Abstract Introduction Iatrogenic injuries of the membranous trachea have become increasingly common and may trigger a cascade of immediate life-threatening complications. Case presentation A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration. Conclusion Our technique was proved to be safe, effective and not technically demanding. Early recognition with prompt surgery is the gold standard of managing such cases, although small tears can be managed conservatively.</p

A Mussi

BP Madden

Christodoulos Tsilikas

Christos Lafaras

Dimitrios Paliouras

E Chen

Georgios Samanidis

H Kaloud

HS Hofmann

I Kouerinis

JP D'Odemont

Nikolaos Barbetakis

P Borasio

S Gabor

T Angelillo-Mackinlay

Theodoros Bischiniotis

English

PubMed

Crossref

Intraoperative tracheal reconstruction with bovine pericardial patch following iatrogenic rupture

Abstract Introduction Iatrogenic injuries of the membranous trachea have become increasingly common and may trigger a cascade of immediate life-threatening complications. Case presentation A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration. Conclusion Our technique was proved to be safe, effective and not technically demanding. Early recognition with prompt surgery is the gold standard of managing such cases, although small tears can be managed conservatively.</p

Bischiniotis Theodoros

Lafaras Christos

Paliouras Dimitrios

Samanidis Georgios

Barbetakis Nikolaos

Tsilikas Christodoulos

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Patient Safety in Surgery

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BioMed CentralPatient Safety in Surgery
ssOpen AcceCase report
Intraoperative tracheal reconstruction with bovine pericardial 
patch following iatrogenic rupture
Nikolaos Barbetakis*1, Georgios Samanidis1, Dimitrios Paliouras1, 
Christos Lafaras2, Theodoros Bischiniotis2 and Christodoulos Tsilikas1
Address: 1Thoracic Surgery Department, Theagenio Cancer Hospital, A. Simeonidi 2, Thessaloniki, 54007, Greece and 2Cardiology Department, 
Theagenio Cancer Hospital, A. Simeonidi 2, Thessaloniki, 54007, Greece
Email: Nikolaos Barbetakis* - nibarb@otenet.gr; Georgios Samanidis - gsaman@yahoo.gr; Dimitrios Paliouras - dpaliour@yahoo.gr; 
Christos Lafaras - iatros_the@panafonet.gr; Theodoros Bischiniotis - teobischi@yahoo.gr; Christodoulos Tsilikas - ctsilik@yahoo.gr
* Corresponding author    
Abstract
Introduction: Iatrogenic injuries of the membranous trachea have become increasingly common
and may trigger a cascade of immediate life-threatening complications.
Case presentation: A case of a 48-year-old man with an iatrogenic membranous tracheal wall
rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented.
Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and
reinforcement with the gastric conduit which was moved toward the posterior wall of the
membranous trachea sealing the wall laceration.
Conclusion: Our technique was proved to be safe, effective and not technically demanding. Early
recognition with prompt surgery is the gold standard of managing such cases, although small tears
can be managed conservatively.
Introduction
Iatrogenic injuries of the membranous trachea are rare but
potentially lethal and can complicate procedures such as
endotracheal intubation, mediastinoscopy, percutaneous
tracheostomy and excision of neoplasms with mediastinal
involvement. Statistically women are more predisposed to
this than men [1]. Further risk factors include poor medi-
cal condition, short stature, use of steroids, previous
chemotherapy and mediastinal radiotherapy. A case of a
48-year-old man with an iatrogenic membranous tracheal
wall rupture after double-lumen intubation during Ivor
Lewis esophagogastrectomy is presented. Tracheal injury
was successfully managed surgically with the use of
bovine pericardial patch and reinforcement with the gas-
tric conduit which was moved toward the posterior wall of
the membranous trachea sealing the wall laceration.
Case presentation
A 48-year-old man was admitted to our department with
the diagnosis of an adenocarcinoma of the gastroesopha-
geal junction. Preoperative staging was negative for dis-
tant metastases. Endoscopic ultrasound findings
confirmed the presence of a locally advanced tumor (type
I – Siewert classification). It was an adenocarcinoma of
the distal esophagus arising from an area with intestinal
metaplasia and infiltrating the esophagogastric junction
from above. As a consequence preoperative synchronous
chemoradiotherapy was proposed. The scheme was con-
Published: 20 February 2008
Patient Safety in Surgery 2008, 2:4 doi:10.1186/1754-9493-2-4
Received: 24 November 2007
Accepted: 20 February 2008
This article is available from: http://www.pssjournal.com/content/2/1/4
