BRONCHOPLEURALBRONCHOPLEURAL FISTULAFISTULA DURINGDURING

VIDEOVIDEO -- ASSISTED ENDOSCOPICASSISTED ENDOSCOPIC ESOPHAGECTOMYESOPHAGECTOMY PROCEDUREPROCEDURE

– REPORT OF TWO CASES

Nguyen Thi Thanh HuongNguyen Thi Thanh Huong

DEPTDEPT OF ANAESTHESIOLOGYOF ANAESTHESIOLOGY && CRITICAL CARE BCRITICAL CARE B

HUE CENTRAL HOSPITALHUE CENTRAL HOSPITAL

Hue Central Hue Central HospitalHospital

VIDEOVIDEO--ASSISTEDASSISTED ENDOSCOPICENDOSCOPIC ESOPHAGECTOMYESOPHAGECTOMYIntroduction

• Has become a common procedure which was widely used in gastrointestinal surgery

• Had applied in Hue Central Hospital since 2007

• With many advantages:

+ avoiding large thoracotomy

+ decreased the serious respiratory

complications in postoperative period

+ avoid the risk of mediastinal inflammation+ …

Rothenberg SS. Thoracoscopic pulmonary surgery. Semin Pediatr Surg. 2007;16:231–7http://www.laparoscopicexperts.com/esophagectomy.html

• However, anesthetic technique for this type of surgery is difficult

+ intraoperative complications may occur

+ requiring the anesthesiologist must have

expertise and experience

+ well-equipment monitorshttp://www.laparoscopicexperts.com/esophagectomy.html

VIDEOVIDEO--ASSISTEDASSISTED ENDOSCOPICENDOSCOPIC ESOPHAGECTOMYESOPHAGECTOMYIntroduction

• We present two case of accidental intraoperative bronchopleural fistula during video-assisted endoscopic esophagectomy procedure

•

• We discuss differential diagnoses including the role of end-tidal carbon dioxide monitoring as an aid to prompt diagnosis

VIDEOVIDEO--ASSISTEDASSISTED ENDOSCOPICENDOSCOPIC ESOPHAGECTOMYESOPHAGECTOMYObjectives

- REPORT - - REPORT -

The 1st caseThe 1st case

• Patient name: Hoang Van M.+ Sex: male+ Age: 49 years + Weigh: 53kg+ Past medical and surgical history: normal + Presented in hospital due to dysphagia+ ASA physical status II + Diagnosis: oesophagus carcinoma+ Indication: video-assisted endoscopic esophagectomy+ Preanesthetic evaluation: patient's physical conditions

and any other medical problems are covered+ Surgery schedule: 22 Octobre 2013

Pre-operative

Barium esophagram demonstrates an change in the caliber and contour of the esophagus caused by an irregular circumferential stricture containing focal

ulcerations

• Inserted 2 peripheral IV catheters• Inserted the epidural catheter analgesia for the

management of postoperative pain; local anesthetics have been administered by continuous infusion with:

+ marcaine 0.1mg/kg/h, fentanyl 1μg/kg/h, adrénaline 1/200000mg

• Induction of anesthesia was performed with propofol, fentanyl, rocuronium

• Tracheal intubation with a size 37 of the left-sides Robertshaw tube

• General anesthesia was maintained with sevoflurane 3% (fiO2 50%)

• Inserted a right radial arterial catheter for continuous arterial blood pressure monitoring

• The patient was placed in a left lateral decubitus position

Intra-operative

•The surgeons confirmed good lung isolation after: CO2 insufflation of the pleural cavity:

- pleural pressure of 4 to 6 mm Hg

- basal flow of 3-4 L/min of CO2 

was maintained to ensure lung collapse & optimal visualization

• Adjusted the ventilator settings to VT of 6 mL/kg and respiratory rate of 18 breaths/min

• ETCO2 increased from 35 mm Hg to about 45 mm Hg.

• Surgery proceeded uneventfully for the first 90 minutes

Intra-operative (cont.)

•When the surgeon were dissected the lymph nodes, we observed:

+ a sharp increase in the ETCO2 concentration from 45 mm Hg to 106 mmHg + a gradual decrease in the arterial blood pressure, and lowest at 67/43 mmHg

+ there was insignificant tachycardia + the oxygen saturation did not change significantly

+ the peak inspiratory pressure increased always higher than 30 mm Hg

Intra-operative (cont.)

a sharp increase in the ETCO2 concentration

from 45 mm Hg to 106 mmHg

• The initial thought was possible:+ CO2 or air embolism

+ a major airway injury The gas being insufflated into the right

pleura was being entrained into the airway being sampled by the ETCO2 sensor the inordinately high ETCO2

• The surgical team was informed about the sudden change in the patient’s condition. We then asked the surgeons to consider the possibility of a major airway injury

• At this time, the patient’s VT had decreased from 4 mL/kg to 5 mL/kg and the respiratory rate had increased from 22 to 28 breaths/min

Intra-operative (cont.)

