Life-Threatening Tracheal Diverticulum Rupture Following Laparoscopic Cholecystectomy: A Rare Case Report

Introduction

Tracheal rupture after tracheal intubation is a severe but very rare complication that can be fatal. The documented incidence of tracheal rupture linked to intubation varies across reports in the literature; however, it is commonly approximated to occur in below 1% of patients who undergo intubation, or even as low as in 0.005% of cases. Establishing accurate predictive indications for this complication is challenging due to the unspecific nature of the risk factors associated [1]. The main mechanism for a lesion is increased pressure in the trachea, which can happen due to a blunt trauma or vigorous coughing, as an example [2]. A tracheal diverticulum is a rare medical condition that can be a great risk factor for tracheal rupture. An acquired diverticulum is an outpouching of a weakened tracheal wall, meaning it is more susceptible to tear under the predictive factors mentioned. A tracheal diverticulum is usually asymptomatic, which makes many cases go unnoticed and makes the tracheal diverticulum infrequently mentioned in the literature [3]. The clinical manifestations of tracheal injury can vary, depending on the location and extent of the injury. The most prevalent symptom is respiratory distress, due to the trachea being compromised. Subcutaneous emphysema is also a predominant symptom that clinically serves as a protective factor, meaning, its presence is a strong indicator of the possible threat of tracheal rupture and helps to expedite the process of diagnosing and treating it [4].

We report an unusual case of tracheal diverticulum rupture and asystole following laparoscopic cholecystectomy.

Case Report

A 71-year-old woman (American Society of Anesthesiologists class II, body mass index 28.58) underwent a planned laparoscopic cholecystectomy. Her comorbidities included stable angina pectoris, arterial hypertension II, and congestive heart failure, New York Heart Association class II. In the preoperative examination, the chest X-ray did not reveal any abnormalities of the trachea (Figure 1). She had a blood pressure of 135/75 mmHg, heart rate of 79 beats per min, SpO2 of 100%, and eupneic breathing. General anesthesia was induced by a propofol bolus of 200 mg (Fresenius Kabi Deutschland GmbH, Germany), a fentanyl bolus of 100 μg (Kalceks, A/S, Latvia), and an atracurium bolus of 30 mg (Kalceks, A/S, Latvia). One hour before the surgery, oral midazolam 7.5 mg (ROCHE, Latvia) was administered. Intubation with a cuffed 7-mm inner diameter tube was performed, without a stylet. Intubation happened with no complications or difficulties. Larynx visualization in direct laryngoscopy was Cormack grade II. Intubation was performed on the first attempt. Vital signs after induction and intubation were heart rate of 70 beats per min, blood pressure of 100/72 mmHg, SpO2 of 100%, EtCO2 of 28 mmHg. Ventilation was delivered by an Ohmeda anesthetic machine, with pressure-controlled ventilation mode, peak inspiratory pressure 16-18 cm H2O, and positive end-expiratory pressure 5 cmH2O. The duration of the surgery was 45 min. During the surgical intervention, no life-threatening aggravations or other complications and considerations were documented. After 5 min of the abdominal cavity desufflation, the patient’s vital signs were measured at EtCO2 20 mmHg, hypotension at 50/30 mmHg, bradycardia, with heart rate of 17 beats per min, followed by asystole. Atropine 1 mg (Sopharma PLC, Bulgaria) was administrated before asystole occurred. After 2 min of immediate cardiopulmonary resuscitation (CPR), spontaneous circulation returned, the patient’s condition was stable, and her vital signs returned to normal. No other medications were administered during CPR. It was deemed safe to extubate the patient, and she was admitted to the Intensive Care Unit (Table 1). At 20 min after CPR, the patient was awake, alert, and hemodynamically stable. Any myocardial injuries that might have caused the asystole were excluded owing to negative cardiomarkers, such as troponin I and creatinine kinase muscle/brain. Electrocardiography did not show any dynamic changes. After 20 h of Intensive Care Unit admission, chest and neck subcutaneous emphysema occurred. The patient had neck pain and voice hoarseness. Vital measurements showed SpO2 of 96%, without oxygen supply.

Esophageal X-ray with contrast dye was performed to exclude esophageal rupture (Figure 2). A computed tomography (CT) scan of the chest showed subcutaneous neck emphysema, bilateral pneumothorax, extensive pneumomediastinitis, with a pocket-like defect filled with air, that extended 10×32 mm in the distal part of the trachea, which had possibly ruptured. Radiologists confirmed it as the congenital diverticulum of the trachea (Figures 3, 4).

