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| CASE REPORT |
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| Year : 2022 | Volume
: 24
| Issue : 3 | Page : 120-121 |
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Successful Management of Accidental Tracheal Tear using an Adaptation of an Endotracheal Tube
Shamik Kumar Paul, S Kiran, Deborshi Guha, Kaminder Kaur, Debashish Paul
Department of Anesthesia and Critical Care, AFMC, Pune, Maharashtra, India
| Date of Submission | 21-May-2021 |
| Date of Decision | 10-Jun-2021 |
| Date of Acceptance | 10-Aug-2021 |
| Date of Web Publication | 01-Jul-2022 |
Correspondence Address:
Lt Col (Dr) Debashish Paul
Department of Anesthesia and Critical Care, AFMC, Pune - 411 040, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_77_21
Although tracheal injury during esophagectomy is a rare complication, it is a dreaded one when encountered in the intraoperative period. It can be managed conservatively or by primary repair. We report an incident and successful management of tracheal injury during transhiatal esophagectomy performed in a case of carcinoma esophagus (upper one-third). The tracheal rent of the posterior wall of the trachea was repaired with bovine pericardial patch through a right thoracotomy we added one endotracheal tube (ETT), cut at 19 cm mark from its patient end, reversed to another ETT with a refashioned ETT connector. This innovation gave us enough length to place the tube comfortably inside the left main bronchus without making the ETT cuff herniate inside the tracheal tear. The tracheal rent was repaired with bovine pericardial patch hitched with pledgeted sutures through a right thoracotomy. Postrepair, the patient was electively ventilated; gastric pull-up was postponed pending the healing of the trachea. At the time of second surgery, we had to take all the precautions not to disrupt the repaired wall. The tracheal wall was found intact with some permanent deformity but functionally competent.
Keywords: Airway management, esophagectomy, injury, innovation, trachea
How to cite this article:
Paul SK, Kiran S, Guha D, Kaur K, Paul D. Successful Management of Accidental Tracheal Tear using an Adaptation of an Endotracheal Tube. J Mar Med Soc 2022;24, Suppl S1:120-1 |
| Introduction | |  |
Although tracheobronchial injury or tracheal tear is a rare complication during transthoracic esophagectomy (TTE) when it happens, it becomes a dreaded complication.[1] We present a case of intraoperative tracheal tear during TTE in a 55-year-old patient with carcinoma esophagus, and its successful intraoperative management with some innovation to maintain the airway and the definitive surgery later on.
| Case Report | | |
This patient was taken up for TTE in ASA II. One lung ventilation (OLV) was achieved by bronchoscopy guidance with 39 Fr left-sided double-lumen tube (DLT). Laparoscopic esophageal mobilization till esophageal hiatus was done using standard three-port insertion with the right lung down. As the cervical part of the esophagus was being mobilized, there was a sudden loss of airway pressure. The capnography (EtCo2waveform) was lost and there was an audible and visible air leak from the site of the incision. The oxygen saturation (SpO2) dropped to 85% which improved on manual ventilation. The patient started developing subcutaneous emphysema and became hypotensive. Suspecting a left tension pneumothorax due to a tracheal rent, an ICD was placed on the left side. After achieving oxygenation and hemodynamic stability, fiber-optic bronchoscopy revealed a 4 cm tear on the posterior wall of the trachea just above the carina. It was decided to repair the tracheal rent with a bovine pericardial patch hitched with pledged sutures through a right thoracotomy.
DLT being a contraindication due to its large external diameter and the difficulty with the inflated cuff of the single-lumen endotracheal tube (ETT) which might get prolapsed into the tracheal tear, we took one more 7.0 mm size ETT and cut out 19 cm from its patient end, reversed it, and attached another 7.0 mm size tube with a refashioned ETT connector [Figure 1]. This innovation gave us enough length to place the tube comfortably inside the left main bronchus without making the ETT cuff herniate inside the tracheal tear. After re-establishing OLV, the tracheal rent was repaired. | Figure 1: (a) he “refashioned” endotracheal tube (ETT), (b) Normal and Modified ETT
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| Discussion | | |
Early recognition of tracheobronchial injuries and prompt airway control can be life-saving.[2] In this case, the tracheal tear was recognized instantly due to a sudden gush of air from the operative site. This sudden loss of airway pressure brought us to the differential diagnosis of pneumothorax, pneumoperitoneum, subcutaneous emphysema, mediastinal emphysema, or tracheal tear as it happened in this case.[3]
There are case reports of tracheal injury in infants[4] along with previous reports of six cases of tracheal injury during esophagectomy.[5] As per that report, the injury was recognized intraoperatively in five patients and a leak from the operative site was detected on the first postoperative day in one patient.
Two large case series[6],[7] reported an incidence of tracheal tear of 0.4% and 1.6% of patients undergoing esophagectomy, most frequently the membranous trachea.
In this case, the most vital step was an early recognition of tracheal tear and innovation to manage the airway so that the tracheal repair could be performed instantaneously.
There are other means to isolate the lung-like using an Arndt blocker or endobronchial intubation, but we present this case to demonstrate the innovation by increasing the length of the ETT enabling the cuff to be placed beyond the tear proving it to be critical during such emergencies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Pang PY, Su JW. Tracheal injury causing massive pneumoperitoneum following change of a tracheostomy tube. Ann Acad Med Singap 2012;41:532-3.  |
| 2. | Wei P, Yan D, Huang J, Dong L, Zhao Y, Rong F, et al. Anesthetic management of tracheal laceration from traumatic dislocation of the first rib: A case report and literature of the review. BMC Anesthesiol 2019;19:149. |
| 3. | George SV, Samarasam I, Mathew G, Chandran S. Tracheal injury during oesophagectomy-incidence, treatment and outcome. Trop Gastroenterol 2011;32:309-13. |
| 4. | Kiran S, Ahluwalia C, Chopra V, Eapen S. Bronchotomy for removal of foreign body bronchus in an infant. Indian J Anaesth 2014;58:772-3. [ PUBMED] [Full text] |
| 5. | Hulscher JB, ter Hofstede E, Kloek J, Obertop H, De Haan P, Van Lanschot JJ. Injury to the major airways during subtotal esophagectomy: Incidence, management, and sequelae. J Thorac Cardiovasc Surg 2000;120:1093-6. |
| 6. | Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL. Two thousand transhiatal esophagectomies: Changing trends, lessons learned. Ann Surg 2007;246:363-72. |
| 7. | Koshenkov VP, Yakoub D, Livingstone AS, Franceschi D. Tracheobronchial injury in the setting of an esophagectomy for cancer: Postoperative discovery a bad omen. J Surg Oncol 2014;109:804-7. |
[Figure 1]
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