Tension Pneumoperitoneum Pharyngolaryngoesophagectomy

Adarsh B. Lal, FFARCSI, Diplomate

NB, Department of Anesthesiology,

from Tracheal

Tear During
A. Sami, MD

Naresh Kumar, FRCS, and Khalid

King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

ension pneumoperitoneum is a rare but well-established clinical entity (1). This lifecomplication has been reported threatening after gastrointestinal hollow viscus rupture (1,2), cardiopulmonary resuscitation (3), barotrauma due to high-pressure ventilation in respiratory distress syndrome (4), and urologic procedures (5). We report here a case of tension pneumoperitoneum developing secondary to a tracheal tear following abdominocervical pharyngolaryngoesophagectomy with successful management.

Case Report
A 33-yr-old female patient (ASA Grade I), with postcricoid carcinoma presented for pharyngolaryngoesophagectomy with gastric pull-up operation. She had had an uneventful endoscopy, biopsy, and tracheostomy performed a week earlier. After premeditation with morphine 7.5 mg and scopolamine 0.3 mg, the usual monitoring plus intraarterial pressure monitoring were instituted. Anesthesia was induced with fentanyl 0.1 mg and propofol 100 mg intravenously (IV), and intermittent positive pressure ventilation commenced after skeletal muscle paralysis was induced with IV atracurium. The in situ fenestrated rigid tracheostomy tube was changed to a cuffed flexometallic tracheostomy tube (size 6, Laryngoflex@ tube, Rusch, Kernen, West Germany) and the peak inflation pressure was 20 cm H,O. Anesthesia was maintained with 1% isoflurane in a 35% oxygen/nitrous oxide mixture and intermittent IV injections of fentanyl. A right subclavian double lumen central venous line was inserted without problems to monitor the central venous pressure. Temperature and urinary output were monitored throughout the
Accepted for publication September 20, 1994. Address correspondence to Adarsh B. Lal, FFARCSI, Diplomate NB, Department of Anesthesiology, MBC No. 22, Kini Fa&al Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia.

procedure. An epidural catheter was inserted at the L2-3 level for postoperative analgesia. Hourly analyses of arterial blood gases were performed during the procedure and were unremarkable. After pharyngolaryngectomy, the esophagus was mobilized by an abdominal, transhiatal approach and the stomach pulled up into the neck. The abdominal incision was closed after placing closed tube suction drains and the pharyngeal reconstruction was completed with a stomach tube. The entire procedure was uneventful and the operation completed. Before dressing the wounds, the laryngoflex tube was changed to a cuffed rigid tracheostomy tube. The inflation pressures started to increase, and it was becoming increasingly difficult to ventilate the patient. The inflation pressures were over 60 cm H,O. The oxygen saturation decreased to 40% despite increasing fractional inspired oxygen concentration to 1.0, and the arterial blood pressure decreased to 40 mm Hg. The patient had developed severe distention of the abdomen. A diagnosis of tension pneumoperitoneum was made. This was relieved by applying continuous open suction to the abdominal drains, which were until then connected to a closed suction system. The clinical picture rapidly improved. A chest radiograph taken at this time revealed a right-sided pneumothorax, and a chest tube was inserted. A rigid bronchoscopy, performed through the tracheostomy, revealed a longitudinal tear of the trachea in the posterior membranous part, 2 cm above the carina. The cervical wound was reopened, and a sternomastoid flap was turned down between the trachea and the stomach tube. On the patients arrival in the intensive care unit, a radiograph revealed the development of a left-sided pneumothorax requiring a chest tube and underwater seal. The patient was ventilated for a day with low-pressure inflation of the cuff to prevent recurrence of the leak. Although controlled ventilation was terminated, she required pressuresupported spontaneous ventilation for four more days. The patient recovered from the procedure without further events and was discharged home.
01995 by the International Anesthesia Research Society 0003-2999/95/$5.00

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Anesth

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1995;80:408-9

ANESTH ANALG 1995;80:408-9

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Discussion
Tension pneumoperitoneum is a rare but life-threatening complication characterized by acute massive distention of the abdomen not resolving with gastric drainage and causing severe cardiorespiratory embarrassment. The incidence of tracheal tear as a complication of pharyngolaryngoesophagectomy has been reported at l%-10% (6-8). The potentially lethal complications of tracheal rupture have been reported as tension pneumothorax, mediastinitis, tracheal stricture, and respiratory failure (9). However, no case of tension pneumoperitoneum developing as a result of this tear has been reported. In our patient, the tension pneumoperitoneum developed at the end of the procedure after the flexometallic tracheostomy tube had been changed to a rigid tracheostomy tube. The tracheal tear probably occurred during the esophageal dissection and was unmasked during the changing of the tracheostomy tubes, as no difficulty was experienced during the changing of the tubes. The gases tracked down the passage created by the transhiatal dissection of the esophagus and into the peritoneal cavity. The consequences of increased intraabdominal pressure from ascitic fluid have been well documented (10,ll). The hypotension caused by tension pneumoperitoneum has been shown to be due to decreased venous return from caval compression, and the rise in intrathoracic pressure transmitted from the abdomen further contributes to hypotension (12). Tracheal rupture as a direct complication of tracheal intubation has been described. Overinflation of the cuff has been implicated in most of these cases (9). Blunt dissection during pharyngolaryngoesophagectomy against a distended cuff has been suggested as a cause of tracheal tears. It has been advocated that the cuff be deflated during this dissection and to avoid the use of cuffed tracheostomy tubes in the postoperative period (13). During pharyngolaryngoesophagectomy, with the removal of the esophagus, the posterior membranous part of the trachea becomes weak and unsupported. Hence, it is more vulnerable to pressures from the cuff of endotracheal tubes. It has been recommended that the cuff pressures be kept to the minimum and that anesthetic gas mixtures, and not air, be used to inflate the cuff (9). Management of this life-threatening complication is of similar urgency to the management of a tension pneumothorax. Even though our patient had abdominal drain tubes, the tubes were connected to closedsuction bottles. Once the diagnosis of tension pneumoperitoneum was made, the drains were connected to open continuous suction, relieving the tension pneumoperitoneum. A wide-bore needle, trocar, or large chest tube have been used to decompress the

peritoneum (14). The tracheal tears have been variously managed with primary repair and with fascia lata, pericardium, or polytetrafluoroethylene (PTFE) patches (12). A technique for repair of such injuries using intercostal muscle flap has been described (15). We used an interposed sternocleidomastoid flap for repair. Ventilation can be a major problem in these cases. This is managed by: a single lumen endotracheal tube inserted beyond the tear; a single endobronchial tube or two endobronchial tubes-one into each main stem bronchus; high-frequency positive pressure ventilation or high-frequency jet ventilation (16). We were able to use the first option. Tension pneumoperitoneum remains a rare but lifethreatening complication which can be managed swiftly and easily, provided the possibility of this condition is kept in mind.

References
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