SOURCE OF INFORMATION: The patient as well as the discharge summary.

HISTORY OF PRESENT ILLNESS: This is an extremely pleasant (XX)-year-old morbidly obese male. He was diagnosed with pulmonary hypertension 12 years ago. He had a recent decompensation of his heart failure secondary to pulmonary hypertension and was admitted to an outside hospital. He was treated in the intensive care unit. He did develop worsening respiratory failure, and a tracheostomy was eventually done.

He was transferred here for further management of primary diagnosis, respiratory failure, with tracheostomy, on continuous aerosolized trach collar during the day as well as ventilator at night and secondary diagnosis of pulmonary hypertension with cor pulmonale. The patient, having been previously independent at home, would like to return home once again.

He will receive aggressive physical and occupational therapies as well as progressing to cardiopulmonary rehabilitation as well prior to his discharge home.

FAMILY HISTORY: The patient states the family history is noncontributory. No history of cancer in the family.

PSYCHOSOCIAL HISTORY: The patient, as mentioned, was previously living independently at home. He has no steps to enter or within the home. He denies any previous alcohol or tobacco use. The patient did wear home O2 at 5 liters per nasal cannula but was able to perform all activities of daily living as well as cooking and cleaning for himself and transportation, transporting himself to the grocery store as well as doctor’s appointments with his oxygen.

REVIEW OF SYSTEMS: The patient does not have impaired hearing. He claims not to have any swallowing difficulties. He is unable to speak currently secondary to tracheostomy, on continuous aerosolized trach collar. There is no goiter. He does have ankle swelling secondary to his pulmonary disease as well as shortness of breath with exertion. He denies any chest pains. He does not have palpitations. The patient does take a p.o. diet. There is no tube feeding. He denies any heartburn, nausea, vomiting, diarrhea or constipation. There have not been any bloody or tarry stools. He does have a Foley catheter in place. There are no rashes other than venous stasis changes on his lower extremities bilaterally. He denies any headaches, blackouts, dizzy spells or seizures.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9 degrees, pulse 88, respirations 20 and blood pressure 172/80. GENERAL: This is a very pleasant (XX)-year-old morbidly obese male. He is talkative and appropriate. He is in no apparent distress, on continuous aerosolized trach collar at 60%. HEENT: Extraocular movements are intact. Pupils are equal, round and reactive to light. No scleral icterus is present. He does have a slight white coating on his tongue, but mucous membranes are moist. There is no cervical lymphadenopathy. Trach site is clean and dry. CARDIOVASCULAR: Regular, S1 plus S2. Heart sounds are normal, dynamic. PULMONARY: Breath sounds are equal bilaterally. Markedly decreased in the lower half of bilateral lungs. There are no wheezes, rales or rhonchi able to be auscultated. GI: Abdomen is markedly obese, soft, nontender and nondistended. Positive bowel sounds heard throughout all 4 quadrants. Unable to palpate any masses or hepatosplenomegaly. EXTREMITIES: Warm and dry. There are 1-2+ bilateral lower extremities with venous stasis skin changes of the lower extremities bilaterally as well. NEUROLOGIC: The patient is alert and oriented x3. He has no focal deficits noted.

ADMISSION MEDICATIONS:
1. Lasix 80 mg p.o. q.d.
2. Celexa 40 mg p.o. q.d.
3. Coumadin 2 mg p.o. q.h.s.
4. Lanoxin 0.25 mg p.o. q.d.
5. Norvasc 10 mg p.o. q.d.
6. Nystatin powder to groin b.i.d. p.r.n. yeast.
7. Theophylline 300 mg p.o. q.12h.
8. Zyloprim 300 mg p.o. q.d.
9. Ambien 10 mg p.o. q.h.s. p.r.n. sleep.
10. Ativan 2 mg p.o. q.i.d.
11. Vicodin 5/500 mg one p.o. q.4h. p.r.n. moderate to severe pain.
12. Albuterol 0.5 mL and unit dose Atrovent hand-held nebulizer q.4h. plus q.2h. p.r.n.

