Download Anesthetic management of a patient with a mediastinal foregut

Anesthetic management of a patient with a
mediastinal foregut duplication cyst: A case
report
Aaron R. Gopp, CRNA, MSN
Nampa, Idaho
2003 Student Writing Contest Honorable Mention
Foregut duplication cysts are rare. There is no mention of
this type of mediastinal mass in searches of the anesthesia
literature.
A 42-year-old woman undergoing preoperative evaluation for elective bilateral breast augmentation was found by
chest radiograph to have a mediastinal mass. She was
referred for additional evaluation. After thorough radiographic and physical examination, the patient underwent
successful resection of a foregut duplication cyst that
involved esophageal, right lung, pericardial, and subcarinal
tissues.
The location of the foregut duplication cyst, its mass
effect, and the anatomical structures involved with the cyst
T
he presence of a mediastinal foregut duplication cyst in an adult can present significant
challenges to anesthetic providers. Often the
cyst is discovered incidentally, with no previous symptoms described by the patient.
Mass location, size, and involvement of adjacent
mediastinal structures may have a profound effect on
the patient’s hemodynamic and pulmonary function
during induction, maintenance of, and emergence
from general anesthesia.
Comprehensive evaluation of the mass, the adjacent structures, and potential concurrent systemic
anomalies is imperative in providing appropriate
anesthetic management. This article discusses the
occurrence of mediastinal foregut cyst and the evaluation, anatomic, physiologic, and anesthetic management concerns for an adult patient with such a cyst.
Case summary
A nonsmoking 42-year-old female runner lost more
than 10 kg during the preceding year through a regimen of diet and exercise and decided to undergo bilateral breast augmentation. She was an ASA class II
patient owing to her long-standing history of arrhythmias and paroxysmal dyspnea and recently developed
chest pain. During preoperative evaluation at another
facility, a mediastinal mass was discovered on the
chest radiograph. The patient elected to postpone the
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may present numerous challenges for anesthesia providers.
Airway management, arterial cannulation, and central
venous access may be difficult. In addition, patients with
foregut duplication cysts are at risk for pneumothorax,
pneumomediastinum, profound hemorrhage, esophageal
injury or rupture, vascular lesions, neurologic injury, gastric
aspiration, and cardiovascular collapse due to anatomical
disturbances caused by the mass. Comprehensive evaluation and development of an anesthetic plan based on this
evaluation will improve patient outcome and help prevent
potentially catastrophic complications.
Key words: Mediastinal foregut duplication cyst.
augmentation surgery pending further evaluation of
the mass. At the referral center, she underwent radiologic and pathologic evaluation, including computed
tomography (CT) scan and endoscopic fine-needle
biopsy. Nine days after the needle biopsy, she came to
the emergency department with excruciating chest
pain, fever, shortness of breath, tachycardia, anorexia,
and extreme dysphagia. She was given intravenous
broad-spectrum antibiotics, patient-controlled analgesia for her chest pain, and was scheduled for an emergency exploratory thoracotomy for mass resection
and definitive pathological evaluation.
Owing to the emergency nature of the surgery, the
preanesthetic evaluation was conducted in the preoperative holding area. Respiratory examination
revealed bilateral clear lungs, no respiratory distress,
and an unremarkable pulmonary function test. An
anteroposterior and lateral chest radiograph showed
moderate fullness in the right hilum, while the
remainder of the thorax, lungs, and heart were unremarkable (Figure 1). Cardiac evaluation confirmed a
20-year history of dysrhythmias, which previously
were diagnosed as Wenckebach (second-degree type 1
block), paroxysmal atrial tachycardia, atrial fibrillation, and conduction delay. The patient also described
brief periods of random, paroxysmal chest pain, dyspnea, and near syncope associated with arrhythmic
episodes. The latter occurred less than once a year and
AANA Journal/February 2005/Vol. 73, No. 1
55
Figure 1. Anterior-posterior chest radiograph of
patient with embryologic foregut cyst
The mass originates at approximately the T4 level, extending inferiorly and into the right mediastinum and pleura at
the level of the left atrium. At its widest, the mass
measures 3.5 cm anteroposteriorly and 5 cm transversely.