© 2008 Barbetakis et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Patient Safety in Surgery 2008, 2:4 http://www.pssjournal.com/content/2/1/4sisted of fluorouracil (15 mg/kg of body weight) daily for
five days and cisplatin (75 mg/m2 of body surface area)
on day 7 and a course of radiotherapy (40 Gy adminis-
tered in 15 fractions, anterior-posterior mediastinal
fields) over a a three week period, beginning concurrently
with the first course of chemotherapy. After the comple-
tion of chemoradiotherapy, the stage of the disease was
reevaluated (CT scans of the abdomen, chest, pelvis,
upper gastrointestinal endoscopy and ultrasound).
Restaging was completed with no evidence of distant dis-
ease and surgical removal of the primary tumor and lym-
phadenectomy was proposed. The patient was eligible for
an Ivor Lewis esophagogastrectomy.
He was intubated with a left-sided 37-F double-lumen
endotracheal tube by a specialist anesthesiologist experi-
enced in cardiothoracic surgery anesthesia. The technique
includes the following points. The tube was held with the
bronchial curve concave anteriorly. As the tip was passed
through the larynx, the tube was rotated 90 degrees to
direct the endobronchial part to the intended side. The
tube was then connected to the breathing circuit via a dou-
ble catheter mount.
The abdominal part of the operation was uneventful. Dur-
ing the second phase and while the intrathoracic esopha-
gus was being mobilized a hissing noise was heard and a
careful inspection revealed part of the double-lumen tube
and the inflated tracheal cuff protruding through the rup-
tured membranous tracheal wall into the operating field.
This resulted in an approximately 3 × 1 cm oval-shaped
laceration of membranous trachea, extending to 1 cm
above the carina (Figure 1). The ventilation and oxygena-
tion of the patient could now only be continued by occlu-
sion of the tear by the surgeon's finger and subsequently
by a surgical gauze swab. Our first attempt was primary
interrupted suturing which failed and resulted in enlarge-
ment of the laceration probably due to the previous chem-
oradiotherapy. Tracheal repair was then performed by
tailoring and suturing a bovine pericardial patch, using a
running Vicryl 4-0 suture. This led to control of the leak-
age and normal ventilation was re-instituted. The main
operation was completed by performing a classical Ivor
Lewis esophagogastrectomy with a 2-field lymphadenec-
tomy. Esophagogastric continuity was restored with an
end-to-end anastomosis using an EEA 25 mm circular sta-
pling device.
In order to reinforce the tracheal repair at the end of the
operation, the gastric conduit was moved toward the pos-
terior wall of the membranous trachea. Single interrupted
nonabsorbable 3-0 prolene sutures were placed between
the stomach and the lowest edge of the rigid tracheal rings
(Figure 2). This manipulation moved the gastroesopha-
geal conduit into contact with the pericardial patch on the
posterior wall of the membranous trachea, sealing the
wall laceration. In order to check the effectiveness of our
technique the pleural cavity was filled with normal saline
and the ventilation pressure was raised to 30 cm H2O. A
careful inspection for air leakage was negative. Two tho-
racic drains were placed as usually and the patient was
transferred to the intensive care unit intubated and
mechanically ventilated. A no 7.5 single lumen endotra-
cheal tube was substituted for the double-lumen tube and
was advanced bronchoscopically to just above the carina.
The patient was extubated on the second postoperative
day and had an uneventful recovery. Nutrition and subse-
quent airway management were in line with our usual
protocols. Chest tubes were removed on 9th postoperative
day, two days after the patient started to feed orally. He
was discharged home on 14th postoperative day without
any respiratory or swallowing problems.
Discussion
Tracheal rupture after endotracheal intubation is a rare
entity. Most retrospective reviews focus on elective intuba-
tions by experienced anesthesiologists and show an inci-
dence of rutpture of less than 1% [2]. There are multiple
factors leading to injury. Operator errors (multiple
attempts, inexperienced phycisians), equipment selection
(inappropriate use of stylets, cuff overinflation, malposi-
tion of the tube, incorrect tube size), patients' movements
(abrupt movements, excessive coughing) and medical fac-
tors (steroid or radiation-weakened membranes, chronic
obstructive pulmonary disease, tracheomalacia) contrib-
ute to the problem [3]. Other risk factors include age>50
years, short stature, obesity, double lumen tubes and per-
cutaneous tracheostomy [3]. Women are more frequently
