DP13: POST-OPERATIVE ACUTE RESPIRATORY FAILURE AFTER PLACEMENT OF A SELF-EXPANDING ESOPHAGEAL STENT
Arden Woods, DO1; Jacqueline Ragheb, MBBS, MD1; Colby Skinner, MD1; Katherine Ammon, MD2
1University of Miami/Jackson Memorial Hospital; 2Memorial Healthcare System
Introduction/Background: Esophageal stent placement is a treatment of choice for closing bronchoesophageal fistulas that develop from late-stage malignancies and radiation. Though often a simple procedure, the placement of self-expanding metal stents can be associated with major complications, including stent migration, perforation, tracheoesophageal fistula development, and both acute and delayed bronchial compression. Here, we describe a case of acute respiratory failure due to bronchial obstruction after insertion of a self-expanding esophageal stent, occurring in the acute post-operative setting.
Methods: The patient is an 81-year-old male with a history of metastatic lung carcinoma complicated by left bronchoesophageal fistula who underwent an esophageal stent placement by gastroenterology in an Ambulatory Endoscopy Unit. The patient received general anesthesia with propofol, fentanyl and rocuronium. After endotracheal tube placement, anesthesia was maintained with sevoflurane. An EGD was performed, and a self-expanding metal stent was deployed in the upper/middle thirds of the esophagus. Upon completion, the patient was extubated but began to develop hypoxemia and desaturated to 75-80% with audible left-sided expiratory wheezing before leaving the procedure room. High-flow oxygen, albuterol, and BiPAP were trialed without subsequent improvement in O2 saturation or PaO2. Chest X-ray revealed complete collapse of the left lung and a fully expanded esophageal stent in the appropriate location. Given persistent hypoxia, the patient was reintubated to attempt expansion of the collapsed lung. but positive pressure ventilation failed to improve oxygenation. The patient deteriorated into cardiac arrest. CPR was initiated, and ROSC was achieved after one round of chest compressions. Subsequent flexible bronchoscopy revealed a collapsed left main bronchus due to external pressure from the fully expanded esophageal stent with additional mucous plugging. Suctioning was performed with improvement of oxygenation. The patient was then admitted to the ICU and the stent was removed.
Results: Following removal of the stent and admission to the ICU, the patient’s oxygenation improved, and repeat chest x-rays showed partial left lung reinflation. Unfortunately, as a complication of CPR, the patient sustained fractured ribs resulting in a left sided pneumothorax. This was treated with chest tube placement, and the patient was eventually discharged home with no permanent sequelae.
Discussion/Conclusion: Acute post-operative respiratory failure due to bronchus collapse from a self-expanding esophageal stent is reported sparingly in radiology, thoracic surgery, and internal medicine literature. No such cases were found in our review of anesthesia literature. In those cases reported, compression was often delayed, greater than two weeks after the procedure. All required rapid repositioning or removal of the esophageal stent. This case highlights the importance of rapidly recognizing and treating this rare and unforeseen life-threatening complication. We aim to raise awareness of this complication to anesthesia providers charged with respiratory care.
Through this case, we stress two key points: 1) Acute respiratory failure from post-operative stent expansion is a rare but life-threatening complication of esophageal stent placement, and 2) maintaining high standards of monitoring and preparedness is critical in Non-OR Anesthesia settings, as emphasized by the American Society of Anesthesiologists.
