providing anaesthesia for tte is always a challenge for the anaesthesiologists because of intraoperative need for one - lung ventilation and its associated problems . post - operative pulmonary complications in the early post - operative period can lead to increased morbidity and mortality . pulmonary complications can also occur due to surgical issues that may mislead the perioperative team and result in unnecessary and avoidable interventions . we would like to share our experience of two cases that underwent tte and developed acute respiratory distress in the post - operative period . a 39-year - old woman , known case of oesophageal carcinoma , was scheduled for tte with extended two - field lymphadenectomy with gastric pull - up with cervical neck oesophago - gastric anastomosis and feeding jejunostomy . she had history of hypertension since 4 years and controlled on amlodipine ( 10 mg ) and atenolol ( 50 mg ) . the anaesthetic management and monitoring were as per institutional protocol and was administered epidural and general anaesthesia . as a part of operative procedure , she was shifted to intensive care unit ( icu ) for post - operative monitoring and analgesia . her oxygen saturation decreased from 97% to 84% over  h in spite of oxygen supplementation with hudson mask . on auscultation , air entry was decreased on the right side and the percussion note was tympanic . she was put on oxygen at 15 l / min through venturi mask ( fio2 0.60 ) . the respiratory distress was only partially relieved and the air leak from the icd continued . due to on - going respiratory distress , the patient 's trachea was intubated . hence , we suspected air leak from the cervical drain and it was decided to remove the cervical drain and suture the defect . a 56-year - old man , case of carcinoma mid - oesophagus underwent tte with extended two - field lymphadenectomy with gastric pull - up and oesophago - gastric anastomosis in neck . the patient developed respiratory distress and air leak through right icd and saturation decreased to 86% despite oxygen supplementation . it was decided to conduct bronchoscopy . before bronchoscopy , we observed bubbles ( air leak ) from neck drain site . on removal of corrugated neck drain and resuturing the neck wound , air leak stopped and there was no further respiratory distress . a 39-year - old woman , known case of oesophageal carcinoma , was scheduled for tte with extended two - field lymphadenectomy with gastric pull - up with cervical neck oesophago - gastric anastomosis and feeding jejunostomy . she had history of hypertension since 4 years and controlled on amlodipine ( 10 mg ) and atenolol ( 50 mg ) . the anaesthetic management and monitoring were as per institutional protocol and was administered epidural and general anaesthesia . as a part of operative procedure , she was shifted to intensive care unit ( icu ) for post - operative monitoring and analgesia . her oxygen saturation decreased from 97% to 84% over  h in spite of oxygen supplementation with hudson mask . on auscultation , air entry was decreased on the right side and the percussion note was tympanic . she was put on oxygen at 15 l / min through venturi mask ( fio2 0.60 ) . the respiratory distress was only partially relieved and the air leak from the icd continued . due to on - going respiratory distress , the patient 's trachea was intubated . hence , we suspected air leak from the cervical drain and it was decided to remove the cervical drain and suture the defect . a 56-year - old man , case of carcinoma mid - oesophagus underwent tte with extended two - field lymphadenectomy with gastric pull - up and oesophago - gastric anastomosis in neck . the patient developed respiratory distress and air leak through right icd and saturation decreased to 86% despite oxygen supplementation . , we observed bubbles ( air leak ) from neck drain site . on removal of corrugated neck drain and resuturing the neck wound , air leak stopped and there was no further respiratory distress . our two cases reveal a rare cause of respiratory distress and air leak in patients who underwent tte . in these cases , slipped chest drains , lung parenchymal injury , tracheobronchial injury are well - documented causes of post - operative air leak and subsequent respiratory distress and pneumothorax . only two cases of pneumothorax associated with neck drains have been described . in both the cases , air leak was seen following transhiatal oesophagectomy . in our cases , air leak and subsequent pneumothorax were seen after tte . to the best of our knowledge , there is no literature suggesting air leak / respiratory distress following tte and subsequent improvement after removal of neck drain . after oesophagectomy , apart from icd , corrugated neck drain insertion is an acceptable technique . during tte , pleura were opened and gastric pull - up is done thus creating a communication between thorax and neck . generally , this is not a problem because the stomach tube seals the communication between the chest and the neck and the negative intrathoracic pressure is not transmitted to the neck . however , in certain situations , the corrugated drain may provide ample space for sucking atmospheric air during patient 's spontaneous respiratory efforts which creates negative intrathoracic pressure . the performance of extended lymphadenectomy , especially in the upper mediastinum may result in a wider communication between the chest and the neck . the communication between the chest and neck might then transmit negative intrathoracic pressure to the neck . if the defect size is larger than two - third of tracheal diameter , the air will preferential enter through this defect leading to pneumothorax . use of corrugated neck drain may also precipitate emphysema of neck and thus may compromise the airway as well . the possible causes of post - operative pneumothorax after thoracotomy and oesophagectomy include lung parenchymal leak / injury , bronchopleural fistula , ruptured bullae and malpositioned chest drains . the airway injury ( bronchus and lung ) during the surgery may lead to continuous air leak through chest drain or cause surgical emphysema of the face and neck . furthermore , ensuring the absence of air leak from lung before closure of thoracotomy incision needs to be emphasised . chest drains may occasionally slip out in the post - operative period which can normally be recognised by identifying the tube fenestrations outside the thorax . in our case air leak from lung parenchymal injury usually settles spontaneously in 1 - 2 days post - operatively . alternative drainage systems or avoidance of neck drains may be considered to prevent this complication . we also emphasise on the need for careful monitoring of respiratory status in patients having corrugated neck drain after tte .
transthoracic oesophagectomy is a standard surgical procedure for oesophageal cancer . because of thoracotomy and lung handling , 
 perioperative pulmonary complications make such procedures challenging . 
 the issues related to respiratory complications may be predicted and managed accordingly . 
 however , we report two cases of respiratory compromise caused due to a peculiar iatrogenic component .