ASSESSMENT AND PLAN:
1. Respiratory failure. On continuous aerosolized trach collar during the day as well as ventilator at night. We will consult Pulmonology for assistance with trach collar and ventilator management and weaning. Continue aggressive hand-held nebulizer treatments and pulmonary toilet. Ultimate goal is certainly to wean the patient from his nighttime ventilator usage, maybe slightly more difficult to take the patient off the aerosolized trach collar long term. I suspect this is a patient whose lung disease is fairly advanced. It may require chronic tracheostomy, especially with the likelihood of needing increased ventilation at night secondary to his pickwickian syndrome.
2. Pulmonary hypertension. We will continue anticoagulation with Coumadin, checking PT and INR values on Mondays and Thursdays.
3. Cor pulmonale. The patient is on Lasix. We will watch fluid status carefully.
4. Renal insufficiency. Check basic metabolic panel in the morning. Watch creatinine closely, on regimen of Lasix. The patient is currently not on any potassium supplementation. We will possibly need to start this if he has major losses of potassium secondary to diuretics.
5. Hypertension. Currently, the patient is slightly hypertensive on admission. I suspect that this is secondary to just having been transported and moved around. We will follow up in the morning to see if blood pressure has normalized. We will continue Norvasc and add further agents as needed.
6. Depression. Continue Celexa.
7. Anxiety. We will continue Ativan.
8. Gout. Continue Zyloprim, currently asymptomatic.

He states that he feels quite healthy and that is why has never sought any medical care. However, a month ago, he started developing a dry cough, which 1 week later turned into a productive cough of purulent sputum.

He was seen in a walk-in clinic last week, where they did a chest x-ray; however, at that time, they said there was no need for antibiotics. Despite over-the-counter remedies, the patient’s symptoms have persisted and have not improved at all. This is in the setting of having recurrent measured temperatures, most recently at 101.4.

He denies any shortness of breath or wheezing with this. He does have associated rhinitis and has had some sick contacts also. His kids have been ill with similar symptoms over the last couple of weeks. He denies any recent travel and did not get his flu shot this year.

He denies any pleuritic chest pain and has not had any diarrhea, muscle aches, neck pain or photophobia. He has had intermittent headaches but none for a couple of days.

PAST MEDICAL HISTORY: Not significant; however, the patient did have a positive PPD on arrival to the US but a negative chest x-ray. He denies any exposure to tuberculosis in the past.

SOCIAL HISTORY: The patient is a nonsmoker. Occasionally drinks. He is married and has children. He exercises infrequently; however, he states that his diet is quite balanced.

ALLERGIES: NKDA.

FAMILY HISTORY: The patient’s father had diabetes.

OBJECTIVE: General: The patient is a well-appearing male in no distress. Vitals: Heart rate is 72, blood pressure is 122/82, and temperature is 98.4. Examination of his hands reveals that he has got no clubbing, no pallor. His pulse is regular with a good volume and no abnormal character. Examination of the head and neck reveals he has no jugular venous distention, no adenopathy. His pharynx is mildly erythematous but has no exudate or tonsillar enlargement. Pupils are equal, round and reactive to light. He has no thyromegaly. Chest is clear to auscultation bilaterally. Heart: Sounds S1 and S2 are present. No added sounds, no murmurs. Abdomen: Soft, nontender, nondistended, with bowel sounds auscultated diffusely. He has no organomegaly. Peripherally, he has got no edema. Good pedal pulses.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old gentleman coming in with cough and also for general health maintenance with no significant past medical history.
Cough: Given the fact that his symptoms have persisted and he has been recurrently febrile despite over-the-counter remedies, we feel it is likely that he has a bacterial bronchitis. For now, we will give him a 5-day course of azithromycin. Chest x-ray was done, which the patient states was normal. We will obtain a report of that in the interim.
Health maintenance: As mentioned, the patient has no past medical history of note. At this time, we will check total cholesterol and direct LDL. We will also get a baseline CBC and metabolic profile given the history of diabetes in the family.

