Anesthetic management of a case of achalasia cardia with meg
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Achalasia along with megaesophagus may lead to airway compression leading to the respiratory compromise. However, cardiovascular compromise has not been reported previously. We present a patient who underwent thoracoscopic assisted esophagectomy with gastric pull-up for achalasia cardia with megaesophagus which resulted in compression of the left bronchus and the great vessels during its separation from the surrounding structures.

Case Report:
A 46-year-old male was scheduled for thoracoscopic assisted esophagectomy with gastric pull-up. Pulmonary function tests reported moderate restriction and mild airway obstruction. Chest radiograph revealed a markedly dilated esophagus with small air-fluid levels in the mediastinal region with bilateral minimal pleural effusion. Barium swallow skiagram showed a grossly dilated esophagus with residual food suggestive of achalasia cardia and dilated esophagus. Computed tomography of thorax revealed grossly dilated lower third esophagus. Standard monitoring and general anesthesia with left sided double lumen tube (DLT), and thoracic epidural anesthesia was administered. The patient was placed in the left lateral position, and right thoracoscopy was started. As the surgeons started separating the esophagus from the surrounding structures, hemodynamic instability, and arrhythmias occurred coincident with the motion of the thoracoscope. Later, it was noticed that the bellows were gradually collapsing and capnogram showed a decreased value followed by a fall in SpO2. The patient had episodes of hypotension requiring 0.1 mg boluses of phenylephrine. DLT position was reconfirmed. Despite these efforts hypotension persisted and dopamine @ 5-10 mg/kg/min was started. After complete separation of esophagus, thoracic cavity was closed, patient was made supine, DLT was exchanged with 7.5 cuffed endotracheal tube, and the rest of the surgery proceeded uneventfully with tapering off the dopamine infusion...

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