Two hours after establishing the diagnosis, an emergency surgery was performed to close the tracheal defect. During the surgery, no complications were experienced, and the tracheal defect was successfully closed. The patient’s recovery was successful, and after spending 15 days at the hospital, the patient was discharged.

Written informed consent was obtained from the patient to publish this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Discussion

Tracheal diverticulum is a rare and benign entity. It usually presents with no symptoms and is diagnosed by accident during unrelated imagining or autopsy. The prevalence is estimated to be around 1% to 2.5% of the general population [5,6]. Tracheal diverticulum can be classified into 2 categories, congenital diver-ticulum or acquired diverticulum, based on an assessment of its causes and pathological characteristics. A congenital diverticulum occurs due to an anomaly in the process of endodermal differentiation while the tracheal cartilage is forming in the sixth week of fetal development. Males have a higher prevalence of congenital tracheal diverticulum than do females. Congenital diverticulums are smaller and usually are found just above the carina or around 5 cm below the vocal cords [7]. Unlike congenital diverticulum, acquired tracheal diverticulum have a wall composed primarily of respiratory epithelia, devoid of smooth muscle and cartilage, as they originate from increased intraluminal pressure [8]. Acquired diverticulums can be found on all levels of the trachea and more than 95% of the time are located on the right posterolateral side, as the right side lacks protection that the aortic arch and esophagus provide to the left side of the trachea [7,9]. Multiple factors contribute to tracheal injury, both mechanical and anatomical. Blunt trauma to the neck and chest, as well as tracheal intubation, bronchoscopy, foreign body aspiration, and chemical or penetrating injuries, can all cause tracheal diverticulum rupture. We suspect that in our presented case, the tracheal diverticulum rupture occurred during CPR as a mechanical compression of the thorax, which caused extremely elevated airway pressure.

The cardiac arrest might be caused by 4 the Ts: tension pneumothorax; tamponade (cardiac); thrombosis (coronary and pulmonary); toxins (poisoning), and the 4 Hs: hypoxia; hypo-/ hyperkaliemia and other electrolyte disorders; hypo-/hyper-thermia; hypovolaemia [10]. The surgery was planned and the patient was adequately prepared, to minimize the risk of cardiac arrest. Preoperative and postoperative blood testing revealed no significant electrolyte imbalances. Potassium levels remained within the normal range the whole time the patient stayed in the hospital (Table 2). This is consistent with our hypothesis regarding the cause of asystole.

The clinical manifestations of tracheal injury, as in this case, tracheal diverticulum rupture, usually develop immediately or soon after extubation and include signs of respiratory distress, such as dyspnea and dysphonia, hemoptysis, and most often, subcutaneous emphysema [11]. Typically, the symptoms manifest themselves either during surgery or shortly after it. Occasionally, it may not manifest until several hours later. In our case, the tracheal intubation was performed successfully in the first attempt, and the symptoms indicating a tracheal rupture occurred after 20 h. That gave us the idea that the diverticulum rupture was a result of CPR.

Hemodynamic disturbances have the potential to induce a variety of protective physiological reflexes. There are only a few recorded cases of the Bezsold-Jarich reflex occurring in clinical settings. Hemodynamic disturbances associated with the Bezold-Jarisch reflex can be misconstrued as some adverse cardiac event. This reflexive response manifests itself immediately and leads to severe bradyarrhythmia with hypotension and asystole [12]. When a patient is undergoing laparoscopic surgery, disturbances such as asystole can happen when the arterial baroreceptor response gets overridden. Following gas insufflation, abnormal myocardial squeezing brought on by forceful contraction around virtually empty heart chambers can stimulate the ventricular receptor [13].

A CT scan is considered the criterion standard for characterizing the location, size, and origin of the diverticulum. It should be performed promptly upon noticing unexpected subcutaneous emphysema, which can suggest tracheal laceration. The tactics of management of this injury should be decided upon quickly, as the rupture can be fatal if not treated correctly. In this case, we decided on an early surgical repair, as there was an uncontrolled air leak. There are cases in which a conservative treatment would be preferable, for example, if the lesion is less than 4 cm in length and does not display necrotic tissue and the patient is hemodynamically stable [14].

Conclusions

In our case, asystole and the event following CPR were trigger factors in diagnosing tracheal diverticulum. Our case illustrates that tracheal diverticulum is mainly diagnosed by accident, but its rupture can lead to life-threatening conditions. Many circumstances can provoke tracheal diverticulum rupture. We should keep in mind that tracheal rupture can be made not only by the endotracheal tube itself but also in unexpected conditions, such as CPR. Rapid desufflation of the abdominal cavity in laparoscopic surgery can lead to asystole, which is induced by the Bezold-Jarisch reflex.