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Ann Thorac Surg 2006;81:2285-2287
© 2006 The Society of Thoracic Surgeons

Case report

Major Iatrogenic Tracheal Injury During Pneumonectomy: Conservative Treatment

Edoardo Mercadante, MD a , * , Cristiano Giovannini, MD a , Fabio Castaldi, MD a , Roberto Dell'Avanzato, MD a , Settimio Zazza, MD a , Giorgio Andreozzi, MD b , Domenico Curatola, MD b , Massimo Carlini, MD a

a Department of General Abdominal and Thoracic Surgery, S. Eugenio Hospital, Rome, Italy
b Department of Intensive Care Unit, S. Eugenio Hospital, Rome, Italy

Accepted for publication July 11, 2005.

* Address correspondence to Dr Mercadante, Department of General Abdominal and Thoracic Surgery, S. Eugenio Hospital, P.le dell'Umanesimo 10, Rome, 00144 Italy (Email: e.mercadante{at}tiscali.it).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We hereby present the case of a 55-year-old woman with an iatrogenic tracheal laceration that occurred during double lumen intubation for left pneumonectomy. Conservative treatment was performed and the patient was discharged 12 days after surgery. No major sequelae after 3 months of follow-up were observed.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Tracheobronchial laceration is a rare but life-threatening complication of endotracheal intubation [1]. The membranous trachea is the common site of injury, more often near the right angle with rigid cartilaginous rings. In the majority of cases, surgery is advisable (ie, primary closure or tracheal resection); conservative treatment could be considered in selected cases. Some authors [2–4] have proposed a number of criteria for nonoperative treatment, including minimal (< 3 cm) longitudinal lacerations, stable vital signs, no respiratory distress, no esophageal injury, minimal mediastinal fluid collection, no pneumomediastinum or subcutaneous emphysema, or no signs of sepsis.

We hereby report our experience with a case of iatrogenic tracheal injury occurring in a patient undergoing left pneumonectomy.

A 55-year-old woman was admitted to our department with adenocarcinoma of the left main bronchus involving both lobar orifices. The tumor was clinically staged as T3N0M0. Bronchial sleeve resection was not feasible, and the patient was scheduled for a left pneumonectomy. A double lumen Carlens tube was placed without difficulty, and the patient was rotated into the right lateral position. A left pneumonectomy was performed, and the Carlens tube was changed with a single lumen tube. As the patient was admitted into the intensive care unit she had massive hemoptysis. Fiberoptic bronchoscopy revealed a longitudinal laceration of the membranous trachea 7 cm long, from 1.5 cm beyond the cricoid cartilage to 1 cm from the carina directed from the right junction between the cartilaginous and membranous portion to the center of the pars mebranacea. The esophagous and mediastinal fat was visible through the tear. The secretions and blood were aspirated, and the tip of the endotracheal tube was placed distally to the end of the injury with the cuff in the right main bronchus. Figure 1 shows a computed tomographic scan of the chest at the time of diagnosis. No subcutaneous emphysema, respiratory failure, or homodynamic imbalance was observed. Because the patient was stable with no sign of infection, and due to the high anesthesiologic and surgical risk to perform a right thoracotomy after left pneumonectomy, we decided to manage the patient conservatively. A large spectrum of antibiotic therapy was instituted. The correct placement of the endotracheal tube was checked daily. The endotracheal tube was retracted proximally during bronchoscopy to allow endoscopical toilette of the site of injury and topical instillation of antibiotics once per day. On day 3 we instilled fibrin glue through the operative channel of the bronchoscope with a specially designed catheter. Mechanical ventilation continued until day 8 when stable healing of the injury allowed safe extubation. A computed tomographic scan before discharge (see Fig 2) showed the complete obliteration of the left residual pleural space and the radiologic resolution of the complication. Day 10 fibrobronchoscopy did not show any sign of stenosis or tracheomalacia (Figs 3, 4). Go After 3 months, the clinical status of the patient is good without dyspnea, disphagy, cough, or respiratory discomfort.


Figure 1
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  		Fig 1. Day 1 computed tomographic scan showing tube in the right main bronchus (arrow).