REFERRING PHYSICIAN: John Doe, MD

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female patient who, per report, had a nonsyncopal fall resulting in trauma to her face and head. In view of this, the patient was brought to the emergency room. Cervical spine revealed no fracture but severe spinal stenosis with cord impingement at C4-C5 as well as C5-C6 with possible compression on this area. She also had plain films of the pelvis that showed a lucent lesion with sclerotic margins in the right femoral neck. Chest x-ray revealed the presence of a right hilar fullness, possible mass, as well as right upper lobe infiltrate. CT of the maxillofacial showed multiple periosteal disease involving the maxillary sinus and a nondisplaced fracture involving the lateral wall of the left maxillary sinus. Scalp hematoma on the left frontal region. Abnormal soft tissue density in the posterior left lobe, which could represent hemorrhage or neoplasm. Orbital floor was poorly evaluated. Presently, the patient is confused and a very poor historian, but she is alert and agitated. We have been consulted for evaluation and management of her abnormal chest x-ray.

PAST MEDICAL HISTORY: Significant for dementia. The patient has had a history of diabetes mellitus. She has had a history of chronic obstructive pulmonary disease as well as irritable bowel syndrome. She has had a history of hypothyroidism, history of previous sinusitis and transient ischemic attack in the past. She has had a history of breast cancer on the left as well as spinal stenosis, history of degenerative joint disease, history of frontal hygroma, recent TIA in the past. She has a history of hypertension.

PAST SURGICAL HISTORY: She has had previous left mastectomy, tonsillectomy, cholecystectomy, appendectomy, and lipoma surgery.

MEDICATIONS: She has been on regular insulin sliding scale, Seroquel, Glucotrol, Zyrtec, Advair, Lasix, Tylenol, Diovan, verapamil, Celexa, levothyroxine, Depakote, Hemocyte, Ativan, DuoNeb and Robitussin.

ALLERGIES: MULTIPLE DRUG ALLERGIES.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: This patient lives in an extended care facility.

REVIEW OF SYSTEMS: Unable to be obtained as the patient is confused but alert.

PHYSICAL EXAMINATION: Temperature 98.4, pulse 96, respiratory rate 18 and blood pressure 136/66. She is an elderly lady, in no acute distress at the moment of my evaluation. HEENT revealed hematoma over the left orbit. No active bleeding. Eyes with anicteric sclerae. No active bleeding from the eyes. No evidence of jugular venous distention. Trachea was in the midline. Heart exam was regular rate and rhythm without any appreciable gallops or rubs. Lung sounds are symmetrical bilaterally without excursion. No use of any accessory muscles of respiration. No dullness to percussion. There were some mild occasional rhonchi and increased expiratory phase. Abdominal exam was benign. Bowel sounds normoactive. Extremity exam with trace lower extremity edema but no cyanosis. No venous cords were palpated. The patient was moving all 4 extremities. Neurologically, she is alert but confused.

DIAGNOSTIC DATA: An electrocardiogram showed normal sinus rhythm at a rate of 96, possible left atrial enlargement, borderline low voltage in the frontal leads, probable anteroseptal MI.

LABORATORY DATA: White blood cell count 9.4, hemoglobin 10, platelet count 286. Sodium 146, potassium 4.2, chloride 106, CO2 of 30, glucose 104, BUN 54, creatinine 1.3, calcium 9.6. UA showed 0 to 4 red blood cells, 0 to 4 white blood cells.

IMPRESSION:
1. Status post nonsyncopal fall resulting in facial fracture as outlined above.
2. Cervical spine showing spinal stenosis as well as cord impingement, possible compression at the level of C4 to C6.
3. Abnormal chest x-ray with the presence of a right perihilar mass-like density as well as a right upper lobe infiltrate. Question whether the patient has aspiration pneumonitis.

