• Maki Ichinose, Hiroaki Sakai, Ikuo Miyazaki, Akihiro Muraoka, Miyuki Aizawa, Kaigen Igarashi, and Atsushi Okazaki.
• Department of Anesthesiology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295, Japan.
• J Anesth. 2008 Jan 1; 22 (3): 282-5.

AbstractThis case report describes the difficult respiratory management of an esophageal cancer patient with acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) caused by a postoperative tracheogastric roll fistula. A single-lumen tracheal tube could not seal the fistula, and therefore a double-lumen tracheal tube (DLT) for the left side was used. Although the proximal cuff of the DLT failed to seal the fistula, independent lung ventilation (ILV) improved blood gas levels. During right thoracotomy, the left lung was ventilated conventionally with 5 cmH2O positive end-expiratory pressure (PEEP), and in addition, high-frequency oscillation ventilation (HFOV) to the right lung was employed. This combination allowed the maintenance of adequate oxygenation, and the HFOV to the right lung decreased the PaCO2 level during surgery without interruption of the surgical field. These techniques provided the opportunity to successfully remove a necrotic gastric roll and achieve closure of the fistula using an intercostal muscle flap. This report documents and discusses the difficulty of performing appropriate anesthetic management of a patient with these complex complications after esophageal surgery.

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