European Journal of Cardiovascular Medicine

Mediastinal teratomas are germ cell tumours arising from ectopic pluripotent stem cells, comprising of elements of more than one embryonic cell layer that failed to migrate from yolk endoderm to the gonad.^1,2 Mediastinal teratomas account for 16% of germ cell tumours in adults and 19% of germ cell tumours in the paediatric age group.³ Surgical excision is the treatment of choice for benign teratomas of mediastinum.^1,4 Tumour recurrence is rare following complete surgical resection. Our patient presented with recurrence of tumour after ten years of excision, which is uncommon. We decided to publish this case because it demands multidisciplinary care to ensure safe anaesthesia and a successful approach for the removal of recurrent mediastinal tumours.

23-year-old male patient, with a BMI of 21 kg/m², presented to the OPD with complaints of chest pain for 3 months. He underwent thoracotomy 10 years ago for an anterior mediastinal mass and left phrenic nerve excision. He had no comorbidities. On physical examination, his vitals were stable. All his laboratory investigations were within normal limits. On contrast-enhanced computed tomography (CECT) of the chest, a large, well-defined, multiloculated heterogeneous cystic lesion measuring 6.6x10.8x14.2 cm was noted in the anterio-superior mediastinum, extending superiorly from the level of D1 vertebrae, inferiorly up to the level of D7 vertebra, anteriorly from the level of the thoracic inlet, and posteriorly up to the level of the carina, abutting it with mild compression of the superior vena cava with no obvious infiltrative changes. The lesion was causing displacement of the mediastinum towards the left side. After thorough pre-anaesthetic evaluation, the patient was scheduled for redo-sternotomy. On the day of surgery, after routine monitors were attached and a thoracic epidural was secured at T7-T8 level, an invasive arterial line was secured on the left radial artery under local anaesthesia, and the left femoral vein was cannulated with a triple lumen central venous catheter. In a supine position with the head end elevated, the patient was preoxygenated and induced with injection Propofol (1.5 mg/kg). After checking ventilation, injection Succinylcholine (1.5 mg/kg) was given, and the patient was intubated with a flexometallic tube of size 8.00 mm I.D and fixed at 21 cm. Anaesthesia was maintained with Sevoflurane 2% with intermittent doses of injection Vecuronium. For analgesia, injection Ropivcaine 0.2% at 5 ml/hr was given epidurally along with injection Paracetamol and injection Fentanyl (2 mcg/kg). Two pints of PRBC were transfused intraoperatively. At the end of the procedure, the patient was shifted to the ICU with the endotracheal tube in-situ for elective mechanical ventilation and was extubated the morning after the surgery. Postoperatively, epidural infusion of Ropiacaine 0.2% at 4 ml/hr was continued. The patient was discharged on postoperative day 7.

Germ cell tumours are neoplasms derived from the primordial germ cells and can be categorized as mature (benign) or immature (malignant), gonadal or extra-gonadal in origin. The common extra-gonadal site is the mediastinum (anterior, middle or posterior).⁴ In general, anterior mediastinal tumours pose the most severe and often life threatening complications due to compression of vital structures. Patients are typically asymptomatic (30-59%) at diagnosis, with the most common presentations being chest/ back pain, dyspnea and cough. Rarely they may present with haemoptysis, recurrent respiratory infection, facial puffiness or weight loss.^4,5  The anaesthetic management of anterior mediastinum teratomas is quite challenging as many patients experience tumour compression on the airway, heart , SVC and pulmonary artery.^6,7 Patients with suspected mediastinal tumour should undergo thorough clinical and radiological evaluation to guide safe anaesthesia administration.

Airway collapse and /or cardiovascular collapse are anticipated risks associated with general anaesthesia in patients with large anterior mediastinal tumours. Consequently conventional (non-staged) induction is deemed unsafe in these patients. To avoid acute hypoxemia, due to airway obstruction, it is preferable to opt for awake fibro-optic bronchoscopy, spontaneous ventilation using inhalation induction or staged induction.^7,8,9

Philip et al conducted a prospective observational study in patients with moderate to severe airway obstruction due to mediastinal masses, concluding that there was no worsening of central airway compression during induction, positive pressure ventilation and neuromuscular blockade when introduced in staged manners.¹⁰ In case of life-threatening airway compression (CICO), emergency CPB using femoro-femoral bypass should be considered. ^1,11

Catastrophic cardiovascular instability is anticipated in tumours with direct compression over the heart (impaired diastolic filling), other adjacent vasculature especially pulmonary artery (right ventricular outflow obstruction) and pericardial effusion. Additionally, anaesthetic agents can reduce cardiac contractility and preload diminishing cardiac output. As cardiovascular compromise is anticipated, it is mandatory to institute intensive monitoring and keep inotropic support ready. Due to the proximity of surgery to major vasculature, arrangements for blood products should be made. It is preferable to avoid supra-cardiac venous catheterization. A large bore venous access has to be secured in the lower limb along with central venous access through the femoral route.^7,11

In patients undergoing median sternotomy, perioperative pain management is crucial, particularly during the recovery phase. Therefore multimodal analgesia needs to be considered. Thoracic epidural with continuous infusion intraoperatively and postoperatively period provides satisfactory analgesia⁴.

Following surgery, awake extubation in the sitting position is recommended. Intense monitoring for twenty-four hours is advised to reduce complications related to postoperative edema of the tissue surrounding the pathology.¹

Patients with large anterior mediastinal masses need exhaustive pre-operative evaluation and meticulous preparation, prior to surgery, with multidisciplinary management involving the anaesthesiologist, intensivist and thoracic surgeon. In view of anticipated difficult airway either staged induction or fibre-optic intubation should be considered.

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