Research at Cirugia de Torax – Thoracic Surgery

High Altitude Surgery: Carotid Body Tumors

a different kind of case here at Cirugia de Torax

A Carotid paraganglion / carotid body tumor in Bogotá, Colombia

K. Eckland, ACNP-BC, MSN, RN & Ricardo Buitrago, MD

Case History: 62-year-old Hispanic female who presented with complaints of a right neck mass X 3 years, accompanied by occasional dysphagia, itching and soreness of right neck. Patient denied history of weight loss, anorexia, aspiration or recent pneumonias. No history of previous stroke.

Past medical / surgical history: TAH, 25 years prior, Hypertension, previous DVT of the RLE. Home medications: ASA 100mg po Q day.

On examination, the patient had a palpable, reducible mass over the right carotid, with no bruits on auscultation.

Diagnostics: carotid duplex showing a right-sided carotid body tumor arising at the bifurcation of the common carotid. No evidence of hemodynamically significant atherosclerotic plagues, or elevated velocities. Mass measured at 7cm at widest point.

Labs: All labs within normal limits including a Hgb 16/ Hct 48

Operative:

After administration of general anesthesia, and endotracheal intubation, the patient was positioned, prepped and draped in sterile fashion. A 4cm vertical skin incision was made on the right side of the neck. After blunt dissection and retraction of sternoclastomastoid muscle, the common carotid artery was identified and retracted with a vessel loop. Identifying the bifurcation and loosely clamped external and internal carotids. Care was taken to identify and prevent injury to the hypoglossal nerve and fascial branches.

Extensive ligation of tributary vessels was undertaken while performing blunt dissection to the avascular plane. Once the tumor was separated from the carotid bifurcation, it was removed and sent for final pathology.

At the conclusion of the case, a small jp drain was placed. The patient was awakened in the operating room and extubated. Patient demonstrated no new neurological deficits.

specimen — less than 5% of tumors are malignant

Post-operative:

JP drain was discontinued on the morning of POD#2 and the patient was subsequently discharged. Patient reported no dysphagia, hoarseness or paresthesia.

Discussion:

The carotid body serves as an important function of the detection and moderation of hypoxia. This has been shown in several studies of post-operative carotid endartectomy patients who are unable to adjust/ acclimatize to increasing altitude as well as the increased incidence of carotid body tumors (CBT) at altitudes of 2000 meters of greater (Ojeda Parades).

Carotid body tumors occur most frequently at altitudes greater than 2,500 meters but significant differences have been noted in the prevalence, size and other characteristics of carotid body tumors occurring at lower altitudes. The vast majority (95%) of these tumors are benign but in a minority of these cases, these tumors may represent metastatic disease.

Despite the location of these tumors, (at the bifurcation of the common carotid into the external and internal carotid), the chances for successful excision and resection is high with a mortality of less than 1%. The most common complication of this procedure is damage to the adjacent nerve, causing hoarseness.

References

Boedecker, C. C. (2011). Paragangliomas and paraganglioma syndromes. Head and Neck Surgery, 2011 (10). A nice review article of paragnaglions including paragrangliomas of the head and neck.

Cerecer – Gil, N. Y., Figuera, L. E., Llamas, F. J., et. al. (2010). Mutation of SDHB as a cause of hypoxia related high altitude paraganglion. Clin Cancer Res 2010; 16: 4148-4154. [free full-text pdf.]

Conde, S. V., Ribeiro, M. J., Obeso, A., Rigual, R., Monteiro, E. C., Gonzalez, C. (2012, recently published research). Chronic caffeine intake in adult rat inhibits carotid body sensitization produced by chronic hypoxia but maintains intact chemoreflex output. Molecular Pharmacology Fast Forward. 46 page report on animal study. [full-text available.]

Moore, J. P., Claydon, V. E., Norcliff, L. J., Rivera-Ch, M. C., Leon-Velarde, F., et. al. (2006). Carotid baroreflex regulation of vascular resistance in high-altitude andean natives with and without chronic mountain sickness. Experimental Physiology 91(5); 907-913. [free full-text pdf.]

Ojeda, L. P., Durango, E., Rodriquez, C., & Vivar, N. (1988). Carotid body tumors at high altitude: Quito, Ecuador, 1987. World J. Surg. 12: 856- 860.

Park, S. J., Kim, Y. S., Cho, H. R. & Kwon, T. W. (2011). Huge carotid body ganglion. J Korean Surg Soc 2011; 81: 291- 294. Case report. [free full text pdf available.]

Rodriguez – Cuervasm S., Lopez – Garcia, J. & Labastida – Alemandro, S. (1998). Carotid body tumors in inhabitants of altitudes higher than 2000 meters above sea level. Head & Neck, Aug 1998: 374-377. [free full-text pdf available.]

Authors conducted a study of 120 CBT in Mexico City, D.F looking at the incidence and characteristics of all CBTs over a thirty year period (1965 – 1995) in comparison to previously published reports of CBT at lower altitude. Findings similar to previous and existing literature with a predominantly female population (89% of cases). Mean age 49. Mean size 5.4 cm. They reported a 20% incidence of cranial nerve injury after resection.

Ruben, R. J. (2007). The history of the glomus tumors nonchromaffin chemodectoma: a glimpse of biomedical Camelot. Acta Oto-Laryngeologica 2007; 127: 411-416. If you can get past his fanciful writing style which resembles an ardent love letter, the article gives a nice history of paraganglion tumors (including carotid body tumors).

Protected: Register to participate in high altitude research project

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Research update: Recruiting interested surgeons

Cirugia de Torax extends an invitation to all thoracic surgeons interested in participating in clinical research.