•The instability in the patient’s hemodynamic and ventilatory status continued untill the cause was found:

An iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph nodes

•The bronchoplasty was performed.

Intra-operative (cont.)

A large iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph

nodes

Once the bronchial injury was repaired:

•The patient’s condition continued to improve and the remainder of the intraoperative course was relatively uneventful

•The ETCO2 returned to a normal range of 45 to 50 mm Hg•Arterial blood gas drawn at the end of surgery revealed slight respiratory acidosis (pH = 7.31, PaCO2 = 52 mm Hg, PO2 = 179 mm Hg, HCO3 = 22.5 mmol/L, BE = −3.5)

Intra-operative (cont.)

• The patient was transferred to the intensive care unit at the end of surgery

• The controlled ventilation was performed• Weaning from mechanical ventilation was

successful, extubation at the same evening• The patient was transferred to the

gastroenterology department after 4 days• Patient was discharged from hospital 9 days

later

Post-operative

- REPORT - - REPORT -

The 2nd caseThe 2nd case

• Patient name: Nguyen Xuan Q.+ Sex: male+ Age: 52 years + Weigh: 70kg+ Past medical and surgical history: normal + Presented in hospital due to dysphagia+ ASA physical status II + Diagnosis: oesophagus carcinoma+ Indication: video-assisted endoscopic esophagectomy+ Preanesthetic evaluation: patient's physical conditions

and any other medical problems are covered+ Surgery schedule: 10 March 2014

Pre-operative

• Inserted 2 peripheral IV catheters• Inserted the epidural catheter analgesia for the

management of postoperative pain; local anesthetics have been administered by continuous infusion with marcaine 0.1mg/kg/h, fentanyl 1μg/kg/h, adrénaline 1/200000mg

• Induction of anesthesia was performed with propofol, fentanyl and rocuronium

• Tracheal intubation with a size 39 of the left-sides Robertshaw tube

• General anesthesia was maintained with sevoflurane 3% (fiO2 50%)

• Inserted a right radial arterial catheter for continuous arterial blood pressure monitoring

• The patient was placed in a left lateral decubitus position• The surgeons confirmed good lung isolation after

CO2 insufflation of the pleural cavity. A basal flow of 3-4 L/min of CO2 and pleural pressure of 4 to 6 mm Hg was maintained to ensure lung collapse and optimal visualization

• Adjusted the ventilator settings to VT of 6 mL/kg and respiratory rate of 18 breaths/min

• ETCO2 increased from 35 mm Hg to about 45 mm Hg• Surgery proceeded uneventfully for the first 90 minutes

Intra-operative

•When the surgeon were dissected the lymph nodes, we observed:

+ a sharp increase in the ETCO2 concentration from 46 mm Hg to 67 mmHg + a gradual decrease in the arterial blood pressure, and lowest at 87/53 mmHg

+ there was insignificant tachycardia + the oxygen saturation did not change significantly

+ the peak inspiratory pressure increased always higher than 30 mm Hg

Intra-operative (cont.)

• The initial thought was possible a major airway injury

• The surgical team was informed about the sudden change in the patient’s condition. We then asked the surgeons to consider the possibility of a major airway injury

• At this time, the patient’s VT had decreased from 4 mL/kg to 5 mL/kg and the respiratory rate had increased from 22 to 26 breaths/min

• The instability in the patient’s hemodynamic and ventilatory status continued untill the cause was found:

An iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph nodes

• The bronchoplasty was performed.

Intra-operative (cont.)

An iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph nodes

•Once the bronchial injury was repaired, the patient’s condition continued to improve and the remainder of the intraoperative course was relatively uneventful

•The ETCO2 returned to a normal range of 45 to 50 mm Hg•Arterial blood gas drawn after the patient’s status stabilized revealed mild mixed acidosis (pH = 7.27, PaCO2 = 46.5 mm Hg, PO2 = 129 mm Hg, HCO3 = 16.5 mmol/L, BE = −6.6)

Intra-operative (cont.)

• The patient was transferred to the intensive care unit at the end of surgery

• The controlled ventilation was performed• Weaning from mechanical ventilation was

successful, extubation at the same evening• The patient was transferred to the

gastroenterology department• Patient was discharged from hospital 9 days

later

Post-operative

DISCUSSION DISCUSSION

•These two cases exemplifies an acute life-threatening surgical complication of video-assisted endoscopic esophagectomy, which was first suspected by inordinately increasing ETCO2

•The successful outcome underscores:+ the vigilance of the anesthesia team+ knowledge of the surgical procedure+ close communication with the surgeons

•These two case highlights the role of ETCO2 monitoring in a patient undergoing video-assisted endoscopic esophagectomy

Discussion

Kakodkar PS et al.. Capnography can aid in diagnosis of tracheobronchial injury. Anaesthesia. 2001;56:594–5Shulman D et al. Capnography in the early diagnosis of CO2 embolism during laparoscopy. Can Anaesth Soc J. 1984;31:455–9

