Letters to the Editor International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 1 | Jan-Mar 2013 92 time of surgical intervention can determine the survival outcome. We recommend that patients with aggressive NHL who complain of abdominal pain during systemic chemother- apy and steroids get immediately evaluated for GI ulcers or even perforation and the clinical index of suspicion should be higher in patients with multiple co-morbidities. Hamid S. Shaaban, Tamara Johnson 1 , Gunwant Guron Departments of Hematology/Oncology, and 1 Internal Medicine, St. Michael’s Medical Center, Newark, New Jersey, USA Address for correspondence: Dr. Hamid S Shaaban, Department of Hematology/Oncology, St. Michael’s Medical Center, 111 Central Avenue, Newark-07102, New Jersey, USA. E-mail: hamidshaaban@gmail.com REFERENCES 1. Jambhulkar MI, Joshi MA, Balsarkar D, Chandak M, Parab S. Perforation of jejunal non Hodgkin’s lymphoma. Indian J Gastroenterol 2004;23:110-1. 2. Pine RW, Wertz MJ, Lennard ES, Dellinger EP, Carrico CJ, Minshew BH. Determinants of organ malfunction or death in patients with intra-abdominal sepsis. A discriminant analysis. Arch Surg 1983;118:242-9. 3. Steriof S, Orringer MB, Cameron JL. Colon perforations associated with steroid therapy. Surgery 1974;75:56-8. 4. Torosian MH, Turnbull AD. Emergency laparotomy for spontane- ous intestinal and colonic perforations in cancer patients receiving corticosteroids and chemotherapy. J Clin Oncol 1988;6:291-6. 5. Kobayashi T, Takizawa T, Yoshiyuki T, Suzuki H, Kikuchi T, Ide Y, et al. A case of malignant lymphoma with jejunal perforation. Geka 1995;57:359-61. Access this article online Website: www.ijciis.org Quick Response Code: DOI: 10.4103/2229-5151.109431 Incidental tracheal cuff rupture during placement of double-lumen tubes, What to do? Sir, A 60 years male who was taking anti-tubercular treatment presented in emergency for severe breathlessness. He was managed and investigated found to having upper and middle lobe right lung aspergillosis. Patient was planned for right thoracotomy and upper and middle lobe pneu- monectomy in General Anesthesia with double lumen tube. First of all thoracic epidural catheter is placed and general anesthesia given as per protocol. The height of the patient was 170 cm, so 39 F size double lumen tube of disposable polyvinyl chloride (Broncho Cath DLT, Mallinckrodt Medical, Inc. St. Louis, MO) was selected and checked for any manufacturer defect. Patient trachea was intubated afer direct laryngoscopy guided well lu- bricated lef sided 39 F, DLT and tube fxed at 29 cm mark. On ventilation there stared gargling sound showing leak from trachea. On again checking rupture tracheal cuf was confrmed. Afer removal of frst DLT showing ruptured tracheal cuf [Figure 1]. Another same size 39F lef sided DLT was placed with help of Glideoscope video laryn- goscope under vision with all precaution. Tube position was again confrmed by fberscope and secured. Afer the surgery DLT was changed to 8.5 size cufed normal PVC endotracheal tube. The cufs of plastic DLTs are fragile and easily torn by the teeth, usually during a “difcult” laryngoscopy. In a study done on for lef sided DLT placement 1,169 at- tempted intubations the bronchial cuf was torn once and the tracheal cuf 11 times (0.9%). [1] As our patient airway was Mallampati Grading –I and no buck teeth and, the possible causes of tracheal cuf rupture may be either from teeth or larangoscope blades while negotiating DLT tube in trachea. The patient due to his intrinsic pathol- ogy having fbrosis of upper and middle lobe may have presented altered angulation of the tracheobronchial tree. On reviewing the literature, we found that if a difcult intubation is anticipated, the tracheal cuf of a DLT can be protected by various methods. Both cufs of a modern plastic DLT can be damaged by teeth or by the laryngo- scope blade during intubation of the airway. The larger tracheal cuf is usually at greater risk than the bronchial cuf. When a cuf tear occurs, the tube must be replaced with an intact DLT. This is not only expensive, but requires additional time and may place the patient at increased risk Figure 1: showing ruptured tracheal cuff of DLT