7/27/2019 Trachea Rupture and Tension Pneumoperitonium

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Tension Pneumoperitoneum from Tracheal Tear DuringPharyngolaryngoesophagectomyAdarsh B. Lal, FFARCSI, Diplomate NB, Naresh Kumar, FRCS, and Khalid A. Sami, MDDepartment of Anesthesiology, King Faisal Specialis t Hospital and Research Centre, Riyadh, Saudi Arabia

T nsion pneumoperitoneum is a rare butwell-established clin ical entity (1). This life-threatening complication has been reportedafter gastrointestinal hollow viscus rupture (1,2), car-diopulmonary resuscitation (3), barotrauma due tohigh-pressure ventilat ion in respiratory distress syn-drome (4), and urologic procedures (5). We report herea case of tension pneumoperitoneum developing sec-ondary to a tracheal tear following abdominocervi-cal pharyngolaryngoesophagectomy with successfulmanagement.

Case ReportA 33-yr-old female patient (ASA Grade I), with post-cricoid carcinoma presented for pharyngolaryngoe-sophagectomy with gastric pull-up operation. She hadhad an uneventful endoscopy, biopsy, and tracheos-tomy performed a week earlier.

After premeditation with morphine 7.5 mg and sco-polamine 0.3 mg, the usual monitoring plus intraarte-rial pressure moni toring were instituted. Anesthesiawas induced with fentanyl 0.1 mg and propofol 100mg intravenously (IV), and intermittent positive pres-sure vent ilation commenced after skeletal muscle pa-ralysis was induced with IV atracurium. The in situfenestrated rigid tracheostomy tube was changed to acuffed flexometallic tracheostomy tube (size 6, Laryn-goflex@ tube, Rusch, Kernen, West Germany) and thepeak inflation pressure was 20 cm H,O. Anesthesiawas mainta ined with 1% isoflurane in a 35%oxygen/nitrous oxide mixture and intermittent IV in-jections of fentanyl. A right subclavian double lumencentral venous line was inserted without problems tomonitor the central venous pressure. Temperatureand urinary output were monitored throughout the

Accep ted for publication September 20, 1994.Address correspondence to Adarsh B. Lal, FFARCSI, Diplomate

NB, Department of Anesthes iology, MBC No. 22, Kini Fa&al Spe-cialis t Hospital and Research Centre, P.O. Box 3354, Riyadh 11211,Saudi Arabia.

408 Anesth Analg 1995;80:408-9

procedure. An epidural catheter was inserted at theL2-3 leve l for postoperative analgesia. Hourly analy-ses of arteria l blood gases were performed during theprocedure and were unremarkable.

After pharyngolaryngectomy, the esophagus wasmobilized by an abdominal, transhiatal approach andthe stomach pulled up into the neck. The abdominalincision was closed after placing closed tube suctiondrains and the pharyngeal reconstruction was com-pleted with a stomach tube. The entire procedure wasuneventful and the operation completed. Before dress-ing the wounds, the laryngoflex tube was changed toa cuffed rigid tracheostomy tube. The inflation pres-sures started to increase, and it was becoming increas-ingly difficult to ventilate the patient. The inflationpressures were over 60 cm H,O. The oxygen satura-tion decreased to 40% despite increasing fractionalinspired oxygen concentration to 1.0, and the arterialblood pressure decreased to 40 mm Hg. The patienthad developed severe distention of the abdomen. Adiagnosis of tension pneumoperitoneum was made.This was relieved by applying continuous open suc-tion to the abdominal drains, which were unti l thenconnected to a closed suction system. The clin ical pic-ture rapidly improved. A chest radiograph taken atthis time revealed a right-sided pneumothorax, and achest tube was inserted.

