Development of Pneumomediastinum Following Blunt Dissection of Esophagus in Mediastinum for Transhiatal Esophagectomy

Abstract

The use of the stomach has become a well established method of reconstruction of the alimentary tract after total laryngopharyngoesophagectomy (TLPE). The method of extrathoracic extraction of the esophagus by transhiatal blunt finger dissection has become the technique commonly employed for performing TLPE with gastric pull-up. The resection part of this procedure has been blamed as likely to do more damage than the reconstruction,1 especially while doing blunt finger dissection in the mediastinum to extract the thoracic esophagus. Blunt finger dissection in the mediastinum to mobilize and extract the esophagus has been reported to produce serious complications varying from pleural effusion, pneumothorax to catastrophic tracheal tears.2−6 This adds to the morbidity of the procedure, as it is very often performed in patients who are in poor general health. Though pneumothorax in these procedures has previously been reported, the development of intraoperative pneumomediastinum has not been reported before. A 40-year-old, 50 kg, ASA (American Society of Anesthesiologists) I man was scheduled for transhiatal esophagectomy. His preoperative blood investigations and physical examination were within normal limits. Anesthesia was induced with fentanyl and propofol and the trachea was intubated after muscle relaxation was achieved with vecuronium. Surgery proceeded uneventfully. For extrathoracic extraction of the esophagus, blunt dissection of the esophagus in the mediastinum was employed, which lasted for about 4 minutes. At this time, the patient’s lungs were ventilated manually with 100% oxygen. At the completion of blunt dissection, the invasive arterial blood pressure tracing was noted to have decreased to about 0−30 mmHg. The electrocardiogram (ECG) tracing was of low amplitude but normal morphology with few premature atrial ectopics. Radial arterial pulse was hardly palpable with only a few occasional palpable beats (1−2/min). Peak airway pressure continued to remain at 15−17 cmH2O, and there was no drop in oxygen saturation. Development of Pneumomediastinum Following Blunt Dissection of Esophagus in Mediastinum for Transhiatal Esophagectomy