The arrow indicates the location of the mass at the lateral
right border. (Note: this image is black-white inverted to
optimize visualization of anatomical structures.)
resolved when she assumed the supine position and
drew her knees up to her chest.
The patient’s 3 most recent electrocardiograms
revealed atrial fibrillation, normal sinus rhythm with
right axis deviation, and borderline first-degree atrioventricular block. Echocardiography showed normal
chamber function and wall motion and a mediastinal
mass radiating from the right side of the esophagus at
the T4 level, extending below the carina toward the
upper pericardium. The patient’s history also revealed
infrequent dysphagia and nausea and vomiting occurring 1 or 2 times a year.
Upper gastrointestinal endoscopic ultrasound
revealed a “cystic” mass that contained a significant
amount of viscous proteinaceous material. Examination of the specimen from transesophageal fine-needle
biopsy was unsuccessful in determining the mass
pathology. Subsequent swallow studies revealed that
no esophageal atresia or communicating fistula was
present.
A CT scan indicated a right-sided, posterior, elongated mediastinal mass extending downward from the
level of the carina to the lower part of the left atrium
and located immediately adjacent to the esophagus.
The widest diameter, occurring at the level of the
proximal right intermediate bronchus, was 3.5 cm in
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AANA Journal/February 2005/Vol. 73, No. 1
the anteroposterior plane and 5 cm in the transverse
plane without infiltration into the lung parenchyma.
The CT density indicated the mass to be solid or complex; findings for the remainder of the chest were
unremarkable. Radiographic differential diagnoses
included neurogenic tumor, lymphoma, and esophageal duplication cyst.
The physical examination revealed a physically fit,
ASA status II, 168-cm, 54-kg woman with a social
drinking history. She was employed as a beautician
and often stood for extended periods without difficulty. Before her admission, the patient walked or ran
3 to 6 miles every day on a treadmill and participated
in weight training several times each week. The previous surgical and anesthetic history included extraction of wisdom teeth and bilateral radial keratotomy.
She had 4 normal vaginal deliveries, 2 with epidural
anesthetics. Her family history was noncontributory.
Daily medications included digoxin, 0.25 mg; verapamil, 90 mg; and oral contraceptive, multivitamins,
and calcium supplements. Allergies included penicillin and sulfa drugs, both of which caused hives.
Ciprofloxacin sensitivity resulted in diarrhea when
taken for an unrelated upper respiratory infection.
Airway evaluation revealed a Mallampati class 2,
improving to an Mallampati 1 with phonation, 3finger-breadth thyromental distance, full range of
neck motion, wide mouth opening, and intact, native
dentition. Her vital signs were as follows: temperature, 37.5°C; SpO2, 96% on room air; pulse, 105 beats
per minute; and blood pressure, 106/58 mm Hg. Laboratory test results were as follows: white blood cell
count, 12.1 ¥ 109/L; hemoglobin concentration, 9.9
g/dL; hematocrit, 29%; and platelet count, 564 ¥
109/L. The results of electrolyte and coagulation studies were within normal limits.
The patient consented to invasive monitoring, thoracic epidural catheter placement to aid postoperative
pain relief, and general anesthesia. Although the
patient was extremely anxious, an intravenous line
was inserted and sedation administered, and thoracic
epidural placement was uneventful.
The patient was brought to the operating room,
and an arterial line and additional intravenous line
were inserted before induction. Radial artery cannulation proved unsuccessful bilaterally. Subsequently, a
left brachial artery catheter was inserted.
