Independent lung ventilation combined with HFOV for a patient suffering from tracheo-gastric roll fistula

Abstract

lation with a large tidal volume or high peak pressure should be avoided. By contrast, unexpected hypoventilation may occur because of air leakage from the fi stula. Furthermore, the size and location of the fi stula may vary, and therefore the method of treatment may also vary; no optimal treatment strategy has been established. This complication happens rarely after the surgical treatment of esophageal cancer, but it can be fatal. In general, it is necessary to perform an urgent surgical procedure even in the presence of adverse conditions such as systemic infl ammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), and malnutrition.The present report describes the perioperative respiratory management, using independent lung ventilation (ILV) combined with high-frequency oscillation ventilation (HFOV), while thoracotomy was performed for a patient suffering from ARDS and SIRS caused by a tracheo-gastric roll fi stula. Case reportA 62-year-old man with mid-lower esophageal cancer underwent resection and reconstruction of the esophagus, with the use of a gastric roll through the posterior mediastinum. He was extubated on day 1 after the surgery, however, pneumonia in the right lung continued for more than 1 week and the bronchoscope examination revealed edema in the trachea and the right main bronchus. On day 20, he complained of respiratory distress and the trachea was re-intubated. A chest X-ray revealed obvious infi ltrations in the right lower lobe and scattered infi ltrations in the left lung. Tracheal suction fl uid contained gastric contents, and a tracheo-gastric roll fi stula was discovered 2 cm above the carina. Blood tests revealed a white blood cell count of 18 500/μl, Creactive protein, 27 mg·dl −1 and a Pa O 2 /FI O 2 (P/F) ratio of 150 mmHg; SIRS and ARDS were also diagnosed. To Abstract This case report describes the diffi cult respiratory management of an esophageal cancer patient with acute respiratory distress syndrome (ARDS) and systemic infl ammatory response syndrome (SIRS) caused by a postoperative tracheogastric roll fi stula. A single-lumen tracheal tube could not seal the fi stula, and therefore a double-lumen tracheal tube (DLT) for the left side was used. Although the proximal cuff of the DLT failed to seal the fi stula, independent lung ventilation (ILV) improved blood gas levels. During right thoracotomy, the left lung was ventilated conventionally with 5 cmH 2 O positive end-expiratory pressure (PEEP), and in addition, highfrequency oscillation ventilation (HFOV) to the right lung was employed. This combination allowed the maintenance of adequate oxygenation, and the HFOV to the right lung decreased the Pa CO 2 level during surgery without interruption of the surgical fi eld. These techniques provided the opportunity to successfully remove a necrotic gastric roll and achieve closure of the fi stula using an intercostal muscle fl ap. This report documents and discusses the diffi culty of performing appropriate anesthetic management of a patient with these compl...

Anesthetic Approach for Endoscopic Repair of Acquired Tracheoesophageal Fistula

“…The use of double lumen tube (DLT) for lung isolation with high frequency oscillation ventilation has been described for optimizing gas exchange in a patient with a low tracheal TEF and acute respiratory distress syndrome. 4…”

“…The use of double lumen tube (DLT) for lung isolation with high frequency oscillation ventilation has been described for optimizing gas exchange in a patient with a low tracheal TEF and acute respiratory distress syndrome. 4 In patients with TEF, a rapid sequence induction, with general anesthesia and endotracheal intubation is advised. Anatomic position of the fistula in the respiratory tract can guide the anesthetic plan for airway management and ventilation.…”

“…Five minutes after the start of endoscopy, a massive air leak in the ventilator circuit with a drop in tidal Seminars in Cardiothoracic and Vascular Anesthesia 21 (4) volume and inability to ventilate the patient occurred. Immediately, FiO 2 was changed to 100% and the gas flow was increased while manual ventilation was initiated.…”

Intra- and Extrathoracic Malignant Tracheoesophageal Fistula—A Differentiated Reconstructive Algorithm

“…Furthermore, the clearance of bronchial secretions by bronchoscopy supports the healing of flaps. Prolonged side selective ventilation was performed in patients with bronchial fistulation to facilitate flap healing [25][26][27].…”