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Perioperative challenges in managing a morbidly obese patient with COVID-19 undergoing an elective tracheostomy

Teah KM, Tsen SSY, Fong KK, Yeap TB

BMJ Case Rep, 2021 Jun 08;14(6).
PMID: 34103307 DOI: 10.1136/bcr-2021-243559

Tracheostomy is an aerosol-generating procedure and performing it in patients with COVID-19 requiring mechanical ventilation raises significant concerns of infection risk to healthcare workers. We herein report a case of tracheostomy in a critically ill patient with severe COVID-19 acute respiratory distress syndrome. This article depicts the use of personal protective equipment, highlighting the common challenges it presents and ways to address them.
Fulltext Case report: A giant hemorrhagic adrenocortical carcinoma causing cardiorespiratory embarrassment

Yeap BT, Teah KM, Tan JBG, Azizan N

Ann Med Surg (Lond), 2021 Nov;71:102996.
PMID: 34840751 DOI: 10.1016/j.amsu.2021.102996

Background: Adrenocortical carcinoma (ACC) is a rare aggressive tumor that can be hormone or non-hormone secreting. It is usually associated with fatal outcomes due to its physiological hormonal interaction. We report a successful anaesthetic and surgical management for a patient who presented to us with a huge hemorrhagic ACC which was complicated with acute respiratory failure.
Case presentation: A 56-year-old lady presented to us with progressive abdominal distension and right hypochondriac pain for two months. She was anemic with elevated liver enzymes. Urgent computed tomography (CT) of the abdomen and pelvis showed a huge right supra renal mass. She subsequently developed respiratory failure due to splinting of diaphragm, of which successfully underwent an emergency exploratory laparotomy. Subsequent endocrine and histopathological work up showed an adrenocortical carcinoma (ACC).
Discussion: Suprarenal masses usually originate from the adrenal glands. They should be investigated to rule out phaeochromocytoma, which originate from the inner adrenal medulla or outer cortex to form ACC. The latter usually occur in women and of poor prognosis. Huge ACC may cause acute respiratory failure by way of splinting of diaphragm. Both anaesthetic and surgical teams should be well trained in handling patients who undergo adrenal surgeries.
Conclusion: A giant hemorrhagic functional ACC is extremely uncommon with very poor prognosis. Such conditions should be investigated to rule out phaeochromocytoma. Its potential neuro-hormonal interactions and anatomical correlations can cause fatal perioperative cardio-respiratory embarrassment. The anaesthetic and surgical teams should be capable in managing the hemodynamic instabilities that may present during surgical manipulation and resection of a large ACC.
Fulltext Jejunojejunal intussusception secondary to inflammatory fibroid polyp: A rare cause of small bowel obstruction

Tan JS, Teah KM, Hoe VC, Khairuddin A, Sellapan H, Hayati F, et al.

Ann Med Surg (Lond), 2020 Nov;59:251-253.
PMID: 33088499 DOI: 10.1016/j.amsu.2020.10.009

Background: Adult intussusception is a relatively rare clinical entity. The majority of cases of intussusception in adults are due to a pathologic condition that serves as a lead point and requires surgery. Small bowel intussusception is usually caused by benign or malignant neoplasms appearing at the head of the invagination. Inflammatory fibroid polyp (IFP) of the small bowel is an unusual benign neoplastic lesion that has been rarely reported to cause intussusception, especially in the jejunum.
Case presentation: We present a rare case of adult intussusception who presented with a triad of intestinal obstruction. Computed tomography revealed small bowel intussusception with bowel ischemia. Intraoperatively, she required resection of the small bowel and primary anastomosis. Macroscopic examination revealed a single pedunculated polyp, which is the lead point of intestinal obstruction and confirmed histologically.
Conclusion: Inflammatory fibroid polyp should be considered as a cause of intussusception among adults with small bowel obstruction.
Fulltext Case report: A rare occurrence of a huge mediastinal mass from disseminated prostate carcinoma

Teah KM, Bong CP, Mudin K, Soe MZ, Thevarajah S, Yeap BT

Ann Med Surg (Lond), 2021 Nov;71:102952.
PMID: 34703592 DOI: 10.1016/j.amsu.2021.102952

Background: Prostatic carcinoma is the commonest malignancy among men. It usually metastasizes to the spine and regional lymph nodes. However, it is extremely rare for it to metastasize to the mediastinum.
Case presentation: An elderly man presented to us with progressive onset of bilateral lower limb weakness which was associated with thoracic radiculopathy and urinary incontinence. An urgent magnetic resonance imaging (MRI) of the spine showed severe cord compression with enlarged prostate and superior mediastinal mass. A computed tomography (CT) guided biopsy of the mediastinal mass was suggestive of prostatic malignancy. An emergency posterior instrumentation and fusion (PSIF) in prone position was successfully done. Histopathological examination of the spine showed malignant glandular tissues, suggestive of prostate.
Discussion: A huge mediastinal mass can compromise the cardiorespiratory system and is very challenging for the anaesthetist to safely secure the airway for surgical procedures. Androgen deprivation therapy (ADT) for patients with metastatic prostatic carcinoma can be achieved either by medical castration or with bilateral orchidectomy.
Conclusion: It is extremely uncommon for a prostatic carcinoma to metastasize to the mediastinum. Patients with a huge mediastinal mass possess risks of cardiorespiratory collapse perioperatively. Chemoradiotherapy and androgen deprivation therapy (ADT) can be utilized for metastatic prostatic carcinoma with good outcomes.
Fulltext A rare occurrence of a metastatic urothelial carcinoma to the thoracic vertebra: A case report

Soe MZ, Bong CP, Thevarajah S, Teah KM, Yeap BT

Ann Med Surg (Lond), 2022 Feb;74:103297.
PMID: 35127072 DOI: 10.1016/j.amsu.2022.103297

Background: Urothelial carcinoma (UC) is a common urinary tract malignancy that predominantly affect the urinary bladder with a low recurrence rate after surgical removal. It usually metastasizes to the lungs, regional lymph nodes, and liver. However, it rarely spread to the thoracic spine and bones, especially in the Asian populations.
Case presentation: A 50-years-old Asian man, with a one-year history of surgically resected UC, presented to us with a complaint of worsening upper back pain for three months. Magnetic resonance imaging (MRI) showed a destructed second thoracic (T2) vertebra with lytic lesion. A thoracic vertebrectomy was performed and histopathological examination (HPE) showed high-grade infiltrating metastatic malignant UC. Postoperatively, he was well and did not have any back pain. He was followed up under combined spine and oncology clinic regularly and was planned for chemoradiotherapy.
Discussion: UC commonly metastasizes to the lungs, liver, and lymph nodes. In young Asians, thoracic spinal metastases are rare. Urgent palliative spinal surgery is indicated to prevent further deterioration of function. Intraoperative usage of targeted controlled infusion (TCI) of remifentanil and propofol as maintenance of anaesthesia are gold standard in assisting spine surgeons who are guided by neuromuscular monitoring.
Conclusion: Spinal metastasis to the thoracic vertebra is rare among young Asian men. Patients presented with acute neurological deficits and back pain are indicated for spinal surgery. Multidisciplinary approach is needed for management of patients with spinal metastasis. Targeted controlled infusion (TCI) of remifentanil and propofol are gold standard for maintenance of anaesthesia for spine surgeries which are guided by somatosensory, and motor evoked potential monitoring.