The surgeon requested that the patient be intubated with a 37F left-sided, double-lumen bronchial
tube. Following slow induction with 20 mg of etomidate, 325 µg of fentanyl, 5 mg of midazolam, and 6 mg
of vecuronium and ventilation with 1.5% isoflurane, 2
attempts were made to insert the double-lumen endo-
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bronchial tube. The tube passed easily through the
vocal cords and superior trachea but could not be
advanced past the T1 level without binding and causing posterior tracheal distortion. To secure the airway,
the patient was intubated with a 7.5 oral endotracheal
tube. Subsequent fiberoptic bronchoscopy revealed no
apparent intratracheal mass or deviation of the trachea or bronchogenic structures. A 35F left-sided,
double-lumen tube then was placed successfully, and
the position was confirmed with the bronchoscope.
An 8F central venous sheath was placed in the
right internal jugular vein, and the central venous
pressure was monitored; the initial reading was 11
mm Hg. General anesthesia was maintained with 1.2%
isoflurane, 100% oxygen, intermittent fentanyl
boluses, and vecuronium for the duration of the case.
A 120-mg bolus of lidocaine was injected through the
epidural catheter during surgical preparations to provide an adjunct to the general anesthetic and minimize narcotic use. Before surgical incision, an 8F
Salem sump style nasogastric tube was inserted
through the right naris and its position verified by
gastric return and auscultation. To facilitate surgery,
the right lung was collapsed before incision, and it
remained deflated for the duration of the case.
Surgical dissection revealed a mass that seemed to
emanate from the esophageal wall, was located anterior to the azygos vein, and extended inferiorly from
just above the azygos vein downward to the posterior
aspect of the pericardium. It extended largely into the
right side of the chest and impinged on the right pulmonary vein, resulting in inflammation and erosion.
The mass was densely adherent to the adjoining
lung, azygos vein, and left portion of the pericardium.
The cyst’s wall was very thick and wrapped around the
right and left mainstem bronchi. The base of the mass
contained a thin area that included the left inferior
pulmonary vein. It contained approximately 200 mL
of pus within the lumen, and, despite a fistula 2 cm in
diameter connecting it to the esophagus, it was,
according to the operative report, noncommunicating
with the esophagus.
Coagulum and the multiple septations of the mass
indicated chronicity of the mass and its development
from an embryological origin. The mass was dissected
from around the pulmonary artery without difficulty,
and surgical evaluation confirmed the preoperative
diagnosis of esophageal duplication.
Surgical pathological evaluation of the dissected
mass revealed smooth muscle bundles that formed a
well-defined layer within the cystic wall composed of
respiratory epithelium and stratified squamous
epithelium. Although chronic and acute inflammatory
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infiltrates were noted throughout, 1 of the 3 samples
contained a small nodule of benign cartilage. The
presence of cartilage indicates bronchogenic origin,
whereas the smooth muscle layers are consistent with
an esophageal duplication. Foregut duplication cystic
development will be further examined in the “Case
discussion” section.
Resection of the left part of the cyst denuded the
esophageal mucosa of 7 to 8 cm of circular and longitudinal muscle, allowing visualization of the nasogastric tube in the esophageal lumen. This necessitated
the placement of a T tube into the esophagus, which
was brought through the right lateral chest wall to
allow drainage of secretions. The esophagus was
repaired with muscular flaps from the right intercostal
musculature. Two Jackson-Pratt drains were placed on
either side of the thoracic incision line, and 3 chest
tubes were placed around the esophageal defect and
externalized from the right lateral side of the chest.
Hemodynamic and pulmonary stability were maintained throughout the surgery. The chest was closed,
and the patient was extubated immediately postoperatively and transferred to the surgical intensive care
unit. Estimated blood loss was 750 mL, urine output
was 975 mL, and intraoperative fluid administration
included 3,100 mL of crystalloid, 500 mL of colloid,
and 3 U of packed red blood cells. Because the patient
had a low hemoglobin concentration and hematocrit
value preoperatively and significant blood loss was
anticipated, the surgical team requested replacement
of blood loss with an equal volume of packed red
blood cells to optimize oxygen-carrying capacity and
hemodynamic function.
On arrival to the intensive care unit, a 6-mL bolus
of 0.5 % bupivacaine and 10 µg/mL of hydromorphone was given through the epidural catheter. Subsequently, an epidural infusion of the same analgesic
mixture was started at 8 mL/h and titrated to effect
until its removal 72 hours postoperatively.