affected by an iatrogenic tracheobronchial rupture. Cer-
Oval-shaped laceration (arrow) of membranous trachea extended to 1 m ab ve the carinaFigure 1
Oval-shaped laceration (arrow) of membranous tra-
chea extended to 1 cm above the carina.Page 2 of 4
(page number not for citation purposes)
Patient Safety in Surgery 2008, 2:4 http://www.pssjournal.com/content/2/1/4tainly, their small body size and therefore the risk of plac-
ing the tube too distally in a short trachea and an incorrect
tube size might be responsible. Additionally, a vulnerable
and weak trachea is often suspected in women[4].
Iatrogenic tracheal rupture involves almost exclusively the
membranous trachea [5]. Early recognition with prompt
surgery is the gold standard of managing such cases,
although small tears can be managed conservatively [6].
In general tracheobronchial ruptures of the middle and
lower third are operated on through a right and in rare
exceptional cases, a left thoracotomy [7]. The approach to
injuries in the upper third of the trachea is the left cervical
side. Angelillo-Mackinlay proposes a transcervical access
in the sense of a mediastinotomy for injuries to the distal
trachea, which is, nevertheless, fairly controversial, due to
the creation of additional trauma (longitudinal tracheot-
omy)[8]. For the repair, patients should be intubated
using a double-lumen tube. Single lumen tube with posi-
tion in the contralateral main bronchus or high-frequency
jet ventilation can be used alternatively. However, disad-
vantages of the jet ventilation technique are the tendency
to produce carbon dioxide retention and the danger of
blood aspiration into the bronchial system. After limited
lateral and posterior paratracheal dissection, the injury is
repaired by interrupted or running absorbable suture,
sometimes covered with mediastinal fat or pleural flap
and/or by fibrin glue [9]. Direct suture of a tracheal rup-
ture in a patient previously treated with chemoradiother-
apy is not an option as this was proved in our case and
resulted in enlargement of the laceration. Our technique
adopted here, was based on the competence of the gastric
wall to sustain the tension against the tracheal rings and
furthermore to push the bovine pericardial patch toward
the posterior wall, sealing the tear. The above mentioned
technique is proposed for surgical management of tra-
cheal wall lacerations as it proved safe, effective and not
technically demanding. The use of an endotracheal stent
could be proposed but the urgent situation (almost
impossible ventilation and oxygenation) led us to resolve
the problem surgically. However, the employment of a
covered expandable stent should be considered for the
treatment of a tracheal or bronchial tear. The develop-
ment of these stents represents an effective, direct and less
invasive means of sealing tracheal tears [10]. Stent deploy-
ment commits the patient to continued outpatient sur-
veillance to monitor for complications. Although
uncommon these include granulation tissue formation,
stent migration, halitosis and recurrent respiratory tract
infections [10].
Iatrogenic tracheobronchial ruptures are mainly caused
by emergency intubations [1]. Percutaneous dilational
tracheostomies and double-lumen intubations do not
show higher signs of complications compared with single-
lumen intubations or conventional tracheotomies, if they
are accompanied by verification through bronchoscopy
[1]. Patients without any respiratory failure and a small
tracheobronchial rupture may undergo conservative treat-
ment. They must be checked by repeated bronchoscopies
to detect granulation tissue and relevant tracheal stenosis.
Early surgical treatment of the latter must be the therapy
of choice.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
NB, GS, DP, CL and TB took part in the care of the patient
and and contributed equally in carrying out the medical
literature. CT participated in the care of the patient and
had the supervision of this report. All authors approved
the final manuscript.
Consent
Written informed consent was obtained from the patient
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.
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The gastric conduit was moved toward the posterior wall of the membranous trachea by means of single inter upted non-absorbable 3-0 prolene sutur s which wer plac d betwee  sto a h (do bl  arrow) and t e lo st edge of the rigidracheal ngs (ar w) (asterisk – es pha ogas ric anastom -sis)Figu  2
The gastric conduit was moved toward the posterior 
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Intraoperative tracheal reconstruction with bovine pericardial patch following iatrogenic rupture

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