- Case Report
A 78-year-old male with a history of coronary artery disease, angina pectoris, and hypercholesterolemia was diagnosed with a cT3N2M0 adenocarcinoma of the distal esophagus. After neoadjuvant chemoradiation (41.4 Gy in 23 fractions with 5 weeks of Carboplatin and Paclitaxel), a minimally invasive transthoracic esophagectomy according to Ivor Lewis was scheduled. A preoperative PET-CT scan showed no detectable change in the mainstem bronchus.
The operation was performed under general anesthesia with antibiotic prophylaxis. To achieve OLV, an SLT was used in combination with an EZ-BlockerTM EB. Before insertion, the head of the patient was placed in the midline position. The endotracheal tube was withdrawn under direct vision using fiberoptic bronchoscopy until it was 4 cm above the carina. After connecting the multiport adapter, the EZ-BlockerTM EB was advanced with deflated cuffs and positioned at the carina under direct bronchoscopic guidance. The right cuff was inflated, deflated, and marked. The volume of air required to inflate the cuff was noted.
During the laparoscopic phase in the supine position, a standard lymph node dissection was performed. Next, the gastric conduit was created and a feeding jejunostomy tube was placed. The patient was then placed in the prone position for the thoracoscopic phase of the operation. While turning the patient, the cuffs of the EZ-Blocker
TM EB were kept deflated to reduce the risk of traumatic complications. The position of the EZ-Blocker
TM EB was rechecked after turning the patient, but bronchoscopic inspection was more difficult with the patient in the prone position because of an excessive central airway collapse below the level of the tube. At the start of the thoracoscopic stage of the surgery, two-lung ventilation was supplied with pressure-controlled ventilation using low driving pressures, with the following ventilator settings: tidal volume (Vt), 300 ml; respiratory rate (RR), 20 /min; peak pressure (P
max), 14 cmH
2O; positive end-expiratory pressure (PEEP), 3 cmH
2O; and fraction of inspired oxygen (FiO
2), 0.85. The patient was hemodynamically stable. A pneumothorax was created by insufflation of carbon dioxide at a maximal pressure of 7 mmHg. The inferior pulmonary ligament was divided. After opening the pleura towards the right mainstem bronchus, the tip of the EB unexpectedly came into view, perforating the bronchus (
Fig. 3). The esophageal dissection was completed and the resection specimen was stapled to the gastric conduit; the proximal esophagus was transected near the thoracic inlet.
A bronchoscopy was performed via the endotracheal tube. Both distal extensions of the EB appeared to be in the right mainstem bronchus. The left arm of the Y-shaped tip was perforating the bronchus 4–5 cm distal to the carina, and the right arm was positioned more distal, intraluminal in the ostium of the right lower lobe bronchus.
The SLT was exchanged for a 39 French left-sided DLT with the perforating EB still in place. The patient was positioned in the left lateral decubitus position. The right mainstem bronchus was selectively blocked. The ventilator settings were: Vt, 240 ml; RR, 16 /min; P
max, 21 cmH
2O; PEEP, 8; FiO
2, 0.80. The patient remained hemodynamically stable. A right posterolateral muscle-sparing thoracotomy was performed. The mediastinal pleura was opened near the carina, after which the EZ-Blocker
TM EB was identified perforating the pars membranacea on the dorsal aspect of the right mainstem bronchus (
Fig. 4). The perforating EB was removed by the anesthesiologist under direct vision. The resulting bronchial defect of approximately 2 mm was closed primarily using interrupted 3-0 polydioxanone (PDS
Ⓡ, Ethicon, Johnson & Johnson, the Netherlands) sutures. Air tightness was confirmed with an underwater test. The closed defect was covered with an intercostal muscle flap for extra protection of the vulnerable irradiated tissue. To diminish the risk of postoperative complications, no anastomosis was made. An end cervical left-sided esophagostomy was performed with the intention of reconstructing the gastric conduit at a later stage. The patient was extubated directly post-surgery.
A backup plan in the event of a respiratory insufficiency consisted of selective left mainstem bronchial intubation, followed by OLV of the left lung with lung-protective ventilation using low tidal volumes, higher PEEP levels, and low driving pressures. The patient recovered well and was discharged on day 14.
A follow-up PET scan 2.5 months after surgery unfortunately showed adrenal and chest wall metastases. After consulting the patient and family, it was decided to start palliative radiation therapy and to renounce further surgical procedures.