A rigid bronchoscopy, performed through the tra-cheostomy, revealed a longitudinal tear of the tracheain the posterior membranous part, 2 cm above thecarina. The cervical wound was reopened, and a ster-nomastoid flap was turned down between the tracheaand the stomach tube. On the patients arrival in theintensive care unit, a radiograph revealed the devel-opment of a left-sided pneumothorax requiring a chesttube and underwater seal. The patient was vent ilatedfor a day with low-pressure inf lation of the cuff toprevent recurrence of the leak. Although contro lledvent ilation was terminated, she required pressure-supported spontaneous vent ilation for four moredays. The patient recovered from the procedure with-out further events and was discharged home.

01995 by the International Anesthesia Research S ociety0003-2999/95/$5.00

7/27/2019 Trachea Rupture and Tension Pneumoperitonium

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ANESTH ANALG1995;80:408-9 CASE REPORTS 409

DiscussionTension pneumoperitoneum is a rare but life-threat-ening complication characterized by acute massivedistention of the abdomen not resolving with gas-tric drainage and causing severe cardiorespiratoryembarrassment.

The incidence of tracheal tear as a complication ofpharyngolaryngoesophagectomy has been reported atl%-10% (6-8). The potentia lly letha l complications oftracheal rupture have been reported as tension pneu-mothorax, mediast initis, tracheal stricture, and respi-ratory failure (9). However, no case of tension pneu-moperitoneum developing as a result of this tear hasbeen reported. In our patient, the tension pneumoperi-toneum developed at the end of the procedure afterthe flexometallic tracheostomy tube had been changedto a rigid tracheostomy tube. The tracheal tear proba-bly occurred during the esophageal dissection andwas unmasked during the changing of the tracheos-tomy tubes, as no difficulty was experienced duringthe changing of the tubes. The gases tracked down thepassage created by the transhiatal dissection of theesophagus and into the peritoneal cavity.

The consequences of increased intraabdominal pres-sure from ascitic fluid have been well documented(10,ll) . The hypotension caused by tension pneumo-peritoneum has been shown to be due to decreasedvenous return from caval compression, and the rise inintrathoracic pressure transmitted from the abdomenfurther contributes to hypotension (12).Tracheal rupture as a direct complication of trachealintubation has been described. Overinflation of thecuff has been implicated in most of these cases (9).Blunt dissection during pharyngolaryngoesophagec-tomy against a distended cuff has been suggested as acause of tracheal tears. It has been advocated that thecuff be deflated during this dissection and to avoid theuse of cuffed tracheostomy tubes in the postoperativeperiod (13). During pharyngolaryngoesophagectomy,with the removal of the esophagus, the posteriormembranous part of the trachea becomes weak andunsupported. Hence, it is more vulnerable to pres-sures from the cuff of endotracheal tubes. It has beenrecommended that the cuff pressures be kept to theminimum and that anesthetic gas mixtures, and notair, be used to inflate the cuff (9).

Management of this life-threatening complication isof similar urgency to the management of a tensionpneumothorax. Even though our patient had abdom-ina l drain tubes, the tubes were connected to closed-suction bottles. Once the diagnosis of tension pneu-moperitoneum was made, the drains were connectedto open continuous suction, relieving the tensionpneumoperitoneum. A wide-bore needle, trocar, orlarge chest tube have been used to decompress the

peritoneum (14). The tracheal tears have been vari-ously managed with primary repair and with fascialata, pericardium, or polytetrafluoroethylene (PTFE)patches (12). A technique for repair of such injuriesusing intercostal muscle flap has been described (15).We used an interposed sternocleidomastoid flap forrepair.

Ventilat ion can be a major problem in these cases.This is managed by: a single lumen endotracheal tubeinserted beyond the tear; a single endobronchial tubeor two endobronchial tubes-one into each main stembronchus; high-frequency positive pressure ventila-tion or high-frequency jet ventilat ion (16). We wereable to use the first option.

Tension pneumoperitoneum remains a rare but life-threatening complication which can be managedswiftly and easily, provided the possibility of thiscondition is kept in mind.

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