Sam and Marlene Paffile
Six months ago, Sam Paffile began to experience fatigue and dark red blotches
on his skin. Then on a recent trip to Mexico, Sam developed severe pains
on the right side of his chest and was diagnosed with tuberculous pleuritis
( an inflammation of the pleura as the result of tuberculosis). He was
immediately placed on antituberculous medications. Upon his return, he
sought confirmation of the illness. It was not tuberculosis!
A thoracentesis (a surgical puncture of the chest for removal of fluids)
and a pleural biopsy was performed on June 21, 1997 by Dr. Allen Muramoto
at the Swedish Medical Center in Seattle, Washington. A diagnosis of epithelial
mesothelioma was confirmed by both Swedish Medical Center and Dr. Samuel
Hammar of Diagnostic Specialities Laboratory, Inc. in Bremerton, Washington.
Dr. Hammar is a member of the elite U.S.-Canadian Mesothelioma Panel.
Dr. Ralph Aye, a pulmonary surgeon at Swedish Medical Center, discussed
the possibility of a radical extrapleural pneumonectomy with Sam and his
family. The risks are great. According to Dr. Aye there is a 5% to 8%
mortality risk, and the results in the past have not always been what
they had hoped. However, for Sam it seemed the best approach.
Preparations were made. Dr. Aye and his staff collaborated with Dr. Valeri
Rusch at Sloan Kettering in New York regarding the tri-modal therapy.
This protocol consists of removing the pleural space (pleurectomy), intrapleural
infusion of chemotherapy and intense radiation. Sam, took all the steps
necessary to prepare for his surgery. He had always taken care of himself,
a robust man that looked younger than his 58 years of age. He did not
smoke. On July 7, 1997 Sam Paffile was admitted to Swedish Medical Center
Sam was wheeled into surgery at approximately 3:30 p.m. where a general
anesthetic was administered. A double lumen endotracheal tube (a tube
used inside the trachea to provide an airway through the trachea) was
inserted and cuffed (inflated); along with all the other numerous tubes
necessary to monitor the vitals of Sam. He was place on his left side,
his chest shaved, prepped and draped in the usual sterile fashion.
A standard posterolateral thoracotomy incision (back to front) was made
over the sixth (6th) rib from the scapula (right shoulder blade) to the
spine. The muscle layers were divided and a rib spreader was put in place.
The pleura (membrane around the lung and diaphragm) was peeled off and
a large section of the diaphragm was removed. When they dissected the
pleura off of the tissue (mestiastiumun) around the heart they found that
the tumor had spread and that it was necessary to remove all of the mass
tissue and a portion of the right side of the pericardium (sac) surrounding
the heart. The heart, its large vessels, the trachea, esophagus, thymus
and lymph nodes were all found intact and healthy. Also preserved were
the azygos vein, superior vena cava, inferior vena cava and the internal
mammary artery. Any bleeding from the intercostal vessels was controlled
with clips or 3-0 silk ties.
The next step was to remove the right lung. There was some difficulty removing
the root (pulmonary hilum) of the lung. First, the right mainstem bronchus
was dissected out, and a heavy wire stapler was used to divide this. The
pulmonary artery, inferior and superior pulmonary veins were all dissected
out and stapled. Once all the attached vessels were removed the right
lung, including the parietal pleura was removed and sent off to pathology.
Two ribs, the third and eighth, and portions of three other ribs were
It was then time to put Sam back together again. Remember we told you that
Sam had the top half of his diaphragm removed. This was replaced by using
a 10 x12 cm piece of Gore-Tex sutured to the remaining diaphragm with
2-0 Prolene suture in a running stitch. Another piece of Gore-Tex, 8 x
12 cm, was used to repair the pericardial defect (the sac around the heart).
There was a leak found on the thoracic duct, which was repaired. Before
the closure of the chest a 28 French chest tube was inserted into the
inferior portion of the chest. The ribs were mended using a #1 PDS suture.
All of the layers of muscles were then closed using a #0 Vicryl running
stitch. The shoulder blade was closed and the skin was sutured in place
using a running 3-0 Vicryl subcuticular stitch. (This is a buried horizontal
stitch in which the needle is passed under the skin through the edge of
the wound and back again).
Sam Paffile, post surgery
The operation lasted almost eight hours. Sam was back in the recovery room
at 11:53 p.m. The following day, July 8, 1997, chest x-rays were take.
It showed that fluid was beginning to fill the empty thoracic cavity.
The catheter and the tube positions were secure and the heart size was
stable. The portable chest x-rays over the next few days, through July
11, 1997, appeared to be consistent with the x-ray of July 8, 1997. On
July 10, Sam was moved out of intensive care to the floor. He continued
to be monitored, having his pain medication adjusted and on July 11, 1997
the epidural catheter was removed. On the morning of July 12, 1997 Sam
was discharged from the hospital, and sent home.
Later that afternoon however, Sam was returned to the hospital and was
seen in the emergency department. Sam had gotten his arm stuck in the
bed railing the night before and on the way home the door was slammed
on him, causing him further discomfort. Also, there was increased swelling
above and below his incision and he was having trouble breathing. He told
the attending doctor that there was a strange tightness or heaviness on
his diaphragm and that he was having trouble moving. Mr. Paffile was re-admitted
to the hospital for observation. His pain medication was adjusted and
his incision was iced to decrease the swelling. He was discharged the
Sam went home for a few days. Around July 17th he began to have trouble
breathing during the night. He found that he would have to sit upright
to sleep and there was an increased pain on his right side when he tried
to move his right arm. On July 19, 1997 he was brought to the emergency
department at Swedish Medical Center by his wife, Marlene. Upon examination
he was immediately placed on a cardiac monitor which showed an abnormal
heart rate between 170 - 200. (Anything over 100 beats per minute is considered
abnormal). An IV was established and oxygen was administered. Once the
IV's were in place he was given six (6) milligrams of Adenocard IV,
however there was no change. Another twelve (12) milligrams of Adenocard
was given, and Sam suffered a sudden shortness of breath. The monitor
slowed to a rate of 40 beats per minute, but shot up again to 180. Sam
was in trouble. The attending physician, Dr. Rita Mellema, opted to administer
Lidocaine. Approximately, three minutes after the Lidocaine was administered,
Sam's chest pain ceased and normal sinus rhythm began, easing his
Sam's remaining time in the emergency department was satisfactory.
He continued to have a normal sinus rhythm of 80 - 90, and he had no recurrent
episodes of breathing problems or chest pain. Of course, Sam was admitted
to the hospital for close observation and monitoring. He was examined
thoroughly by doctors and released the following day.
Since that time, Sam has been doing well. On July 29, 1997, he was admitted
to Swedish Medical Center under the care of Dr. Gary E. Goodman to begin
his chemotherapy and radiation. Sam is scheduled to have radiation treatments
every day for five weeks. After that time, Sam will be evaluated.
POSTED AUGUST 21, 1997
Mr. Paffile passed away on June 25, 1998