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BBRROONNCCHHOOPPLLEEUURRAALL FFIISSTTUULLAA DDUURRIINNGG VVIIDDEEOO -- AASSSSIISSTTEEDD 
EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY PPRROOCCEEDDUURREE 
– REPORT OF TWO CASES 
NNgguuyyeenn TThhii TThhaannhh HHuuoonngg 
DDEEPPTT OOFF AANNAAEESSTTHHEESSIIOOLLOOGGYY && CCRRIITTIICCAALL CCAARREE BB 
HHUUEE CCEENNTTRRAALL HHOOSSPPIITTAALL 
HHuuee CCeennttrraall HHoossppiittaall
VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY 
Introduction 
• 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. Se m in Pe d ia tr 
Surg . 2007;16:231–7 
http : //www. la p a ro s c o p ic e x p e rts . c o m /e s o pha g e c to m y . htm l
VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY 
Introduction 
http : //www. la p a ro s c o p ic e x p e rts . c o m /e s o pha g e c to m y . htm • However, anesthetic technique for 
this type of surgery is difficult 
+ intraoperative complications may occur 
+ requiring the anesthesiologist must have 
expertise and experience 
+ well-equipment monitors
VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY 
Objectives 
• 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
-- RREEPPOORRTT -- 
TThhee 11sstt ccaassee
Pre-operative 
•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
Barium esophagram demonstrates an change in the caliber and 
contour of the esophagus caused by an irregular circumferential 
stricture containing focal ulcerations
Intra-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, 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 (cont.) 
•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
a sharp increase in the ETCO2 concentration 
from 45 mm Hg to 106 mmHg
Intra-operative (cont.) 
•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 5mL/k g 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.
A large iatrogenic left lobe bronchial injury when the 
surgeon were dissected the lymph nodes
Intra-operative (cont.) 
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)
Post-operative 
•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
-- RREEPPOORRTT -- 
TThhee 22nndd ccaassee
Pre-operative 
•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
Intra-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 (cont.) 
•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 5mL/k g 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.
An iatrogenic left lobe bronchial injury when the surgeon were 
dissected the lymph nodes
Intra-operative (cont.) 
•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)
Post-operative 
•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
DDIISSCCUUSSSSIIOONN
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 
Ka ko dka r PS e t a l. . Ca p no g ra phy c a n a id in d ia g no s is o f tra che o bro nchia l injury . 
Ana e s the s ia . 2 0 0 1 ; 5 6 : 5 9 4– 5 
Shulm a n D e t a l. Ca p no g ra phy in the e a rly d ia g no s is o f CO 2 e m bo lism during la p a ro s c o p y . 
Ca n Ana e s th So c J. 1 9 8 4; 3 1 : 45 5 – 9
Discussion (cont.) 
•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 
Im p e ra to ri A, Ro to lo N, G a tti M, Na rd e c chia E, De Mo nte L, Co nti V, Do m inio ni L. 
Pe ri-o p e ra tive c o m p lic a tio ns o f vid e o -a s s is te d tho ra c o s c o p ic s urg e ry (VATS). Int J 
Surg . 2 0 0 8 ; 6 (Sup p l 1 ): S7 8 – 8 1 
•Prompt diagnosis was aided by the rapid increase in 
ETCO2 
Ka ko dka r PS, Ka y NH. Ca p no g ra phy c a n a id in d ia g no s is o f tra che o bro nchia l injury . 
Ana e s the s ia . 2 0 0 1 ; 5 6 : 5 9 4– 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 Hs in-Lun Wu e t a l. Se ve re c a rbo n d io x id e re te ntio n during s e c o nd la p a ro s c o p ic s urg e ry fo r 
urg e nt re p a ir o f a n o p e ra tive d e fe c t fro m the p re c e d ing la p a ro s c o p ic s urg e ry . Ac ta 
Ana e s the s io l Ta iwa n. 2 0 0 8 ; 46 (3 ): 1 24−1 2 8
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 
Shulm a n D e t a l. Ca p no g ra phy in the e a rly d ia g no s is o f c a rbo n d io x id e 
e m bo lism during la p a ro s c o p y . Ca n Ana e s th So c J. 1 9 8 4; 3 1 : 45 5 – 9 
usually transient
SSUUMMMMAARRYY
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.
