A seventy four year male, retired professor of plastic surgery who underwent CABG 11 years ago presented to our emergency with massive hematemesis. His Hb was 6.4 g/dl. He had had multiple episodes of hematemesis in the past two weeks requiring one unit of packed cells transfusion every day. Eight months ago he underwent endovascular stenting of proximal descending thoracic aorta in another hospital. Now he was diagnosed to have aorto-esophagial fistula a potentially fatal condition and was referred to Dr.Bashi for further management.
When the patient was brought to SIMS he was in a morbid condition with very low Haemoglobin. He was fed up with his condition and not keen to pursue any further treatment. His relatives, however, were very keen that he should undergo the live savind operation. While in hospital he became very sick and had to be intubated and taken up for emergency surgery.
Dr.Bashi decided to remove the stent graft which was affected and repair the oesophagus. As a first stage gastro surgical team headed by Dr.Patta Radhakrishna laparoscopically mobilised the entire omentum which was pulled in to the left hemi-thorax through the esophageal hiatus of the diaphragm. Then the patient was put on heart lung machine and under controlled circulation, the aorta was clamped and the endograft was removed. The aorta, the distal aortic arch and the thoracic aorta was reconstructed meticulously with a prosthetic performed graft. Omentum was then used to cover the entire graft repair of the oesophagus. He was put on parenteral nutrition for six weeks and was discharged in a stable condition. Six months later, he is eating normally and has resumed surgical practice once again!
The entire marathon surgery (10hrs) was orchestrated in such a way that there was perfect co-ordination between the two nursing teams (cardiac-gastro) in the operation theatre. The OT nurses from both departments got an opportunity to peep into each other’s territory and this enhanced their learning. At the same time it showcased their goodwill and support, as there was no delay and necessary instrumentation was arranged swiftly. The surgery went on well and all of us felt so proud to be a part of this complex surgery and the unit.
Our successful management of such a complicated case shows, how team work with proper planning and execution is important.