A postoperative chest radiograph showed small,
bilateral pneumothoraces that resolved before chest
tube removal. After an uncomplicated 24-hour stay in
the intensive care unit, the patient was transferred to
the general surgery floor for recovery and rehabilitation. On postoperative day 8, gastrostomy and
jejunostomy tubes were inserted under general anesthesia, and the patient was discharged home on postoperative day 16. The patient had no oral intake for
nearly 5 months postoperatively due to persistent dysphagia and esophageal dysmotility and had multiple
uneventful esophageal dilations under general anesthesia to aid in resolution of the dysphagia. Moreover,
she required a cardiac electrophysiology study for
AANA Journal/February 2005/Vol. 73, No. 1
57
ablation of aberrant atrial conduction pathways to
resolve cardiac dysrythmias and near-syncopal episodes.
Case discussion
Foregut malformation cysts are uncommon and are
quite rare in adults.1-3 The vast majority of mediastinal cystic lesions are diagnosed in infancy or early
childhood as a result of symptoms such as dysphagia,
vomiting, dyspnea, and other difficulties. In children,
foregut malformations make up approximately 11% of
mediastinal masses.1 Esophageal duplications make
up between 0.5% and 2.5% of esophageal tumors,
whereas bronchogenic cysts are more common.2,3 Of
all foregut cysts, 25% to 35% are discovered incidentally in adults, and the incidence in men is twice that
in women. Postmortem evaluation of esophageal
duplication reveals an incidence of 1 in 8,200.3
Mediastinal cysts typically are classified only after
comprehensive pathological evaluation. Pathological
determination often is difficult, leaving some pathologists to classify them as foregut cysts of aberrant
embryological pathology rather than specifying bronchogenic cysts or esophageal duplications. At least 2
pathological classification systems of these foregut
cysts are described in the literature.4
Of mediastinal cysts in 27 adults reported by Cioffi
et al,2 16 were classified as bronchogenic and 11 as
esophageal. Bronchogenic cysts typically are lined
with ciliated columnar epithelium, contain cartilaginous material, and may contain mucoid material if
they are noncommunicating with the esophagus.
Esophageal duplications are classified by the presence
of squamous, columnar, pseudostratified, ciliated, or
cuboidal epithelium and are adjacent to the
esophageal wall.2,4
• Diagnosis and radiologic evaluation. The vast
majority of foregut cysts are diagnosed in infancy or
early childhood after evaluation of symptoms, including dysphagia, vomiting, dyspnea, and other difficulties.2 In adults, diagnosis of cystic lesions often is incidental after evaluation of routine chest radiographs.2,5
Roughly one third of adults exhibit no symptoms;
however, symptoms may include epigastric pain,
chest pain, dysphagia, and/or cough.2,6 Chest pain
predominates in patients with bronchogenic cyst,
whereas dysphagia usually is present only in
esophageal duplications.2 Mass location may provide
insight into the diagnosis of certain types of embryological cysts. Of the 27 cases reviewed by Cioffi et
al,2 10 of 16 bronchogenic cysts were located in the
right posterior middle mediastinum.2 In the same
study, the vast majority of the esophageal duplication
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cysts were located in the right posterior inferior mediastinum; however, they also may be located midline in
the posterior mediastinum.7 Foregut cysts also have
been reported intrapericardially, subdiaphragmatically, and thoracoabdominally.2,8,9
Current radiologic literature recommends evaluation of all mediastinal cysts to determine size, location,
and type with magnetic resonance imaging and CT
scanning.10-12 Ultrasonography may provide preliminary information; however, additional radiologic studies generally will be required.12,13 Recommendations
for transesophageal ultrasonography are contradictory:
several authors advocate this method, but others
strongly oppose it.2,13-17 Transthoracic echocardiography may indicate cardiac involvement in cystic formations. Further supporting the difficulty in diagnosis,
there has been a report of a cystic lesion that initially
was diagnosed as a left atrial tumor by chest radiography and transthoracic echocardiography.18 Endoscopic
fine-needle aspiration of cysts before surgery remains
controversial because it may assist in pathologic evaluation but risks seeding the mass with bacteria,2,19 as
apparently happened in the present case.