References 
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
TTHHAANNKK YYOOUU 
FFOORR YYOOUURR AATTTTEENNTTIIOONN TTOO TTHHIISS 
MMAATTTTEERR

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Nguyen t thanh huong ta

  • 1. BBRROONNCCHHOOPPLLEEUURRAALL FFIISSTTUULLAA DDUURRIINNGG VVIIDDEEOO -- AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY PPRROOCCEEDDUURREE – REPORT OF TWO CASES NNgguuyyeenn TThhii TThhaannhh HHuuoonngg DDEEPPTT OOFF AANNAAEESSTTHHEESSIIOOLLOOGGYY && CCRRIITTIICCAALL CCAARREE BB HHUUEE CCEENNTTRRAALL HHOOSSPPIITTAALL HHuuee CCeennttrraall HHoossppiittaall
  • 2. VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY Introduction • 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. Se m in Pe d ia tr Surg . 2007;16:231–7 http : //www. la p a ro s c o p ic e x p e rts . c o m /e s o pha g e c to m y . htm l
  • 3. VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY Introduction http : //www. la p a ro s c o p ic e x p e rts . c o m /e s o pha g e c to m y . htm • However, anesthetic technique for this type of surgery is difficult + intraoperative complications may occur + requiring the anesthesiologist must have expertise and experience + well-equipment monitors
  • 4. VVIIDDEEOO--AASSSSIISSTTEEDD EENNDDOOSSCCOOPPIICC EESSOOPPHHAAGGEECCTTOOMMYY Objectives • 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
  • 5. -- RREEPPOORRTT -- TThhee 11sstt ccaassee
  • 6. Pre-operative •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
  • 7. Barium esophagram demonstrates an change in the caliber and contour of the esophagus caused by an irregular circumferential stricture containing focal ulcerations
  • 8. Intra-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, 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
  • 9. Intra-operative (cont.) •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
  • 10. 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
  • 11. a sharp increase in the ETCO2 concentration from 45 mm Hg to 106 mmHg
  • 12. Intra-operative (cont.) •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 5mL/k g and the respiratory rate had increased from 22 to 28 breaths/min
  • 13. 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.
  • 14. A large iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph nodes
  • 15. Intra-operative (cont.) 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)
  • 16. Post-operative •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
  • 17. -- RREEPPOORRTT -- TThhee 22nndd ccaassee
  • 18. Pre-operative •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
  • 19. Intra-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
  • 20. Intra-operative (cont.) •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
  • 21. 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 5mL/k g 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.
  • 22. An iatrogenic left lobe bronchial injury when the surgeon were dissected the lymph nodes
  • 23. Intra-operative (cont.) •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)
  • 24. Post-operative •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
  • 26. 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 Ka ko dka r PS e t a l. . Ca p no g ra phy c a n a id in d ia g no s is o f tra che o bro nchia l injury . Ana e s the s ia . 2 0 0 1 ; 5 6 : 5 9 4– 5 Shulm a n D e t a l. Ca p no g ra phy in the e a rly d ia g no s is o f CO 2 e m bo lism during la p a ro s c o p y . Ca n Ana e s th So c J. 1 9 8 4; 3 1 : 45 5 – 9
  • 27. Discussion (cont.) •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 Im p e ra to ri A, Ro to lo N, G a tti M, Na rd e c chia E, De Mo nte L, Co nti V, Do m inio ni L. Pe ri-o p e ra tive c o m p lic a tio ns o f vid e o -a s s is te d tho ra c o s c o p ic s urg e ry (VATS). Int J Surg . 2 0 0 8 ; 6 (Sup p l 1 ): S7 8 – 8 1 •Prompt diagnosis was aided by the rapid increase in ETCO2 Ka ko dka r PS, Ka y NH. Ca p no g ra phy c a n a id in d ia g no s is o f tra che o bro nchia l injury . Ana e s the s ia . 2 0 0 1 ; 5 6 : 5 9 4– 5
  • 28. 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 Hs in-Lun Wu e t a l. Se ve re c a rbo n d io x id e re te ntio n during s e c o nd la p a ro s c o p ic s urg e ry fo r urg e nt re p a ir o f a n o p e ra tive d e fe c t fro m the p re c e d ing la p a ro s c o p ic s urg e ry . Ac ta Ana e s the s io l Ta iwa n. 2 0 0 8 ; 46 (3 ): 1 24−1 2 8
  • 29. 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
  • 30. 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
  • 31. 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 Shulm a n D e t a l. Ca p no g ra phy in the e a rly d ia g no s is o f c a rbo n d io x id e e m bo lism during la p a ro s c o p y . Ca n Ana e s th So c J. 1 9 8 4; 3 1 : 45 5 – 9 usually transient
  • 33. 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.
  • 34. References 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
  • 35. TTHHAANNKK YYOOUU FFOORR YYOOUURR AATTTTEENNTTIIOONN TTOO TTHHIISS MMAATTTTEERR