PLAN:
1. The patient has been pancultured. Continue with Avelox for now.
2. CT of the chest without contrast will be obtained.
3. Ophthalmologist will be asked to make maxillofacial surgery consultation.
4. An x-ray Doppler of the lower extremities will be obtained to rule out DVT.
5. Bronchodilator therapy with a DuoNeb q.i.d.
6. Further recommendations will be based on clinical course.

PREOPERATIVE DIAGNOSIS: Bilateral pulmonary nodules.

POSTOPERATIVE DIAGNOSIS: Bilateral pulmonary nodules.

OPERATION PERFORMED:
1. Right chest wall skin nodule excision.
2. Right mini thoracotomy with nodule wedge excision x3.
3. Placement of On-Q pain pump.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 50 mL.

INDICATION FOR OPERATION: The patient is a (XX)-year-old female who had left-sided breast cancer 11 years ago. She had fallen recently and by chest x-ray was noted to have new lung masses, the presence of which was confirmed by CT scan. She presents today for excisional biopsy for definitive diagnosis. She understands the risks and possible complications of the procedure and wishes to proceed.

OPERATIVE FINDINGS: On the chest wall, very close to the axilla, was a palpable nodule in the skin. This was wedged out and sent to pathology. The lung parenchyma had numerous pulmonary nodules varying in size from 2 mm to over a centimeter. These were in all three of the lobes on the right side. There was no effusion and no parietal pleural abnormalities. The first nodule was taken from the right lower lobe and this, by frozen section, was consistent with a carcinoid tumor. A second one was taken from the right middle lobe, in the area that had been hypermetabolic by PET scan, and this again was consistent with carcinoid. The third nodule was taken from the right lower lobe and also submitted for pathology.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced without complication. The patient was placed in the left lateral decubitus position and the right chest prepped and draped in the usual sterile fashion.

A 2 cm elliptical nodule was palpated in the skin of the right chest wall just below the axilla. This felt firm and had some discoloration. Wondering if this was a metastatic skin lesion, we wedged it out sharply and sent it for pathology. This wound was closed with a 2-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure.

Following this, a right lateral mini thoracotomy was made in the 5th intercostal space. The multiple nodules were palpated in the lung parenchyma. Using a TA-45 stapler with thick tissue reload, one of the nodules was wedged out from the right lower lobe and sent for frozen section. This appeared consistent with carcinoid tumor. An additional nodule from the right middle lobe was wedged out in a similar fashion and also sent for frozen section, which yielded the same result. An additional third nodule was removed from the right lower lobe, which has also been sent for pathology.

At the completion of this, after checking for adequate hemostasis, a 32-French tube was placed and secured with 0-Vicryl suture. The ribs were approximated with #2 Vicryl stitches. An On-Q pain pump was placed. The muscular layer closure was done with 0-Vicryl suture and an additional pain catheter placed. The subcutaneous tissues were approximated with #2 Vicryl and the skin with 4-0 Monocryl in running subcuticular fashion. Steri-Strips and sterile dressings were applied.

The patient tolerated the procedure well without any complications. The patient was extubated and transferred to the recovery room in stable condition. Sponge and needle count was correct at the end of the case.

PREOPERATIVE DIAGNOSIS: Left alpha hemolytic streptococcus empyema.

POSTOPERATIVE DIAGNOSIS: Left alpha hemolytic streptococcus empyema.

PROCEDURES PERFORMED:
1. Left video-assisted thoracoscopy.
2. Drainage of empyema.
3. Decortication of the left lung.
4. Intercostal nerve block.
5. Fiberoptic bronchoscopy.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

OPERATIVE FINDINGS: The patient had a large amount of fibrinous debris and fibrous peel over the lower lobe laterally, posteriorly, and inferiorly. The upper lobe was partially entrapped posteriorly. At the end of the procedure, the left lower lobe expanded well. The upper lobe clearly was not entrapped but did not expand, thus a fiberoptic bronchoscopy was done after a double lumen procedure was switched to a single lumen tube to help for re-expansion of this upper lobe. Suctioning prior through the double lumen tube did not appear to help.