• Embryological development, anatomy, intervention,
and pathophysiology. A review of the embryological
development of the lungs and esophagus is essential
to understanding foregut cysts. The esophagus and
trachea initially develop from the ventral wall of the
foregut. Esophageal and tracheal separation occurs
before 5 weeks’ gestation, and at approximately 5
weeks’ gestation the mucosal and submucosal layers
of the trachea and esophagus begin to develop.4,20
Alterations in development at this stage may result in
cystic formation (Figure 2). Typically, the distal
esophagus elongates first, followed by the proximal
esophagus, reaching its full length around 7 weeks’
gestation. The patent lumen develops around 10
weeks. During the same period, the esophageal
epithelium changes from stratified columnar to
cuboidal to ciliated and, ultimately, to stratified squamous. Sympathetic innervation of the esophagus originates from the celiac plexus and thoracic tree,
whereas the vagus nerve provides parasympathetic
innervation.20 Corresponding bronchogenic development occurs along the same timeline.
Of all esophageal duplications, 60% develop in the
lower third, 23% in the upper third, and 17% in the
middle third of the esophagus.3 It is the location of the
cyst rather than cyst volume that has more of an effect
on adjacent intrathoracic structures. Cysts that
develop in the upper mediastinum typically have
greater mass effect per unit volume than do those in
the middle or lower mediastinum.2 This phenomenon
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Figure 2. Diagram of embryological development and
differentiation of foregut tissues
Embryological foregut
Esophageal
duplication
cyst
Bronchogenic
cyst
Triple epithelium cyst
Note that the location of cyst origination in the embryological pregut generally defines the pathology and
location of cyst present at the end of normal gestation.
6
(Adapted from Hoem et al. )
likely is related to the more rigid nature of structures
in upper mediastinum and the limited area for structural movement. Aberrancies in the development or
positioning of the foregut during embryological development may result in a myriad of malformations
including esophageal stenosis, atresia, diverticula,
cysts, and duplications.1,21-23 Because the trachea and
esophagus develop from the same foregut, it is not
uncommon to have concurrent congenital malformation of the respiratory system and esophageal duplication.11,24-28 As development occurs concurrently with
other body systems, foreguts cysts may be associated
with other systemic abnormalities such as spinal malformation and cardiac anomalies.29-32 Each of the
additional systemic malformations should be evaluated carefully to determine its potential effect on anesthetic administration.
A diagnosis of foregut duplication cyst requires
surgical intervention. Treatment of choice is complete
excision via thoracotomy or thoracoscopy with the
typical approach from the right chest to avoid the aortic arch. Thoracoscopic excision is reported to reduce
postoperative pain, provide superior cosmetic results,
and lead to earlier patient discharge.2,33,34 Nomori et
al35 reported continuous esophagoscopic monitoring
of video-assisted thoracoscopic surgery, which they
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believe maintains better esophageal integrity. Specialized monitoring techniques such as this should be discussed with the surgical team to determine the effects
on administering anesthesia.
The present patient’s extensive mass was inflamed
chronically, which may explain several preoperative
symptoms. The location of the mass in the upper
mediastinum, T4 to the subcarina, disrupted adjacent
structures. These structures are relatively fixed in the
upper part of the chest and are compromised easily by
a mass occupying the already limited space. In addition, the size of the mass and the subsequent mass
effect complicated the patient’s course. The intermittent dysphagia she experienced was a likely result of
the displacement and physical disruption of the
esophageal musculature, resulting in inadequate peristaltic movements when swallowing. Her 25-year history of cardiac dysrythmias and several near-syncopal
episodes coupled with dyspnea were likely the result
of impingement (mass effect), acute and chronic
inflammations, and direct adherence of the atrial pericardium, the carina, and pulmonary vasculature to the
cyst. The acute chest pain, dyspnea, fever, and near
syncope after the fine-needle biopsy suggest that the
mass was unintentionally seeded with bacteria, a complication noted by Cioffi et al.2
• Anesthetic considerations. General anesthesia is
indicated for this procedure; thoracic epidural placement may be used as an intraoperative adjunct and for
postoperative pain control. Because cyst location may
have significant effects on cardiovascular and pulmonary systems, preoperative euvolemia should be
achieved, and general anesthesia methods that optimize cardiovascular and pulmonary function should
be used.36,37 Foregut cysts, especially those communicating with the esophageal lumen or containing air,
have the potential to dilate or rupture as a result of
cross-membrane gas diffusion. Therefore, the use of
nitrous oxide should be considered very carefully.