If you are interested in participating in our data collection process as a site investigator – please click on the link to fill out one of our secure, encrypted Site Investigator Applications. While we are strongly recruiting surgeons from areas of moderate to high altitude, we are encouraging interested surgeons from any location to consider participating.

Why participate?

As busy surgeons, many of you just don’t have the time to devote to full-time research, academic projects and scholarly writing. That doesn’t mean you aren’t interested in, and can not make a significant contribution to the literature surrounding topics in thoracic surgery. By signing up as a site investigator, you (or your delegates) will use our new electronic applications to upload and submit de-identified data about your patient populations and outcomes for use in our study. (It’s like the STS general thoracic database – but easier!)

In return, you will have made a significant and lasting contribution to the existing body of knowledge in your chosen specialty, and will receive due credit in all subsequent articles and publications based on these contributions.

Fill out my form!

Mexican Surgeons: See you at the conference in Cancun..

Sociedad Mexicana de Neumologia y Cirugia de Torax

Cirugia de Torax.org heads south of the border for the upcoming Sociedad Mexicana de Neumologia y Cirugia de Torax congreso (conference) this April. It’s also a chance for surgeons to find out more about the high altitude project.

The title of this post is apt in more ways that one. The Mexican Society of Pulmonologists and Thoracic Surgeons is meeting for their 2012 annual meeting this April, and yes, Cirugia de Torax.org is going to be there. We’re hoping to interview and talk to some of Mexico’s greatest innovators and researchers in thoracic surgery during our visit this year.

We will be also talking about the high altitude lung surgery project with interested and potential participants – including prospective timelines, data collection tools (and validity of measurements), and expected responsibilities/ duties of site participants.

This year’s conference is being held in Cancun, from April 9th thru April 13th, 2012. Check back in April for more news and conference coverage.

Project update: electronic data submission

Using today’s handheld technology to conduct the research of tomorrow – a new application of smartphone mobile applications to connect study sites around the world.

Still working on the Android and Apple platform builds for electronic data submission. I’ve been tweaking some of the data fields but should finish in the next couple weeks. I will also be hosting a separate link for people to submit data directly – I’ll post more information in the next coming weeks.

app prtscrn — electronic data collection with real time submission

I’m pretty excited about it – I think it will simplify the data collection process for everyone involved. Before we ‘go live’ in a few months – we’ll have a trial period to make sure that everything works correctly. I’ll need your help, so check back here in the future for more information on where to download the applications, if you are interested in participating.

(We are also welcoming submissions from surgeons at normal altitude, so feel free to email me at k.eckland@gmail.com if you are interested.)

I recently gave a presentation on the electronic data portion, so I am including it here.

Data Collection Tool for Clinical Research ppt

Data Collection and Altitude

Developing electronic applications to ease the task of data collection for clinical research.

In clinical research; results are dependent on data. Data is only as good as the data collection tools used to gather it. Furthermore, the best and most accurate data comes from the surgeon or the surgical team themselves at the time of care (versus third-party lay person data collection via chart review). However, there are some limitations that are imposed when following these guidelines; such as the collection of 30-day follow-up information.

Data collection needs to be simple and relatively speedy. The ideal tools allow surgeons to collect the essential data at the time of discharge (when information is fresh), limit additional paper accumulation and are submitted at the time of completion. This necessitates the development of electronic applications.

At the time of this writing, I am currently working on the development of both smart phone and web-based applications for data collection for the altitude project. These electronic forms will allow data to be entered and submitted at the time of collection.

datacollect2screen — smart phones for data collection

A secondary application is being developed to address the patient re-admission or development of complications post-discharge in the first thirty days after discharge.

Downloadable pdfs and/or spreadsheets will also be available for surgeons who elect to use the ‘paper’ option.

Since the data has only limited patient identifiers, and all data is being submitted to a clinical investigator, (versus outside companies) patient privacy is protected.

When completed, further information will be posted here at Cirugia de Torax.

Surgery at altitude, part I

Calling all thoracic surgeons – particularly those in La Paz, Quito, Bogota and Mexico City.. We have an opportunity for collaborative research.

One of our newest endeavors is a research project on thoracic surgery at moderate altitude. We’ve completed our review of existing literature, and developed our patient parameters and data collection points.

The main base of our operations is Flagstaff, Arizona, which is located at 7000 ft. (2,000 meters) making it the highest altitude cardiothoracic program in the United States. The Flagstaff site has several strengths in that much of our patient population comes from the surrounding areas; which are located at both higher and lower elevations. However, one of the weaknesses in Flagstaff is our small patient population – as a single surgeon site devoted to both cardiac and thoracic surgery – our lung surgery volumes are fairly small.

Right now, I am doing some of the preliminary work with the hospital – meeting with staff to apply for IRB approval, and formalizing the data collection process. I am also interested in recruiting surgeons from other sites to participate in data collection. Dedicated thoracic surgeons with large thoracic surgery practices would be ideal – and all results will be published and presented by surgeon/ and site.

We are particularly interested in recruiting surgeons from the following areas:

1. La Paz, Bolivia

2. Quito, Ecuador

3. Bogotá, Colombia

4. Mexico City, DF – Mexico

These four cities combined house many millions of people living at moderate altitudes, and would help provide for a wider and more expansive collection of data on patients undergoing thoracic surgery. Demographic differences (such as pre-existing thoracic diseases, incidence of heavy cigarette smoking, etc.) of geographic locales will also allow for further points of comparison.

Please contact Cirugia de Torax if you are interested in participating. All participating surgeons and institutions will receive credit (in accordance to level of participation) in any and all subsequent professional and scientific publications.

You can also contact me, K. Eckland, directly at : k.eckland@gmail.com. Please place ‘cirugia de torax’ or ‘altitude project’ in the sibject line.