P-269A PROBLEM WITH BREATHING AFTER OESOPHAGECTOMY

Abstract

Objectives: We present a very interesting case and rare complication following an oesophagectomy for adenocarcinoma of the gastro-oesophageal junction in a 68-year-old male patient. We describe the findings and our management of this complex case. Case description: Our patient developed adenocarcinoma on a background of Barrett's oesophagus. He received three cycles of neoadjuvant chemotherapy followed by left thoracolaparotomy, oesophagectomy and left neck anastomosis. The procedure was uneventful and the patient was extubated. Few hours later he developed respiratory failure and needed reintubation. He had bronchoscopy which showed a severe degree of tracheobronchomalacia, mainly involving the left main bronchus. This was not evident preoperatively, neither clinically nor from investigations. He had CT scan which showed that the gastric conduit had somehow caused compression of the posterior wall of the trachea and left main bronchus. This was the first time we faced such a scenario. We initially managed the patient with tracheostomy, nasogastric tube suction and trial of weaning from ventilator, however this failed. Reviewing the literature we could only find very few cases that described such a problem. Options of management included a revisiting surgery via right thoracotomy to pull the conduit into the right pleural cavity, or airway stenting with removal of the stent three to four months later. As our patient was sick, we felt that a contralateral thoracotomy was not in his best interest. We adopted the stenting option and deployed a stent in his trachea and left bronchus, converted to a Y-stent later. We managed to wean him off on day 38 and discharged him home on day 51. The attempt of removing the stent 6 months later showed that his airway collapsed again within minutes. Since then he had a long-term Y-stent inserted and has been doing well. Conclusion: Although very rare, gastric conduits can cause tracheobronchomalacia. Our patient was managed successfully with stenting.