•Imperatori A. et al. reported approximately 1100 consecutive video-assisted thoracoscopic surgery cases over a 12-year period identified the most frequent complications were:

+ prolonged air leak+ wound infection+ bleeding+ open thoracotomy

•Prompt diagnosis was aided by the rapid increase in ETCO2 

Imperatori A, Rotolo N, Gatti M, Nardecchia E, De Monte L, Conti V, Dominioni L. Peri-operative complications of video-assisted thoracoscopic surgery (VATS). Int J Surg. 2008;6(Suppl 1):S78–81

Kakodkar PS, Kay NH. Capnography can aid in diagnosis of tracheobronchial injury. Anaesthesia. 2001;56:594–5

Discussion (cont.)

• During video-assisted endoscopic esophagectomy, CO2 pneumothorax is routinely performed to ensure and maintain ipsilateral lung collapse to aid surgical exposure

• Capnothorax is typically accompanied by a moderate increase in ETCO2 and is usually well tolerated by most case and is normally not accompanied by hemodynamic perturbations

• The mild hypercapnia can be remedied by slightly increased respiratory rate

• The moderate-to-severe hypercapnia will cause:+ hypovolemic, hypotension, decrease cardiac output + respiratory acidosis, metabolic acidosis+ tachycardia, pulmonary hypertension

Hsin-Lun Wu et al. Severe carbon dioxide retention during second laparoscopic surgery for urgent repair of an operative defect from the preceding laparoscopic surgery. Acta Anaesthesiol Taiwan. 2008;46(3):124−128

Discussion (cont.)

In the first case,•developed a rapid, supraphysiologic increase in ETCO2 was due to:

a bronchopleural fistula, which produced a direct communication between CO2 being insufflated into the pleura and lung/bronchial tissue. The CO2 was then carried into the ETT in the trachea to the capnometer where high ETCO2 readings were detected

•The progressive hypotension was due to rapidly developing tension pneumothorax

Discussion (cont.)

In the second case,

•moderate increase in ETCO2 was due to: the smaller iatrogenic left lobe bronchial injury

than it in the first case and the bronchial cuff did not slack,

the less direct communication between CO2 being insufflated into the pleura and lung/bronchial tissue,

the less CO2 was then carried into the ETT in the trachea to the capnometer where moderate ETCO2 readings were detected

•The tachycardia, the arterial blood pressure and the oxygen saturation did not change significantly

Discussion (cont.)

Other possible causes of rapidly increasing ETCO2 include:

•malignant hyperthermia•thyroid storm•progressive hypoventilation

•CO2 embolism + in the early phase will cause a decrease in

the ETCO2 due to an increase

in dead space to tidal ventilation (VD/VT).

+ hypotension, cardiac arrhythmias, and pulmonary edema

+ the increased ETCO2  is not as marked as occurred in our case and is usually transient

Shulman D et al. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can Anaesth Soc J. 1984;31:455–9

Discussion (cont.)

SUMMARY SUMMARY

• This report illustrates a rare but potentially lethal intraoperative complication of video-assisted endoscopic esophagectomy.

• Prompt diagnosis was aided by the rapid increase in ETCO2 and communication with the surgeons.

• Capnothorax in video-assisted endoscopic esophagectomy is typically accompanied by the risk of many complications.

• It is essential that anesthetic caregivers are aware that capnothorax is created during video-assisted endoscopic esophagectomy and that rapidly increasing ETCO2 may indicate large airway injury.

Summary

1. Duong Xuan Loc, Hoang Trong Nhat Phuong, Ho Van Linh et al. The efficacy of video-assited endoscopic esophagectomy in Gastroentology Department in Hue Central Hospital. The medicine journal of Ho Chi Minh city. 2009, vol.13, No.6: 266–71

2. Imperatori A, Rotolo N, Gatti M, Nardecchia E, De Monte L, Conti V, Dominioni L. Peri-operative complications of video-assisted thoracoscopic surgery (VATS). Int J Surg. 2008;6(Suppl 1):S78–81

3. Gentili A, Lima M, De Rose R, Pigna A, Codeluppi V, Baroncini S. Thoracoscopy in children: anaesthesiological implications and case reports. Minerva Anestesiol. 2007;73:161–71

4. Kakodkar PS, Kay NH. Capnography can aid in diagnosis of tracheobronchial injury. Anaesthesia. 2001;56:594–5

5. Shulman D, Aronson HB. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can Anaesth Soc J. 1984;31:455–9

6. Hsin-Lun Wu, Kwok-Hon Chan, Mei-Yung Tsou, Chien-Kun Ting. Severe carbon dioxide retention during second laparoscopic surgery for urgent repair of an operative defect from the preceding laparoscopic surgery. Acta Anaesthesiol Taiwan. 2008;46(3):124−128

7. Rothenberg SS. Thoracoscopic pulmonary surgery. Semin Pediatr Surg. 2007;16:231–7

References

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