INTRODUCTION: Complications following transhiatal esophagectomy include pneumonia, recurrent laryngeal nerve injury and anastomotic leak. Although damage to the trachea is a potential complication, there are minimal reports of tracheal compression following esophagectomy with gastric pull-through. We report a case of severe tracheal compression and obstruction requiring mechanical ventilation presenting two days post operatively. Placement of a silicone tracheal stent relieved the obstruction in the distal trachea.
CASE PRESENTATION: A 61-year-old male initially presented with a several month history of epigastric pain. Upper endoscopy revealed a mass at the gastroesophageal junction and biopsy confirmed adenocarcinoma; the patient was staged with endoscopic ultrasound and found to have T3N1 disease. The patient was treated with neoadjuvant chemoradiation prior to surgical resection. The patient underwent an uneventful transhiatal esophagectomy. He was extubated shortly after the surgery without any immediate complications. On hospital day two, the patient developed marked respiratory distress, dyspnea and tachypnea requiring endotracheal intubation. A chest CT was performed which showed severe narrowing of the distal trachea with compressive effect of the posterior membrane from the neoesophagus without overt evidence of hematoma. The proximal mainstem bronchi also appeared to be narrowed. No evidence of tracheobronchomalacia was seen on preoperative imaging. A bronchoscopy was performed that verified severe tracheal obstruction. The trachea appeared slitlike in appearance with a mostly fixed posterior membrane causing near total occlusion of the trachea with respiration. The tracheal mucosa was erythematous and friable, and there was also significant posterior collapse of the right and left main bronchi. The patient was taken to the operating room for rigid bronchoscopy. An 18 mm × 40 mm silicone stent (Novatech®) was deployed into the distal trachea which dramatically improved the obstruction. The patient was subsequently extubated without difficulty, and the rest of his hospital course was uncomplicated. Approximately two months later the stent was removed and patient has done well.
DISCUSSIONS: Pulmonary complications following transhiatal esophagectomy are not uncommon, but tracheal compression has only been reported in one prior case study. Kim et al. described a case of respiratory failure following gastric pull up in a patient with achalasia. The patient experienced intermittent stridor and required intubation secondary to respiratory arrest. The diagnosis of tracheal obstruction was made by spirometry and dynamic CT scanning. Initial bronchoscopy revealed no evidence of upper airway obstruction, and dynamic CT scanning during inspiration and expiration revealed that the trachea was compressed both anteriorly by the inominate artery and posteriorly by the intrathoracic stomach. This was discovered after the endotracheal tube was removed to elucidate the dynamic compression of the trachea with forced expiration. The patient subsequently underwent placement of a metallic tracheal stent with improvement in symptoms. To our knowledge, our patient is the first case of tracheal obstruction from posterior membrane compression from the neoesophagus after transhiatal esophagectomy. Symptoms were relieved by tracheal stent placement which was later able to be removed with resolution of the patient's symptoms.
CONCLUSION: It is important to recognize tracheal compression following transhiatal esophagectomy as a potential cause for post-operative respiratory distress. This patient likely had underlying undiagnosed excessive dynamic airway collapse with respiration which was worsened by extrinsic posterior compression from the neoesophagus. This is a treatable cause of respiratory failure and early bronchoscopy with stent placement can facilitate weaning from mechanical ventilation.
DISCLOSURE: Kristin Miller, No Financial Disclosure Information; No Product/Research Disclosure Information