DESCRIPTION OF OPERATION: The patient was placed in the supine position for thoracoscopy and procedures as noted above. General anesthesia was established using double lumen oral endotracheal intubation and its position was confirmed fiberoptically with bronchoscopy. The patient was in the right lateral decubitus position. All pressure points were padded, and Thromboguards were placed. The patient was on IV antibiotics of cefepime and Avelox. The left chest was prepped and draped in the usual sterile fashion. The old chest tube had been removed prior to prepping and draping.

Two ports were made, the first one blind, the other under direct vision and palpation. The old chest tube site was also used and had a fair amount of purulent material in the soft tissues. Between the two ports, the fibrinous debris was removed. Prior to removing fibrinous debris, fluid was sent for aerobic and anaerobic cultures.

After the fibrinous debris was removed, it was clear that the majority of the lower lobe and much of the posterolateral portion of the upper lobe had a fibrous peel, and this was removed thoracoscopically using the ring forceps. Occasionally, we did use the Kelly clamps to develop a plane, and when developed, it seemed to maintain it pretty well.

After the lung was adequately decorticated, which was a slow, tedious process, two inferior ports, which were the new ports, were used for the chest tubes and a right angle 32 chest tube was placed posteriorly and another 36 chest tube was placed laterally and apically. It did appear that the upper lobe had a surface tear, and it may have been caused by the previous chest tube because it was an area which, for the most part, we did not need to work in. When reinflating the lung, the lower lobe reinflated nicely and started to fill the whole lower half of the chest cavity; however, the upper lobe did not inflate. After suctioning, it still did not inflate, but it did appear that it was nice and soft and there was no fibrinous peel, and confident in that, we decided to close and switch over to a single lumen tube and do a fiberoptic bronchoscopy at the end to suction out the upper lobe.

The intercostal nerve block with 0.5% Marcaine was injected into each of the ports. Around the chest tubes, the subcutaneous tissue was cinched around using interrupted 0-Vicryl suture. The skin was closed close to the tube using interrupted horizontal mattress of Monocryl. The more superior port, which had been the previous chest tube site, had the muscle layer closed with interrupted 0-Vicryl suture and the remainder was irrigated and was packed with 4 x 4s. The chest tube was connected to a single Pleur-evac drain using a Y connector.

The patient was placed in the supine position. The double lumen tube was exchanged for a single lumen tube. Fiberoptic bronchoscopy was performed and the left side suctioned of secretions to help re-inflate the upper lobe. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with past medical history of coronary artery disease and hypertension who developed sudden onset of chest pain while sitting and watching television. She denies shortness of breath, diaphoresis, nausea, vomiting, dizziness or lightheadedness. She was not doing anything and had left-sided chest pain that went down to her arm. This is different than before. She normally is a very anxious person and has been having chest pains for quite some time. Her daughter tells me that the last four days, she has been complaining of chest pains as well. Normally, she is not short of breath and is able to do everything without difficultly. She does not have a history of lung disease. She is a lifetime nonsmoker. About five years ago, she had an elective angiogram, which showed coronary disease and underwent bypass. Currently, she does have pain in the chest but is not short of breath at all. In the emergency department, a CT of the chest was done, which showed a small PE in the right upper lobe.

PAST MEDICAL HISTORY: Coronary disease and hypertension.

PAST SURGICAL HISTORY: CABG.

ALLERGIES: No known drug allergies.

CURRENT MEDICATIONS: Isosorbide, aspirin, felodipine, Diovan, pentoxifylline, Vytorin, and clonazepam for anxiety.

FAMILY HISTORY: The patient’s mother died of cancer. Her father has diabetes.

