26-MAY-2025  GHAZWAN SAMI AMEEN 55 YEARS: SECOND PART OF THE SURGERY TO DECOMPRESS THE INVOLVED D7.8 BY THE METASTATIC MALIGNANT PAPILLARY THYROID CARCINOMA AND STABILIZE THE SPINE.

The patient was operated by me 15-May-2025 and the surgery was stopped due to massive bleeding after 13 hours and sent to ICU to correct his homeostasis.   

On examination, the patient is improved for his previous paraplegia, but fixation of the spine did not performed and the tumor was removed around 40% and the spinal cord was decompressed. Sonopet IQ was prepared for the procedure.

With the patient in right side position, the previous incision was refreshed and the the incision over the left chest cage extended more. It seems that during the 11 days the tumor progressed in size denoting the aggressive course. The tumorous left D8-7 lateral mass was removed with the left D7 was removed. The same was done to the tumorous articulation of left D8-9 with removal of the tumorous rib of D9.  Using Sonopet IQ was of no help in decompressing the extrapleural with Barracuda tip, because the tumor was firm solid and contained bones. The tumor was decompressed by several means of cauteries and bipolars and drills. The pleura was opened and the real dimensions and configuration of the mass was realized. This step could yield to remove almost all  the tumor in the area keep the dissection extrapleurally. The left lateral wall of D6 and D9 were exposed and 2-0 angle end plates were applied to the lateral walls of D6 and D9. 5.5x40 mm F.A.S Armada screws were inserted 2 screws to each bones. So as to accept the Nuvasive X-core 2- 41-46 expandable corpectomy cage, further drilling of D7 healthy bone was done. The disc space of D8-9 was eaten by the tumor. The construct was inserted  and distracted  and rigid fixation obtained. We used Attrax bone graft 10 cc was used to fill the inside the corpectomy cage, because the ribs and laminae were tumorous. 2 Rods slightly bended to accept the lordotic area of the spine. and left side fusion of the D6-D9 was achieved. Hemostasis and insertion of underwater seal inserted and the pleura was closed. Ready Vac  drain was also applied. Routine closure of the wounds. The operation time was 24 hours, for what the patient was put in ventilator for 24 hors.

In the ICU, blood transfusion, FFP was given and all the homeostatic parameters was observed and corrected accordingly. The patient the next day 28-May-2025 extubated and with no neurologic deficits.

In 08-June-2025, the patient was ready for discharge after removing the UWS the day before and repeating CXR which was acceptable, during readiness for discharge, but the patient still in the ICU, he progressed massive pulmonary embolism and resuscitation failed and he died at 2.30 p.m.

The tumor was bleeding vigorously, for what so as not to loose the patient, the surgery was prepared promptly. and the surgical mission succeeded. 

The patient performed chest CT-angio after the first surgery and it was normal denying absence of pulmonary embolism. There were no warning signs to predict such event, which made the patient death.

The patient during this period received more than 60 units of packed cells and 120 units FFP and 50 units platelets. At these circumstances, it is difficult cover him with anticoagulants. It seems that even a minimal amount of anticoagulants will increase the amount of transfusion, but could avoid the pulmonary embolism.

In medicine, the puzzle is more complex than chess or AI technology, and you cannot predict when the catastrophe will take precedence.