Rupture of Left Main Bronchus Associated with Radiotherapy-induced Bronchial Injury and Use of a Double-lumen Tube in Oesophageal Cancer Surgery

Abstract

We report a case of rupture of the left main bronchus in a female patient with oesophageal carcinoma, who had received thoracic radiotherapy preoperatively. Endotracheal intubation was achieved with a left-sided double-lumen tube. After almost three hours of intubation and one and half hours of one-lung ventilation, bronchial injury was detected. Immediate surgical repair of the membranous part of the bronchus was undertaken, as well as completion of the oesophagectomy. Radiotherapy-induced damage to the bronchus was thought to have contributed to the rupture. The presentation, diagnosis and management of intraoperative bronchial rupture are discussed.

Management of intra-operative tracheal injuries during transhiatal esophagectomy

“…Radiotherapy weakens the tracheal wall making dissection difficult and trachea vulnerable to damage during blunt dissection [12]. There are many reports and studies of airway injuries during esophagectomy, some with a fatal outcome [8,9,11,13]. In our series, there was no mortality related to airway injury.…”

“…We did not use double lumen endotracheal tube during transhiatal esophagectomy for ventilation; therefore single lumen endotracheal tube was advanced into main bronchus for ventilation in patients who sustained airway injury. Although lung isolation is not necessary in transhiatal esophagectomy, yet cases with tumors in close proximity to the major airway or patients who have undergone radiotherapy may benefit from an electively positioned double lumen endotracheal tube [13].…”

Bronchus perforation by EZ-BlockerTM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation -a case report-

“…The DLT is more rigid and has a larger diameter compared to the SLT with an EB [4]. The disadvantages of the DLT include challenging placement in difficult airway scenarios, inadequate sealing when inappropriately sized, the need for tube exchange when prolonged ventilation is required, and the risk of tracheobronchial injury, or even bronchial rupture [2,4,5]. Tracheobronchial rupture is caused by the larger DLT external diameter compared to the internal diameter of the bronchus, while mainstem bronchus rupture results from overinflation of the tracheal cuff.…”

“…Tracheobronchial rupture is caused by the larger DLT external diameter compared to the internal diameter of the bronchus, while mainstem bronchus rupture results from overinflation of the tracheal cuff. We found two reported cases of rupture of the left main bronchus after radiotherapy with use of a DLT [5,6], and using an SLT with an EB seems to be an interesting alternative. It is more flexible, easier to insert, and leads to less complications compared to using a DLT [2,4].…”

“…The EZ-Blocker TM is advanced through the trachea and placed in the carina under direct bronchoscopic guidance [2–4]. Common complaints with the use of both techniques are hoarseness and sore throat; major complications like airway rupture are very rare, but have also been reported [2,4,5].…”