SOCIAL HISTORY: Lifetime nonsmoker. The patient did not have any exposure to chemical dust or fumes. Occasional alcohol use.

REVIEW OF SYSTEMS: Other than noted above, completely negative with regard to all systems. She does have chronic anxiety.

PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, in no apparent distress.
VITAL SIGNS: Temperature 98.2, pulse 76, respirations 20, and blood pressure 172/68. Currently, oxygen saturation in the emergency department is 99%.
HEENT: Eyes are anicteric bilaterally. Normocephalic and atraumatic. Oropharynx is clear without exudate or erythema.
NECK: Supple. No JVD.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. S1 and S2. Occasional systolic ejection murmur at the right upper sternal border, can hear it in the carotid on the right.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
MUSCULOSKELETAL: There are some deformations of her DIP joints from arthritis.
SKIN: No rashes are noted.
LYMPH: No lymphadenopathy in the neck or supraclavicular area.

LABORATORY DATA: White count 7.8, hemoglobin 15.4, and platelet count 202,000. Sodium 134, potassium 4.7, chloride 100, bicarbonate 26, BUN 17, creatinine 0.8, glucose 170, calcium 9.1, and magnesium 2.1. AST 42, ALT 32, alkaline phosphatase 104, and total bilirubin 0.2. Troponin negative x2. Initial INR is 0.97. PTT is 26.6.

DIAGNOSTIC DATA: We reviewed the CT of the chest with contrast, which showed small right upper lobe pulmonary embolism. Chest x-ray was done, which was unchanged from the previous. D-dimer was elevated at 1020.

IMPRESSION: Pulmonary embolism.

RECOMMENDATIONS:
1. The patient was given Lovenox in the ER and was given Lovenox on the floor, but given her age and likely decreased creatinine clearance, we will switch her to IV unfractionated heparin tonight per protocol. Once the PTT is stable, we will start Coumadin to treat the target INR of 2.5 and range between 2 and 3. She needs to be on Coumadin for at least three to six months thereafter.
2. Studies have shown a very slight increased risk of underlying cancer when people develop pulmonary embolism from apparently unknown cause. She should, therefore, get age-appropriate cancer screening as appropriate.
3. We would like to get her an echocardiogram to evaluate the valves and systolic function and also to look at the right-sided function as well.
4. The patient is scheduled for a stress test in the morning to make sure that the chest pain is not from her heart.
5. We discussed this with the patient and her daughter at the bedside.

PREOPERATIVE DIAGNOSES:
1. Open sternal wound.
2. History of left non-small cell lung cancer.
3. Status post left intrapericardial pneumonectomy.
4. History of right upper lobe non-small cell lung cancer.
5. Status post median sternotomy and right upper lobe wedge resection.

POSTOPERATIVE DIAGNOSES:
1. Open sternal wound.
2. History of left non-small cell lung cancer.
3. Status post left intrapericardial pneumonectomy.
4. History of right upper lobe non-small cell lung cancer.
5. Status post median sternotomy and right upper lobe wedge resection.

PROCEDURES PERFORMED:
1. Irrigation and debridement of the sternum.
2. Bilateral pectoralis myocutaneous advancement flaps.
3. Closure of the sternal wound.
4. Bronchoscopy.

SURGEON: John Doe, MD

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman with a history of left lung cancer treated by pneumonectomy. She had a new primary over two years later that was treated by sternotomy and wedge resection. She initially did well but was readmitted with sepsis and subsequently developed a sternal wound infection. Two days ago, we opened the sternum and debrided it. She has been treated with dressing changes for two days and is brought back now to the operating room.

DESCRIPTION OF PROCEDURE: Briefly, the patient was brought to the operating room intubated from the intensive care unit. The patient’s anterior chest was prepped and draped. The VAC sponge had been removed prior to prepping. The edge of the sternum was then debrided with curettes and appeared to be well vascularized without active infection.

