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| Year : 2013
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: 16 | Issue : 1 | Page
: 61-62 |
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| Megaesophagus: A challenge for anesthesiologists |
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Prabhat Tewari, Devendra Gupta
Department of Anaesthesiology, SGPGIMS, Lucknow, India
Click here for correspondence address and
email
| Date of Web Publication | 2-Jan-2013 |
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How to cite this article:
Tewari P, Gupta D. Megaesophagus: A challenge for anesthesiologists. Ann Card Anaesth 2013;16:61-2 |
A fifty-nine-year male farmer presented with a history of low grade dysphagia, both for solids and liquids for twenty-five years that progressively increased in severity. He had lost weight significantly in recent years and developed spontaneous regurgitation of liquids and food content, heart burn, chest pain after eating and cough. Chest X-ray (PA-view) showed a large curvilinear, radio-opaque density lesion occupying medial 2/3 rd of right hemi thorax with Ryle's tube within the shadow suggesting a large dilated esophagus [Figure 1]. This was not silhouetting the right cardiac border suggesting posterior mediastinal mass; moreover, there was no mediastinal shift. Barium swallow confirmed achalasia-cardia with huge, more than 10 cm in diameter, pouch of esophagus with lower constricted part. The patient did not show any cardiac compromise but lung function tests showed reduced inspiratory and forced vital capacity (60%) and borderline Peak Expiratory Flow Rate (70%). The laboratory investigations were within normal limits. He was planned for transhiatal esophagectomy (THO) with cervical esophago-gastrotomy (OG) and feeding jejunostomy (FJ). He was given one week of rigorous chest physiotherapy under guidance of professional therapists. | Figure 1: X-ray chest (Postero-Anterior view) showing a large sigmoid shaped shadow of megoesohagus on the right side (border marked with arrows). Naso-gastric tube is shown with normal cardiac and lung shadows
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In the operating room after placing the patient on the operation table, a 14 F Ryle's tube was placed into dilated esophageal pouch and 750 ml of fluid mixed with food content was suctioned out and a lavage with normal saline was done. Thereafter, an epidural catheter was placed at T 10- T 11 interspace for post-operative pain relief. After 100% O 2 inhalation for 3 minutes, rapid sequence anaesthetic induction was achieved with intravenous fentanyl 5 μg/Kg and induction dose of thiopentone sodium. Cricoid pressure was continuously applied and succinylcholine 100 mg was given for muscle relaxation. Endotracheal intubation was done and the cuff was inflated and only then cricoid pressure was released. Anesthesia was maintained with propofol and fentanyl infusion and rocuronium for muscle relaxation. Intra-arterial line and a triple lumen central venous catheter (right internal jugular vein) was inserted and invasive arterial and central venous pressures were monitored. During transhiatal surgical manipulation of mediastinal esophagus significant ventricular arrhythmias occurred which were treated with a bolus of lignocaine and then with an infusion of amiodarone. Airway pressure also varied significantly during mediastinal manipulation of esophagus sometimes compromising ventilation. The operating surgeon was informed of ventilatory compromise and were asked to manipulate gently so as not to compromise ventilation. Arterial blood gases, acid base, Na + , K + and lactate were measured at 30 minutes intervals and any abnormality detected was corrected. Total blood loss was about 600 ml. After excision of native esophagus, thorough mediastinal lavage was done and stomach pouch was pulled up and anastomosed with cervical esophagus. Bilateral chest drains and abdominal drains were inserted. In view of long duration of surgery, hypothermia and many episodes of intra-operative hemodynamic instability, the patient was electively ventilated overnight and weaned off next postoperative day. Nutrition was maintained through a feeding jejunostomy. On 9 th postoperative day he developed respiratory distress due to massive left sided pleural effusion, which was drained. Patient was discharged to follow up on 12 th postoperative day.
Megaesophagus constitutes a rare clinical entity of unknown etiology characterized by esophageal motor alteration with dilatation of esophagus. Orringer and Stirling defined megaesophagus as an esophagus with a diameter of 8 cm or more. [1] Megaesophagus can also be a part of a syndrome when associated with Chaga's disease. [2] Episodes of chest infection are common in advanced stage of disease. Any surgery for megaesophagus entails aggressive preoperative pulmonary physiotherapy, regular use of incentive spirometry and appropriate antibiotic therapy if the lungs are infected. Preoperative Ryle's tube is placed and every attempt is made to empty esophageal pouch. Epidural analgesia decreases anesthetic requirement, facilitates early extubation and ensures adequate postoperative pain control. Rapid sequence induction with cricoid pressure minimizes chances of aspiration. Arrhythmias and hypotension during esophageal manipulation due to mechanical irritation of the heart by surgeon's hand are common; therefore, monitoring for arrhythmias and readiness to manage them including application of external defibrillator pads is required. Right internal jugular or subclavian approach is again the rule as left side of the neck is used by surgeons for anastomosis. Double lumen tube (DLT) can facilitate esophageal dissection, particularly, if surgical approach is through thoracotomy; however, aspiration during anesthesia induction is a real possibility; therefore, the authors preferred to intubate trachea with routine endotracheal tube during rapid sequence induction. The mediastinal pleura surrounding the dilated esophagus is redundant and stretched and is easily torn causing pneumothorax thus necessitating chest drains. Early postoperative complications are recurrent laryngeal nerve palsy, anastomosis disruption, chylothorax, supraventricular arrhythmias and sympathetic effusion. [3] Postoperative mediastinitis is suspected when fever persists for 48 hours with high leucocyte count. To conclude megaesophagus is a rare disorder that presents a challenge for both anesthesiologist and surgeon and a thorough planning is needed for better outcome.
 References | |  |
| 1. | Orringer MB, Stirling MC. Esophageal resection for achalasia: Indications and results. Ann Thorac Surg 1989;47:340-5. 
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| 2. | Bellini MF, Manzato AJ, Silva AE, Varella-Garcia M. Chromosomal imbalances are uncommon in chagasic megaesophagus. BMC Gastroenterol 2010;10:20.
[PUBMED] |
| 3. | Watson TJ, Peters JH, DeMeester TR. Esophageal replacement for end stage benign esophageal disease. Surg Clin North Am 1997;77:1099-113.
[PUBMED] |
Correspondence Address:
Prabhat Tewari
Department of Anesthesiology, SGPGIMS, Raibarely Road, Lucknow - 226 014
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9784.105374
[Figure 1] |
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| This article has been cited by | | 1 |
Successful Airway Management in a Patient with Severe Proximal Achalasia Requires Interdisciplinary Cooperation |
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| Benjamin G. Ekstrom,Sarah Dance,Donald E. Low,R. Eliot Fagley | | A & A Case Reports. 2014; 3(11): 153 | | [Pubmed] | [DOI] | |
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