomatous germ cell tumor, damaging to the pulmonary trunk adjacent to the right ventricular outflow tract in a 21‐year‐old male, resulted in life‐threatening massive bleeding for the absence of cardiovascular surgeons during operation. Therefore, they presented some constructive consensus including cardiovascular surgeons should be consulted in advance when handling the area around great vessels and the use of an assisted circulation can be considered for safety reasons 19 . As far as our case is concerned, although the CPB was not used, the surgical plan considering all the possibilities which may be encountered in operation was predesigned, including the use of CPB, and prosthetic vessel replacement.…”

“…Therefore, they presented some constructive consensus including cardiovascular surgeons should be consulted in advance when handling the area around great vessels and the use of an assisted circulation can be considered for safety reasons. 19 As far as our case is concerned, although the CPB was not used, the surgical plan considering all the possibilities which may be encountered in operation was predesigned, including the use of CPB, and prosthetic vessel replacement. As far as current studies are concerned, there is no standardized surgical protocol for PMYST.…”

“…However, similar to the case in our report, some studies have showed that BEP and VIP have no significant effect on tumor size. 6,15,19,20 To date, opinions on the necessity of chemotherapy and the selection of chemotherapy scheme, still remains controversial.…”

“…In PubMed, the English case reports and case series of PMYST during the past decade were searched. The following key words were used for the database search: “yolk sac tumor,” “mediastinum,” “mediastinal.” A total of 73 articles were retrieved, in which 22 articles on the therapy and prognosis of PMYST were extracted, including 16 case reports and 6 case series, involving 52 patients in total 5–26 . Out of all the patients, only six female cases were reported.…”