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Tracheal injury detected immediately after median sternotomy by inexperienced surgeons: two case reports
© The Author(s). 2018
Received: 30 November 2017
Accepted: 27 January 2018
Published: 27 February 2018
Although median sternotomy is standard during cardiac surgery, the procedure is associated with a risk of injury to mediastinal organs. Here, we discuss two cases of tracheal injury following median sternotomy during cardiac surgery.
Ventilation failure occurred in a 78-year-old Japanese man and a 71-year-old Japanese man after median sternotomy, and tracheal injury was identified. The sites of injury were directly repaired and covered with mediastinal fat tissue, following which ventilation was successful. The burn-like deposits observed at the site of tracheal injury and on the removed endotracheal tube support the notion that the injuries in our patients were caused by electrocautery prior to median sternotomy. In one case, short sternotracheal distance may have contributed to tracheal injury during post-sternal manipulation. In both cases, the relative inexperience of both surgeons also supports the suspected cause of injury.
Tracheal injury represents a potential complication following median sternotomy, especially when performed by inexperienced surgeons or in cases of short sternotracheal distance. Anesthesiologists should consider this rare yet potentially lethal complication.
Although median sternotomy is standard for many types of cardiac surgery, the procedure is associated with a risk of injury to mediastinal organs. However, few reports have discussed tracheal or endotracheal tube injury caused by median sternotomy [1–5]. Among these, one case was caused by the electrocautery procedure prior to median sternotomy . Here, we discuss two cases of tracheal injury potentially caused by electrocautery before median sternotomy by inexperienced surgeons. Informed consent was obtained from the patients and their families to report the details of these cases.
A 78-year-old Japanese man with angina pectoris was scheduled for elective off-pump coronary artery bypass grafting under general anesthesia. General anesthesia was induced using fentanyl (0.15 mg), midazolam (5 mg), ketamine (30 mg), and rocuronium (70 mg). An endotracheal tube (Lo-Contour Oral/Nasal Tracheal Tube Cuffed Murphy Eye; COVIDIEN, Dublin, Ireland; internal diameter 8.0 mm) was smoothly inserted, and no ventilation abnormalities were observed. A pulmonary artery catheter was placed in his right internal jugular vein, and a transesophageal echocardiography probe was inserted without complications. General anesthesia was maintained using oxygen (1 L/minute), air (5 L/minute), and sevoflurane (1.5%).
Discussion and conclusions
Although iatrogenic tracheal injury may occur due to tracheal intubation and surgical procedures, such complications are rare [6–9]. Only five case reports to date have discussed tracheal injury caused by median sternotomy during cardiac operations [1–5]. Among these, one case was caused by the electrocautery procedure used to detach the tissue under the upper end of the sternum prior to median sternotomy . Similarly, the burn-like deposits observed at the site of tracheal injury and the cuff of the removed endotracheal tube support the notion that injuries in our patients were also caused by electrocautery prior to median sternotomy. The relative inexperience of both surgeons also supports the suspected cause of injury.
The distance from the posterior surface of the sternum to the anterior surface of the trachea (that is, sternotracheal distance), measured using preoperative computed tomography, was 24.5 mm in case 1 and 11.8 mm in case 2. Given that the distance has been reported as 17.4 mm and 19.2 mm with and without anastomotic leakage following esophagectomy , respectively, the short distance observed in case 2 may have contributed to tracheal injury during post-sternal manipulation.
Our findings indicate that tracheal injury represents a potential complication following median sternotomy. Inexperienced surgeons and supervisors should be very cautious regarding this complication especially in cases of short sternotracheal distance, as this complication is unacceptable. In case of sudden ventilation failure occurring before or after median sternotomy, anesthesiologists should be aware of this rare yet potentially lethal complication. Careful monitoring of ventilatory parameters during the peri-sternotomy period is recommended.
We thank Editage (www.editage.jp) for English language editing.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
JT performed the analysis on all samples, interpreted the data, wrote the manuscript, and acted as corresponding author. KN and NSh performed the analysis on all samples, interpreted the data, and wrote the manuscript. AF, SO, SB, and NSa helped in data interpretation and supervised the manuscript drafting process. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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