https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/368 Thu, 01 Apr 2021 02:20:23 +0000 Background and objective: In transhiatal esophagectomy, iatrogenic injuries to trachea are very uncommon but when it happens it is potentially lethal and has high morbidity. This study aimed to investigate the incidence and outcome of tracheal injuries during transhiatal esophagectomy. Methods: The medical records of 608 patients who underwent transhiatal esophagectomy for esophageal cancer from January 2000 to January 2019 were analyzed. Results: Out of 608 transhiatal esophagectomy, four (0.66%) patients sustained injuries to major airway. Three injuries occurred during transhiatal and one injury during transcervical part of dissection. All the injuries occurred in trachea proximal to carina. All four injuries were closed primarily, re-enforced by muscle and fascial pledgets. Conclusion: Tracheobronchial injury is a rare complication of transhiatal esophagectomy, mostly seen in patients who receive neo-adjuvant therapy or have locally advanced growth with dense adhesions. Its immediate recognition and closure decreases the mortality and morbidity associated with this rare but fatal intra-operative complication. It can be managed effectively by primary closure, with or without muscle and fascial pledget reinforcement. IMC J Med Sci 2021; 15(1): 003.  OPEN ACCESS. DOI: https://doi.org/10.3329/imcjms.v15i1.54198 *Correspondence: Farooq Ahmad Gganie, Department of Cardiovascular and Thoracic Surgery, Sheri-I-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Kashmir, India. Email ID: farooq.ganie@ymail.com   Introduction The squamous cell cancer of esophagus is common in Asian countries of esophageal cancer belt, stretching from eastern Turkey to northern China and India. It is relatively uncommon in United States, Canada and Europe where adenocarcinoma of the lower esophagus and cardia predominate [1]. The predominant risk factors for squamous cell carcinoma are smoking and alcohol consumption and for adenocarcinoma it is gastro-esophageal reflux and Barrett’s esophagus [2]. The most common surgical procedure performed for esophageal cancers is transhiatal esophagectomy. Other options are Ivor-Lewis, McKeown procedure and pharyngo-laryngo-esophagectomy (PLE) for hypopharyngeal and upper cervical esophageal lesions. The rationale for transhiatal esophagectomy is to avoid thoracotomy and its complications. Fashioning of cervical anastomosis is to minimize clinical consequences of anastomotic leak. The common complications include anastomotic leak/stricture, recurrent laryngeal nerve injury, bleeding, and chyle leak. There is a risk of injury to azygous vein, trachea and cardiac instability. Injury to major airway is a rare but potentially fatal complication of transhiatal esophagectomy that needs prompt recognition, isolation and repair [3]. This study aimed to investigate the incidence and outcome of tracheal injuries during transhiatal esophagectomy.   Materials and methods       The tracheal rent was sutured with interrupted polypropylene (4.0) suture using long instruments from distal to proximal. The sutures were buttressed with muscle and fascial pledgets. Care was taken not to puncture the endotracheal tube. At the end of tracheal repair the endotracheal tube was withdrawn to ensure there was no inadvertent suturing of the airway tube. The gastric tube was advanced into the neck, anastomosed to esophageal stump and the procedure completed. Trans-thoracic approach was used in patients with longer tear (> 5 cm) in the trachea. Right postero-lateral thoracotomy through 5th intercostals space was performed. The trachea was dissected from surrounding structures and the tear was sutured with interrupted (40) polypropylene sutures and then the gastric tube was advanced to neck for anastomosis with the proximal esophageal stump. Thoracotomy was closed after placing one intercostal tube drain (32 F) in the pleural cavity.   Out of 608 transhiatal esophagectomies, four patients (0.66%) sustained injuries to major airway. Three injuries occurred during transhiatal and one injury during transcervical part of dissection. All the injuries occurred in trachea proximal to carina. All four injuries were closed primarily, re-enforced by muscle and fascial pledgets. In two patients the trachea was repaired through right thoracotomy and in two patients by the cervical incision that was utilized for mobilization of esophagus in the neck and provided adequate exposure for repair of the trachea. Two patients who sustained intra-operative airway injury received pre-operative chemo-radiation for advanced growth. Discussion In patients with carcinoma esophagus having dense peri-esophageal adhesions after neo-adjuvant chemo-radiation and difficult transhiatal esophageal dissection due to adherent growth, threshold for conversion to trans-thoracic approach (and sharp dissection under vision) should be low. Injury during trans-cervical part of esophageal dissection can be managed through the same incision and injuries as low as carina can be successfully managed without any additional morbidity. The crux of uncomplicated repair of tracheal injuries in transhiatal esophagectomy is immediate recognition, proper exposure, interrupted suture technique, suture reinforcement and proper post-operative care.   1.     Samarasam I. Esophageal cancer in India: current status and future perspectives. Int J Adv Med Health Res. 2017; 4: 5–10.3.     Harney TJ, Condon ET, Lowe D, McAnena OJ. A novel technique for repair of iatrogenic tracheal tear complicating three stage oesophagectomy. Ir J Med Sci. 2009; 178(3): 337–338. 4.     LA Gorenstein, JG Abel and GA Patterson. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg. 1992; 54(4): 784–786. 5.     Foroulis CN, Simeoforidou M, Michaloudis D, Hatzitheofilou K. Pericardial patch repair of an extensive longitudinal iatrogenic rupture of the intrathoracic membranous trachea. Interact Cardiovasc Thorac Surg. 2003; 2(4): 595–597. 6.     Gupta V, Gupta R, Thingnam SKS, Singh RS, Gupta AK, Kuthe S, et al.Major airway injury during esophagectomy: experience at a tertiary care center. J Gastrointest Surg. 2009; 13: 438–441. 7.     Hulscher JB, Hofstede E, Kloek J, Obertop H, de Haan P, van Lanschot JJB. Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg. 2000; 120: 1093–1096. 8.     Nunez JAF, Merino MCU, Escudero JA, Landeira JMV. Tracheal injury during transhiatal esophagectomy without thoracotomy: anesthesiologic management. Rev Esp Anestesiol Reanim. 1990; 37: 32–36. 2026 Ibrahim Medical College. All rights reserved.