Preoperative LV dysfunction is a predictor of severe mitral regurgitation during OPCAB. When poor LV function is suggested, it is necessary to be prepared for further hemodynamic deterioration caused by mitral regurgitation.

lation with a large tidal volume or high peak pressure should be avoided. By contrast, unexpected hypoventilation may occur because of air leakage from the fi stula. Furthermore, the size and location of the fi stula may vary, and therefore the method of treatment may also vary; no optimal treatment strategy has been established. This complication happens rarely after the surgical treatment of esophageal cancer, but it can be fatal. In general, it is necessary to perform an urgent surgical procedure even in the presence of adverse conditions such as systemic infl ammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), and malnutrition.The present report describes the perioperative respiratory management, using independent lung ventilation (ILV) combined with high-frequency oscillation ventilation (HFOV), while thoracotomy was performed for a patient suffering from ARDS and SIRS caused by a tracheo-gastric roll fi stula. Case reportA 62-year-old man with mid-lower esophageal cancer underwent resection and reconstruction of the esophagus, with the use of a gastric roll through the posterior mediastinum. He was extubated on day 1 after the surgery, however, pneumonia in the right lung continued for more than 1 week and the bronchoscope examination revealed edema in the trachea and the right main bronchus. On day 20, he complained of respiratory distress and the trachea was re-intubated. A chest X-ray revealed obvious infi ltrations in the right lower lobe and scattered infi ltrations in the left lung. Tracheal suction fl uid contained gastric contents, and a tracheo-gastric roll fi stula was discovered 2 cm above the carina. Blood tests revealed a white blood cell count of 18 500/μl, Creactive protein, 27 mg·dl −1 and a Pa O 2 /FI O 2 (P/F) ratio of 150 mmHg; SIRS and ARDS were also diagnosed. To Abstract This case report describes the diffi cult respiratory management of an esophageal cancer patient with acute respiratory distress syndrome (ARDS) and systemic infl ammatory response syndrome (SIRS) caused by a postoperative tracheogastric roll fi stula. A single-lumen tracheal tube could not seal the fi stula, and therefore a double-lumen tracheal tube (DLT) for the left side was used. Although the proximal cuff of the DLT failed to seal the fi stula, independent lung ventilation (ILV) improved blood gas levels. During right thoracotomy, the left lung was ventilated conventionally with 5 cmH 2 O positive end-expiratory pressure (PEEP), and in addition, highfrequency oscillation ventilation (HFOV) to the right lung was employed. This combination allowed the maintenance of adequate oxygenation, and the HFOV to the right lung decreased the Pa CO 2 level during surgery without interruption of the surgical fi eld. These techniques provided the opportunity to successfully remove a necrotic gastric roll and achieve closure of the fi stula using an intercostal muscle fl ap. This report documents and discusses the diffi culty of performing appropriate anesthetic management of a patient with these compl...

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