Furthermore, preoperative fluoroscopic placement of
orogastric or nasogastric tubes should be considered
by the anesthesia provider to prevent unintentional
tracking into the cystic lumen and unintentional vascular damage.
Comprehensive review of radiologic studies will
assist the anesthesia provider in evaluating mass effect
and in determining the appropriate diameter and
length of endotracheal tubes.38 Placement of a doublelumen endotracheal tube, bronchial blocker, or other
lung isolation device may be indicated in adults.
Because these devices are not commonly available in
the appropriate size for pediatric patients, right or left
mainstem intubation or bronchial blockade may be
AANA Journal/February 2005/Vol. 73, No. 1
59
required.4,33 Awake fiberoptic bronchoscopy should be
considered preoperatively to rule out intratracheal
mass and to visually evaluate mass effect on the airway
structures. Intraoperative transillumination of the
esophagus also may be needed to assist the surgeon in
maintaining esophageal integrity. Furthermore, provisions for cardiopulmonary bypass may be necessary in
the presence of large masses that involve critical structures or when prolonged resection could result in cardiovascular collapse. Pulmonary function studies
should be evaluated before surgical resection of potentially involved lung tissues. Anesthesia providers also
should conduct a thorough review of all body systems
in patients with foregut cyst because the presence of
concurrent systemic anomalies, as noted previously,
may directly affect anesthetic management.
Potential surgical complications with relevance to
anesthesia include ligation of the vagus or phrenic
nerve, resulting in dysphagia; hemiparesis of the
diaphragm; and unilateral or bilateral vocal cord
paralysis. Infection, hemorrhage, mixed respiratory
complications (iatrogenic or in response to lung isolation), and esophageal dysmotility are other reported
complications necessitating standard antimicrobial
treatment.39 In addition, gastric prokinetics and histamine-2 blockers or proton pump inhibitors may be
used to decrease aspiration risk and to facilitate
esophageal healing. Preoperative administration of a
nonparticulate antacid may minimize effects of
esophageal and gastric contents in the operative area.
Conclusion
The presence of a mediastinal foregut cyst in adults
may present a significant challenge to anesthesia
providers. Anesthesia care may range from monitored
anesthesia care for preoperative radiologic evaluation
to combined regional and general anesthesia for resection. Potential complications include airway difficulties, pulmonary vascular compromise, and cardiovascular collapse. This patient’s anesthetic care was
accomplished successfully as a result of incorporating
a comprehensive preanesthetic evaluation, including
pulmonary, cardiovascular, systemic, and radiologic
studies with an understanding of the implications of a
mediastinal foregut cyst on anesthetic management.
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AUTHOR
Aaron R. Gopp, CRNA, MSN, is a nurse anesthetist at West Valley Medical Center, Caldwell, Idaho, and is currently chief of anesthesia services, 915th Forward Surgical Team, US Army Reserves. At the time this
article was written, he was a nurse anesthesia student at the University
of Iowa Nurse Anesthesia Program, Iowa City, Iowa.
ACKNOWLEDGMENTS
I would like to thank Ann Willemsen-Dunlap, CRNA, PhD; Cormac
O’Sullivan, CRNA, MSN; and Edward Thompson, CRNA, PhD, for
their invaluable guidance and assistance with this article.
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