Bilateral pectoralis myocutaneous flaps were then elevated to the point that they could be reapproximated at midline without undue tension. We did not feel that closing the sternum was necessary or ideal considering her infection, but we felt that flap coverage was a reasonable approach.

After using the Pulsavac to irrigate the wound and assuring hemostasis, two 19-French Blake drains were placed underneath the flap sites and one was placed in the sternal wound. The flaps were then advanced and closed together at midline with interrupted 2-0 PDS sutures. The subcutaneous tissue was then closed with 3-0 Vicryl, and the skin was closed with interrupted nylon mattress sutures. Dressings were placed, and the patient was brought back to the surgical intensive care unit hemodynamically stable and still vented.

PREOPERATIVE DIAGNOSIS: Right upper lobe non-small cell lung cancer.

POSTOPERATIVE DIAGNOSIS: Right upper lobe non-small cell lung cancer.

PROCEDURES PERFORMED:
1.  Right upper lobe sleeve lobectomy.
2.  Pericardial fat pad flap.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

INDICATIONS FOR OPERATION:  The patient is a man with a right upper lobe mass diagnosed as carcinoma at the orifice of the right upper lobe bronchus, which would make standard right upper lobe lobectomy inadequate to achieve negative margin. A pneumonectomy could be performed as necessary; however, it was felt that a sleeve lobectomy would be ideal in offering an ideal oncologic operation while preserving pulmonary parenchyma.

DESCRIPTION OF OPERATION:  A thoracotomy was performed. The right upper lobe pulmonary vein was divided as was the truncus branch of the pulmonary artery to the right upper lobe. The bronchus intermedius and right main bronchus were then encircled. The right upper lobe bronchus was looped.

At this point, we performed bronchoscopy while inserting a needle into the right main bronchus and identified the location just proximal to the tumor that would provide a negative margin. We performed a similar procedure in the bronchus intermedius distal to the tumor. This, therefore, identified the proximal and negative resection lines. The right main bronchus was then divided, carefully dissecting it off of the main pulmonary artery. The bronchus intermedius was then dissected and a specimen was handed off. Frozen section analysis of the separately submitted proximal main bronchial margin showed no evidence of tumor.

After verifying the absence of tension, we then placed 2-0 Vicryl stay sutures at 3 o’clock and 9 o’clock on the main bronchus in the bronchus intermedius. When these were held together, the ends came together without tension. We then performed an end-to-end anastomosis in a standard fashion. Interrupted 4-0 Vicryl sutures were placed circumferentially. We then tied the stay sutures together to relieve tension, and the 4-0 Vicryls were sequentially tied together.

A pericardial fat pad flap was then mobilized, and this was placed circumferentially around the anastomosis and fixed in place with fine sutures. Before tying this down, we had tested the bronchial anastomosis to a maximum of 30 cm of water pressure without any evidence of leak. A 28-French chest tube was inserted, and the thoracotomy was closed after reinflating the lung.

The patient was extubated and brought to the postanesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.

PREOPERATIVE DIAGNOSES:
1. Left liver mass.
2. Lung nodules.

POSTOPERATIVE DIAGNOSES:
1. Left liver mass.
2. Benign lung nodules.

PROCEDURES PERFORMED:
1. Right VATS exploration.
2. Pleural biopsy.
3. Right lower lobe wedge resection.
4. Right upper lobe wedge resection.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old man with a large left liver mass. He is being worked up for resection. A PET scan showed bright uptake in the liver as well as some uptake in the bilateral pulmonary hila as well as in the right supraclavicular region. A CT scan of the chest and abdomen revealed a large left liver mass as well as two very small right lung nodules. There was no enlarged mediastinal adenopathy. There were calcifications in the hilum on the right. There was no palpable supraclavicular adenopathy. In light of these nonspecific PET findings, we felt it would be reasonable to perform a right VATS to obtain wedge resections of the lung and to examine the right hemithorax. The patient agreed and surgery was scheduled.

