Bronchial air leak during transhiatal esophagectomy

T HE ANESTHETIC and surgical management of esophagectomy are challenging because of the anatomic location of the esophagus in the posterior mediastinum, where it is in close proximity to the aorta, heart, and tracheobronchial tree. Esophagectorny may be accomplished either by a partially blinded, blunt dissection through the esophageal hiatus or under direct vision via thoracotomy. Traditionally, a thoracotomy combined with upper abdominal and neck incisions has been preferred because of the excellent surgical exposure gained. The transhiatal approach, which uses only an upper abdominal incision together with a neck incision, has gained popularity. This technique appears to have fewer adverse effects on postoperative respiratory function and is associated with decreased incidence of respiratory complications.l,2 Transhiatal esophagectomy (THE) also decreases the overall operative time. 3,4 Anesthetic management of THE may be less complicated because this approach does not require single-lung ventilation; however, the blunt transhiatal dissection can increase intraoperative blood loss. 4 Brisk bleeding may occur from the azygous vein, aberrant vessels from the aorta, or splenic and hepatic injuries. 5-7 Moreover, multiple adhesions resulting from cancer or coexisting inflammation potentially increase the risk of vascular and tracheobronchial injury. Although the risks of pneumothorax, hypotension from transient obstruction of venous return, arrhythmias, and massive bleeding are generally recognized, s,9 that of tracheobronchial injury has not been emphasized in the anesthesia literature. This case report describes a patient who experienced a sudden decrease in minute ventilation during THE that was caused by a bronchial leak during dissection and mobilization of the esophagus. direct laryngoscopy without difficulty. Five milliliters of air was placed in the endotracheal tube cuff, and no air leak was detectable. Anesthesia was maintained with isoflurane and supplemental doses of vecuronium, fentanyl, and ketamine. The patient was ventilated with an Ohmeda Modulus CD machine using a tidal volume of 700 mL and rate of 10 breaths/rain with peak airway pressures of 22 cmI-IzO. Right radial artery and fight internal central jugular catheters were placed. The patient was positioned supine, and surgery proceeded without incident. During the transhiatal mobilization of the esophagus, the ventilator bellows were suddenly noted to collapse with a 4 L/rain fresh gas flow into the circle breathing system. Tidal volume could be maintained only with a minimal fresh gas flow of 8 L/min. The inspired oxygen concentration was increased from 60% to 100%. The endotracheal pilot balloon was checked and found to be intact. Breath sounds were auscultated and noted to be present and equal bilaterally. The ventilator circuit was checked for a gas leak, and the possibility of ventilator malfunction was ruled out. Arterial saturation remained greater than 97% by pulse oximetry. The surgeons were notified of the large air leak and asked to inspect the surgical field. On close examination of the mediastinum through the esophageal hiatus, a large air leak, originating from the left lower lobe bronchus just below the carina, was found. Ventilation was accomplished by rapid low-pressure breaths that facilitated surgical repair of the bronchial leak. After the repair, the suture line was tested and showed no sign of a gas leak at sustained airway pressures of 40 cmH20, Flexible bronchoscopy was also performed to evaluate the repair and exclude narrowing of the lef~ bronchial lumen, The patient was then ventilated with smaller tidai volumes (450 mL) for the remainder of the operation, At the completion of the surgery, the epidural catheter was activated with 10 mL of bupivacaine 0.25%. The patient was then extubated under deep anesthesia to avoid any coughing on the endotracheal tube. He recovered from the anesthesia and surgery uneventually and was discharged from the hospital on the l l th postoperative day.