Intrapulmonary mature cystic teratoma presenting with haemoptysis treated with right middle lobectomy in a low-resource setting

Article reference: Intrapulmonary mature cystic teratoma presenting with haemoptysis treated with right middle lobectomy in a low-resource setting Vijay Anand Ismavel and Ann Miriam


Intrapulmonary mature cystic teratoma presenting with haemoptysis treated with right middle lobectomy in a low-resource setting – is a case report layered with global health problematics relevant to first world countries.

The first point which stood out to me was the relevance of diagnostic tools and necessity to travel hundreds of kilometers in an emergency situation in order to access a CT scan. Massive hemoptysis, as is present in the patient, is an emergent situation which can lead to hemorrhagic shock. The patient here received bridging therapy with 4 PRBC until definitive treatment, pneumonostomy. Chest X ray was available at the local hospital in Assam, showing an ill-defined space occupying lesion. CT scan was deemed necessary putting the patient at risk of re-bleeding and increased cost due to transport. Outsourcing skilled radiologists from tertiary care centers in India or abroad during such situations, via internet imaging, could potentially spare patients in the future from traveling (provided there is internet access). Development of E-Medicine networks could provide shortened time from imaging to surgical care, decreasing financial burden on the patient.

The second point which was salient in this article is the reticence of lesser qualified hospital institutions to provide lifesaving surgeries due to lack of “perfect” infrastructure. Again in this case due to the life threatening condition, lack of treatment would have been lethal, and the authors used their judgement, patient centered decision making, and tools available to them in order to perform the pneumonostomy. As mentioned by the authors in the text “using a strategy of ‘best possible treatment at the time under the circumstances’.” A surgeon and an anesthesiologist were present at the time of both surgeries, providing necessary anesthesia, analgesia and surgical treatment to the patient. The author does not shy away from asserting the lack of extensive experience in this surgical procedure, yet necessity made him decide to perform the intervention. In countries like India where the number of thoracic surgeons is inadequate to meet the need of the population, one might consider training surgeons in life saving surgical procedures in order to locally treat patients which would be too unstable to transfer to another hospital. As mentioned in the text, patients are lost to follow up and often forego treatment due to distance and/or financial burden of accessing another medical facility.

Thirdly, the in-detail description of providing general anesthesia in a non-tertiary care hospital is a valuable insight. Two different anesthetic techniques and monitoring were described using tools and medication available at the local hospital. The results are incredibly impressive providing low resources, lack of post operative ICU, non-preoperative assessment and optimization as would be required in a developed country prior to such a surgery. The author discusses ether, halothane and nitrous oxide as anesthetics for maintenance of anesthesia during the initial surgery. We would also like to propose the possibly of Total Intravenous Anesthesia (TIVA) with propofol and remifentanyl – a method used in combat field hospitals due to lack of proper anesthesia machine or access to volatile anesthetics (as is now the case with ether in India). TIVA could be useful is facilities where anesthesia machines cannot be repaired, or are no longer in use, ventilation can be done through a ventilator or via a bag valve mask ventilation.

This article demonstrates a wide array of challenges needed to be overcome in order to provide adequate specialized care in a less adequate setting. From the authors we do understand that some of the barriers are placed by the health care provider and the established system of guidelines. As is cited in the article, review of the guidelines is needed in order to take into consideration each case and to provide the best possible solution in a less than perfect setting.


About the author:
Chloe Pinto M.D. Resident in Anesthesiology, Pain and Intensive Care Medicine at Meir Medical Center, Israel.

Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None