DESCRIPTION OF PROCEDURE: After the induction of general anesthesia, a double lumen endotracheal tube was inserted. Its position was verified bronchoscopically. The patient was moved into the left lateral decubitus position, and the right chest was prepped and draped for VATS exploration, pleural biopsy, and right lower and upper lobe wedge resection. Heparin had been given subcutaneously, and antibiotics had been administered systemically.

Three 12 mm thoracoscopy ports were inserted; one in the auscultatory triangle, one in the fifth intercostal space at the anterior axillary line, and one in the eighth intercostal space at the midaxillary line. The right hemithorax was examined. There were a number of mildly raised pigmented lesions of the parietal pleura. One of these was biopsied and sent for frozen section and revealed no evidence of malignancy, merely reactive mesothelial cells.

The lung was then examined. There were two visceral pleural nodules corresponding to the two very small nodules seen on the CT. Both were in the major fissure, one in the upper lobe and one in the lower lobe. Both were resected using the Endo-GIA thick tissue stapler and sent for frozen section. Both were without evidence of malignancy. The hilum was examined through the fissure as well as anteriorly and posteriorly, and there were no suspicious masses. There were calcifications, and we were concerned that dissection in the hilum with these calcified nodes would be risky and of low yield considering the absence of masses on a CT or examination.

The upper mediastinum on the right was then examined, and there were no suspicious masses. With benign nodules in the pleura in both the upper lobe and the lower lobe and no visible abnormalities in the hilum or mediastinum, we felt that a thorough explanation of all the potential spread had been performed. Therefore, after assuring hemostasis, a 20-French straight chest tube was inserted, and the right lung was reinflated. The patient was extubated and brought to the postanesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.

PREOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.

POSTOPERATIVE DIAGNOSIS: Pulmonary alveolar proteinosis.

PROCEDURE PERFORMED: Left total lung lavage.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman who has had a few years of slowly progressive dyspnea. A chest CT revealed a diffuse heterogeneous infiltrative process with increased septal markings. Pulmonary function testing indicated an intact DLCO and volumes. She underwent a lung biopsy via mini right thoracotomy, which demonstrated pulmonary alveolar proteinosis. She was referred to Dr. John Doe for ongoing evaluation and management. After his evaluation, he felt that lung lavage would be appropriate. He met with the patient who concurred. She was therefore booked for left lavage today and right lavage 48 hours from that.

DESCRIPTION OF PROCEDURE: After the induction of general anesthesia, a double lumen endotracheal tube was inserted. She had some difficulty with prior double lumen placement, but this seemed to progress without undue difficulty. It was mildly tight at the cords. We then positioned the tube in the left main stem bronchus under bronchoscopic visualization without difficulty. Heparin had been given subcutaneously, and boots were placed for DVT prophylaxis. A percussion vest was placed on the patient. She was then switched from the anesthesia ventilator to the ICU ventilator on pressure point ventilation maintaining 5 PEEP. Lung isolation was performed, breathing only to the right lung, with minimal desaturation over five minutes. We therefore felt it was safe to proceed with the procedure.

After pre-oxygenation of both lungs, lung isolation was then achieved and lavage of the left lung using warm saline proceeded. One liter would be instilled via the bronchial lumen of the double lumen tube and then drained by gravity. The first bag was quite cloudy. Specimens were sent for microbiologic studies. The remainder of the specimens obtained during the procedure was sent to Dr. John Doe’s lab according to the patient’s consent. A total of 18 L of warm saline was instilled to lavage the left lung.

At the completion of the procedure, the effluent was reasonably clear. There were no significant desaturations during the operation. Her lowest oxygen saturation was 89% during drainage of the final few liters. After completing the lavage, the patient was returned to two-lung ventilation. We performed bronchoscopy briefly through the bronchial lumen to suction any remaining fluid from the left lung. The patient was then extubated and brought to the postanesthesia care unit hemodynamically stable and breathing spontaneously. There were no intraoperative complications.