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LETTER TO EDITOR
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 125-126

Intra-operative mechanical ventilation in amebic liver abscess surgery: Another paradigm


Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Date of Web Publication15-Mar-2017

Correspondence Address:
Aanchal Kakkar
BE-59, West Shalimar Bagh, New Delhi - 110 088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.202189

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How to cite this article:
Kakkar A, Tyagi A, Sethi AK. Intra-operative mechanical ventilation in amebic liver abscess surgery: Another paradigm. J Anaesthesiol Clin Pharmacol 2017;33:125-6

How to cite this URL:
Kakkar A, Tyagi A, Sethi AK. Intra-operative mechanical ventilation in amebic liver abscess surgery: Another paradigm. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2017 Sep 23];33:125-6. Available from: http://www.joacp.org/text.asp?2017/33/1/125/202189

Sir,

We wish to highlight a hitherto unreported intra-operative complication in a 42-year-old male patient of ruptured amebic liver abscess while undergoing surgery for the chronic empyema. A broncho-hepatic fistula was created probably by the institution of the positive pressure ventilation. Timely lung isolation using the in-situ double lumen tube (DLT) prevented the potentially life-threatening respiratory morbidity. The patient presented with complaints of fever for 1 month, pain in right upper abdomen and chest for 10 days. He had mild hepatomegaly associated with tenderness and guarding over right hypochondrium and decreased breath sounds in the right lower zone of the lung. All blood investigations were within normal limits except high leukocyte count (23,000/mm 3) and deranged coagulation (INR of 1.84). The ultrasound of abdomen and subsequent contrast enhanced computed tomography (CECT) showed a large hypoechoic collection measuring 11 cm × 17 cm in the right lobe of the liver, communicating with the right pleural cavity through a 1.3 cm long rent in the diaphragm along with minimal ascites. Ultrasound-guided aspiration from the collection tested positive for Entamoeba histolytica [Figure 1]. The patient was initially managed conservatively with antibiotics.
Figure 1: Contrast enhanced computed tomography chest and abdomen coronal view showing right hemithorax (c), Large liver abscess (b) Ruptured into subphrenic space (a)

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The patient continued to have a cough and on and off fever in spite of antibiotic, hence was scheduled for thoracotomy for nonresolving chronic empyema and ruptured amebic liver abscess. After induction of anesthesia, a left-sided 37 F DLT was inserted in view of the planned thoracotomy for the empyema, and successful lung isolation confirmed by auscultation while the patient was ventilated manually. Mechanical ventilation was initiated at a tidal volume of 8 ml/kg without positive end-expiratory pressure, and the patient positioned in left lateral position with the diseased right lung up.

As soon as the patient was positioned, bilious colored secretions started pouring out from the tracheal lumen. Immediately the bronchial cuff was inflated to avoid the spillage into the healthy left lung. The possibility of broncho-hepatic fistula created consequent to the positive pressure mechanical ventilation was suspected, a finding confirmed intra-operatively. The patient maintained SpO2 of >95% throughout the intra-operative period at FiO2 of 0.4 and was successfully extubated after the completion of surgery.

E. histolytica infection is common in developing countries and intestinal manifestations are its most common presentation. The most common extra-intestinal manifestation is amebic hepatitis including liver abscess, the infection spreading to the liver either by direct extension through the bowel wall, peritoneal cavity, or liver capsule; or indirectly via lymphatic or portal systems.[1],[2] Patients with amebic liver abscess may develop pleuropulmonary complications broncho-hepatic fistula which commonly presents as expectoration of a chocolate colored sputum resulting in natural drainage of the liver abscess.[3],[4],[5]

The above-mentioned patient had no symptoms suggestive of broncho-hepatic fistula in the preoperative period, nor did the preoperative CECT raise any such suspicion although a chronic empyema was confirmed. On re-examining the CECT postoperatively, it was seen that the ruptured abscess cavity was in close proximity to the bronchus, with only a thin wall and diseased lung separating the two structures [Figure 2]. We hypothesize that initiation of positive pressure ventilation probably led to the creation of a broncho-hepatic fistula by creating a traumatic communication between the two structures through the thin separation. It is more likely that the manual ventilation, rather than mechanical ventilation using lowered tidal volumes and monitored safe airway pressures, led to the creation of a broncho-hepatic fistula. Furthermore, prompt usage of the DLT for lung isolation at this time resulted in salvaging the patient from any further respiratory morbidity and mortality.
Figure 2: Contrast enhanced computed tomography chest horizontal view showing right lower bronchus (a) lying close to large abscess cavity in right lung (b)

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Based on these observations, strict use of lung protective ventilation strategy at all times, foregoing manual ventilation even for short interim periods, should be considered in cases of the ruptured amebic liver abscess.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Adams EB, MacLeod IN. Invasive amebiasis. II. Amebic liver abscess and its complications. Medicine (Baltimore) 1977;56:325-34.  Back to cited text no. 1
    
2.
Lyche KD, Jensen WA, Kirsch CM, Yenokida GG, Maltz GS, Knauer CM. Pleuropulmonary manifestations of hepatic amebiasis. West J Med 1990;153:275-8.  Back to cited text no. 2
    
3.
Kubitschek KR, Peters J, Nickeson D, Musher DM. Amebiasis presenting as pleuropulmonary disease. West J Med 1985;142:203-7.  Back to cited text no. 3
    
4.
Saleem MM. Amoebic liver abscess – A cause of acute respiratory distress in an infant: A case report. J Med Case Rep 2009;3:46.  Back to cited text no. 4
    
5.
Yokoyama T, Hirokawa M, Imamura Y, Aizawa H. Respiratory failure caused by intrathoracic amoebiasis. Infect Drug Resist 2010;3:1-4.  Back to cited text no. 5
    


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