Intraoperative tracheal reconstruction with bovine pericardial patch following iatrogenic rupture
© Barbetakis et al; licensee BioMed Central Ltd. 2008
Received: 24 November 2007
Accepted: 20 February 2008
Published: 20 February 2008
Iatrogenic injuries of the membranous trachea have become increasingly common and may trigger a cascade of immediate life-threatening complications.
A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.
Our technique was proved to be safe, effective and not technically demanding. Early recognition with prompt surgery is the gold standard of managing such cases, although small tears can be managed conservatively.
Iatrogenic injuries of the membranous trachea are rare but potentially lethal and can complicate procedures such as endotracheal intubation, mediastinoscopy, percutaneous tracheostomy and excision of neoplasms with mediastinal involvement. Statistically women are more predisposed to this than men . Further risk factors include poor medical condition, short stature, use of steroids, previous chemotherapy and mediastinal radiotherapy. A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.
A 48-year-old man was admitted to our department with the diagnosis of an adenocarcinoma of the gastroesophageal junction. Preoperative staging was negative for distant metastases. Endoscopic ultrasound findings confirmed the presence of a locally advanced tumor (type I – Siewert classification). It was an adenocarcinoma of the distal esophagus arising from an area with intestinal metaplasia and infiltrating the esophagogastric junction from above. As a consequence preoperative synchronous chemoradiotherapy was proposed. The scheme was consisted of fluorouracil (15 mg/kg of body weight) daily for five days and cisplatin (75 mg/m2 of body surface area) on day 7 and a course of radiotherapy (40 Gy administered in 15 fractions, anterior-posterior mediastinal fields) over a a three week period, beginning concurrently with the first course of chemotherapy. After the completion of chemoradiotherapy, the stage of the disease was reevaluated (CT scans of the abdomen, chest, pelvis, upper gastrointestinal endoscopy and ultrasound). Restaging was completed with no evidence of distant disease and surgical removal of the primary tumor and lymphadenectomy was proposed. The patient was eligible for an Ivor Lewis esophagogastrectomy.
He was intubated with a left-sided 37-F double-lumen endotracheal tube by a specialist anesthesiologist experienced in cardiothoracic surgery anesthesia. The technique includes the following points. The tube was held with the bronchial curve concave anteriorly. As the tip was passed through the larynx, the tube was rotated 90 degrees to direct the endobronchial part to the intended side. The tube was then connected to the breathing circuit via a double catheter mount.
Tracheal rupture after endotracheal intubation is a rare entity. Most retrospective reviews focus on elective intubations by experienced anesthesiologists and show an incidence of rutpture of less than 1% . There are multiple factors leading to injury. Operator errors (multiple attempts, inexperienced phycisians), equipment selection (inappropriate use of stylets, cuff overinflation, malposition of the tube, incorrect tube size), patients' movements (abrupt movements, excessive coughing) and medical factors (steroid or radiation-weakened membranes, chronic obstructive pulmonary disease, tracheomalacia) contribute to the problem . Other risk factors include age>50 years, short stature, obesity, double lumen tubes and percutaneous tracheostomy . Women are more frequently affected by an iatrogenic tracheobronchial rupture. Certainly, their small body size and therefore the risk of placing the tube too distally in a short trachea and an incorrect tube size might be responsible. Additionally, a vulnerable and weak trachea is often suspected in women.
Iatrogenic tracheal rupture involves almost exclusively the membranous trachea . Early recognition with prompt surgery is the gold standard of managing such cases, although small tears can be managed conservatively . In general tracheobronchial ruptures of the middle and lower third are operated on through a right and in rare exceptional cases, a left thoracotomy . The approach to injuries in the upper third of the trachea is the left cervical side. Angelillo-Mackinlay proposes a transcervical access in the sense of a mediastinotomy for injuries to the distal trachea, which is, nevertheless, fairly controversial, due to the creation of additional trauma (longitudinal tracheotomy). For the repair, patients should be intubated using a double-lumen tube. Single lumen tube with position in the contralateral main bronchus or high-frequency jet ventilation can be used alternatively. However, disadvantages of the jet ventilation technique are the tendency to produce carbon dioxide retention and the danger of blood aspiration into the bronchial system. After limited lateral and posterior paratracheal dissection, the injury is repaired by interrupted or running absorbable suture, sometimes covered with mediastinal fat or pleural flap and/or by fibrin glue . Direct suture of a tracheal rupture in a patient previously treated with chemoradiotherapy is not an option as this was proved in our case and resulted in enlargement of the laceration. Our technique adopted here, was based on the competence of the gastric wall to sustain the tension against the tracheal rings and furthermore to push the bovine pericardial patch toward the posterior wall, sealing the tear. The above mentioned technique is proposed for surgical management of tracheal wall lacerations as it proved safe, effective and not technically demanding. The use of an endotracheal stent could be proposed but the urgent situation (almost impossible ventilation and oxygenation) led us to resolve the problem surgically. However, the employment of a covered expandable stent should be considered for the treatment of a tracheal or bronchial tear. The development of these stents represents an effective, direct and less invasive means of sealing tracheal tears . Stent deployment commits the patient to continued outpatient surveillance to monitor for complications. Although uncommon these include granulation tissue formation, stent migration, halitosis and recurrent respiratory tract infections .
Iatrogenic tracheobronchial ruptures are mainly caused by emergency intubations . Percutaneous dilational tracheostomies and double-lumen intubations do not show higher signs of complications compared with single-lumen intubations or conventional tracheotomies, if they are accompanied by verification through bronchoscopy . Patients without any respiratory failure and a small tracheobronchial rupture may undergo conservative treatment. They must be checked by repeated bronchoscopies to detect granulation tissue and relevant tracheal stenosis. Early surgical treatment of the latter must be the therapy of choice.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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