P032: ANESTHETIC CONSIDERATIONS IN A COMPLEX CHEST WALL RECONSTRUCTION FOLLOWING ANGIOSARCOMA DIAGNOSIS
Claudia D Najera, MD; Marialla Inoyatov, MD; Robert Toledo, MD
HCA Westside
Introduction: A 77-year-old female with a past medical history of hypertension, diabetes mellitus, and T2 N1 invasive ductal carcinoma of the left breast underwent a modified radical mastectomy following neoadjuvant chemotherapy. Despite initial oncologic control, she developed persistent pain and structural abnormalities in the left chest wall over three years. Subsequent imaging and biopsy confirmed angiosarcoma of the chest wall, as well as an adrenal lesion, necessitating further surgical intervention. Given the extent of the malignancy and structural involvement, she underwent a left chest wall tumor resection with reconstruction using a pedicled latissimus dorsi and serratus anterior flap in conjunction with rib plating.
Methods: The anesthetic management was planned to address the patient’s advanced age, comorbidities, and the extensive nature of the surgery. A multimodal approach was utilized to optimize intraoperative stability and postoperative recovery. Invasive hemodynamic monitoring with an arterial line was implemented for continuous blood pressure monitoring and blood gas analysis. Regional analgesia was provided through an erector spinae plane (ESP) nerve block preoperatively to minimize opioid use and reduce the risk of respiratory depression.
General anesthesia was induced with a balanced technique incorporating intravenous induction agents, neuromuscular blockade, and volatile anesthetics. Lung-protective ventilation strategies were used to minimize barotrauma, and fluid management was carefully titrated to maintain hemodynamic stability while avoiding pulmonary edema.
Results: Intraoperative challenges included maintaining hemodynamic stability during tumor resection due to potential major blood loss and ensuring adequate oxygenation and ventilation following chest wall reconstruction. Rib plating was performed to restore structural integrity, requiring close coordination between anesthesia and surgery. Early extubation was prioritized to minimize postoperative pulmonary complications.
Postoperatively, the patient was monitored in a step-down unit for respiratory compromise, hemodynamic instability, and flap viability. The ESP block provided effective analgesia, reducing opioid consumption and facilitating early mobilization. The multimodal pain management strategy contributed to a stable recovery with minimized opioid-related side effects.
Discussion: This case highlights the anesthetic considerations in complex oncologic and reconstructive surgery in elderly patients. The integration of regional anesthesia with meticulous intraoperative management contributed to a successful perioperative course. The use of multimodal analgesia and lung-protective ventilation was essential in optimizing patient outcomes. This case underscores the importance of individualized anesthetic planning in extensive chest wall reconstruction, particularly in patients with multiple comorbidities and a history of oncologic disease.