 

Figure 2
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  		Fig 2. Day 12 computed tomographic scan of the left pleural space obliteration; esophagus with contrast (asterisk). No mediastinal collection.

 

Figure 3
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  		Fig 3. Day 10 fiberoptic bronchoscopy shows origin of proximal tear (black arrow). White arrows indicate lateral margins.

 

Figure 4
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  		Fig 4. Day 10 fiberoptic bronchoscopy shows origin of distal tear, left bronchial stump, and right main bronchus (arrows).

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Tracheobronchial laceration is a rare complication of endotracheal intubation and the reported incidence after the Carlens tube placement is less than 1% [5]. Clinical symptoms like mediastinal or subcutaneous emphysema, hemoptysis, or pneumothorax appeared soon after mechanical ventilation, which allowed for early diagnosis. In these circumstances, fiberoptic bronchoscopy and conventional chest roentgenogram are considered the main tools for diagnosis. Prompt therapeutic maneuvers are required to prevent complications such as tension pneumothorax, respiratory failure, mediastinitis, and sepsis or tracheal strictures. Surgical treatment is usually required and reconstruction may be performed through a right thoracotomy or cervicothomy. Recently an anterior cervicotomy for distal membranous tracheal repair has been proposed [6].

A number of authors suggest conservative treatment for a selected group of patients with small uncomplicated tracheobronchial laceration (< 3 to 4 cm) [2–4, 7]. However, the international literature does not report any case of huge (> 6 cm) tracheal tear managed conservatively. In the case that we described, the extension of the tear would have required a right thoracotomy potentially associated with a cervicothomy. Due to the left pneumonectomy, the patient would have been unable to tolerate right lung collapse; for these reasons we chose to pursue a conservative approach. In these situations it is of paramount importance to keep the tracheal lumen clean with repeated aspiration through the fiberoptic bronchoscope; the reaction healing of mediastinal tissue can be controlled by computed tomographic scan. We believe that success was due to the careful evaluation of the patient's clinical status and the monitoring of the healing process in this case. Hofmann and colleagues [8] have previously described the endoscopical use of fibrin glue for a small (1 cm) tracheal tear, but other authors consider the instillation of glue as unnecessary and even potentially dangerous [4]. We are not able to add additional information to previous reports because our experience is only with a single case.

Surgical management remains the treatment of choice of these iatrogenic lesions because it allows prompt repair of the injury with a low surgical risk and a relatively short recovery time. Nevertheless, nonsurgical management should be considered a viable option in high surgical risk patients, not only for minimal tracheal tears but also for major tracheal injuries.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Roxburgh JC. Rupture of the tracheobronchial tree Thorax 1987;42:681-688.[Abstract/Free Full Text]
  2. Jougon J, Ballester M, Choukroun E, Dubrez J, Reboul G, Velly JF. Conservative treatment for post intubation tracheobronchial rupture Ann Thorac Surg 2000;69:216-220.[Abstract/Free Full Text]
  3. Ross HM, Grant FJ, Wilson RS, Burt ME. Nonoperative management of tracheal laceration during endotracheal intubation Ann Thorac Surg 1997;63:240-242.[Abstract/Free Full Text]
  4. Lampl L. Tracheobronchial injuries. Conservative treatment Interact Cardiovasc Thorac Surg 2004;3:401-405.[Abstract/Free Full Text]
  5. Spaggiari L, Rusca M, Carbognani P, Solli P. Tracheobronchial laceration after double lumen intubation for thoracic procedures Ann Thorac Surg 1998;65:1837-1838.[Free Full Text]
  6. Angelillo-Mackinlay T. Transcervical repair of distal membranous tracheal laceration Ann Thorac Surg 1995;59:531-532.[Abstract/Free Full Text]
  7. d'Odemont JP, Pringot J, Goncette L, Goenen M, Rodenstein DO. Spontaneous favorable outcome tracheal laceration Chest 1991;99:1290-1292.[Medline]
  8. Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of tracheobronchial tree Eur J Cardio-Thor Surg 2002;21:649-652.[Abstract/Free Full Text]



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