high altitude – 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).

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.

High Altitude Surgery, part I

As our writer returns to moderate altitude in the foothills of the Andes, we take a look at the published research related to altitude illnesses and surgery.

This seemed like a timely entry here at Cirugia de Torax, as I return from Bogotá, Colombia (the third highest capital city in the world.) However, while the concept of surgical constraints due to elevation is not new; but today we will discuss definitions and explore the published literature. I’d also like to apologize to my readers – much of the available medical literature in not available as a free text, so while I am able to access and reference this information – I can not post links to the full articles themselves.

First, we need to define some terms when we talk about altitude, since most of the research is actually looking at very high (versus moderate altitude). This is important because as you will see, very few people are living at, and even fewer people are having surgery at these heights.

Definitions of Altitude: from Muzo, Tulco & Cymerman (2004).

Very-High Altitude: 4250 – 6000 meters elevation (13,943 ft to 19,685 ft): There are few permanent cities at this altitude. At the upper range of very high altitude cities, you are essentially talking about ‘base camp’ settlements of Mount Everest and places like Wenzhuan (Tibet) which is listed as the world’s highest city at an elevation of 16,467. (There is some controversy over this status, as La Riconada, Peru at 16,728 ft. (5100 meters) also claimed status as the highest city. There are no cities with any significant size (greater than just a few thousand residents) at this elevation. However, the majority of altitude research has been conducted at the very high and high altitude elevations.

High-Altitude: 2500 meters – 4249 meters
(8,202 ft to 13,940 ft): this classification includes several larger cities / population centers including three capital cities:

La Paz, Bolivia (est. elevation ranging from 3200 meters to 3,650 meters in different portions of the city) population of metro area: 2.3 million.

Quito, Ecuador (est. elevation 2800 meters or 9186 feet) population: 1.4 million

Bogotá, Colombia (2660 meters, 8727 feet) population: 10 million

According to the majority of scientific and medical literature, physiological adaptation, high altitude effects and illnesses usually do not occur until people reach an altitude of 2500 meters or greater. (However, the authors acknowledge that in certain individuals – these effects can occur at relatively low elevations (1,000 meters).

Moderate Altitude: 1000 meters to 2500 meters (3900 feet to around 8000 ft) This is actually the level that most of the people who are concerned about the effects of elevation live and operate at. This includes Denver, Colorado; Lake Tahoe, California/Nevada; Flagstaff, Arizona and several other American cities in the Sierra Nevada Mountain Range. It also includes several Alpine cities (while the alps themselves are around 4400 – 4800 meters, most of the cities are in the valleys, and most lay at around 1500 meters.)

Low Altitude: below 1000 meters.

References:

Heart. 2006 Jul;92(7):921-5. Epub 2005 Dec 9. Safety and exercise
tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease. Schmid JP, Noveanu M, Gaillet R, Hellige G, Wahl A, Saner H. (Switzerland)

Chest. 1995 Nov;108(5):1292-6. The safety of air transportation of
patients with advanced lung disease. Experience with 21 patients requiring lung transplantation or pulmonary thromboendarterectomy. Kramer MR, Jakobson DJ, Springer C, Donchin Y. (Israel).

Br J Sports Med. 1995 Jun;29(2):110-2. Poor ventilatory response to mild hypoxia may inhibit acclimatization at moderate altitude in elderly patients after carotid surgery. Roeggla G, Roeggla M, Wagner A, Laggner AN. (Austria).

Thorax. 1995 Jan;50(1):22-7. Doppler assessment of hypoxic pulmonary vasoconstriction and susceptibility to high
altitude pulmonary oedema. Vachiéry JL, McDonagh T, Moraine JJ, Berré J, Naeije R, Dargie H, Peacock AJ. (Belgium)

Ann Surg. 1897 Sep;26(3):297-306. II. A Preliminary Comparison
of Methods and Results in Operative Surgery at the Sea Level (New York) and in Places of High Altitude (Denver). Powers CA. (Note the date of publication – 1897 – we’ve been looking at this issue for quite a long time.)

West J Med. 1995 Aug;163(2):117-21. Sea-level physical activity and acute mountain sickness at moderate altitude. Honigman B, Read M, Lezotte D, Roach RC. – This is an interesting study which looks (observational by survey only) at the physiological responses of conference participants from low elevations upon reaching higher elevations (3000 meters in this study / 9,840 ft). The study compared the incidence of altitude sickness/ symptoms among people who defined themselves as physically fit/ physically active (using standardized criteria) versus more sedentary individuals. In total, 28% of the 200+ participants reported three or more symptoms of acute mountain sickness, but surprisingly, there was no difference in incidence among the physically fit (at sea-level) group and the more sedentary group which belies much of the current folklore related to altitude sickness.

Muza, Tulco & Cymerman (2004). Altitude Acclimatization Guide.

Essenbag, V., Halabi, A. R., Churchill-Smith, M & Lutchmedial, S. (2003). Air transport in Cardiac Patients. Chest 2003 Nov; 124(5): 1937-45. McGill University, Montreal, Canada.

Altitudes of World Cities – there are some discrepancies with altitudes listed here and other reference materials.

The 25 Highest US cities

In our next post we will talk more about this research, what it means, and what research is still needed to examine the effects of high altitude surgery, particularly in thoracic patients.