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
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
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
