Esophageal perforation following orogastric suction catheter insertion in an elderly patient

Roland N. Kaddoum*, Fadi Farah**, Rita W. Saroufim*** and Salah M. Zeineldine****

Abstract

Esophageal rupture has been described following iatrogenic manipulation. In this report, we present an elderly lady admitted to the operative theater for laparoscopic cholecystectomy. Multiple intra-operative attempts to place a flexible orogastric tube were unsuccessful because of failure to advance. Post-operatively, the patient developed sepsis and a right pleural effusion. She was transferred to the Intensive Care Unit and she was treated with antibiotics. Radiologic evaluation confirmed an esophago-pleural fistula. Surgical repair was urgently performed for closure of fistula and lung decortication. The patient recovered and was discharged home.

Introduction

Esophageal perforation is a serious complication of procedures performed on or around the esophagus and is mainly iatrogenic1,2. Esophageal perforation is most frequently encountered during endoscopic procedures3 but also during nasogastric tube placement4-9, endotracheal intubation10-14, stricture dilation15,16 and during the use of oesophageal bougies17. This complication has a poor prognosis with inadequate management3. While providing anesthesia to surgical patients, anesthesists frequently insert esophageal dilators, nasogastric tubes or orogastric tubes/suction catheters. Such interventions may cause trauma to soft tissue structures. We describe a case of esophageal perforation secondary to the orogastric insertion of a simple 14 french suction catheter used routinely to deflate the stomach during laparoscopic cholecystectomy. To our knowledge, this is the first case report describing esophageal perforation following the insertion of a flexible orogastric 14Fr suction catheter in an adult patient undergoing laparoscopic cholecystectomy.

* MD, Assistant Professor of Anesthesiology, American University of Beirut Medical Center, Department of Anesthesiology, Beirut, Lebanon (Riad Solh 1107-2020). ** MD, Anesthesiology resident, Formerly of: American University of Beirut Medical Center, Department of Anesthesiology, Beirut Lebanon (Riad Solh 1107-2020). Current Department: St. Elizabeth's Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, 736 Cambridge Street, #213, Brighton, MA 02135. *** Medicine III student, Bachelor degree in Biology, American University of Beirut Medical Center, Department of Anesthesiology, Beirut, Lebanon (Riad Solh 1107-2020). **** MD, Assistant Professor of Clinical Medicine, American University of Beirut Medical Center, Department of Internal Medicine, Beirut, Lebanon (Riad Solh 1107-2020). Corresponding author: Salah M. Zeineldine, MD, Assistant Professor of Clinical Medicine, American University of Beirut Medical Center, Department of Internal Medicine, Beirut, Lebanon (Riad Solh 1107-2020). Tel: +961-1-350 000 x 4706, Fax: +961-1-744 489. E-mail: [email protected]

117 M.E.J. ANESTH 23 (1), 2015 118 Roland Kaddoum et. al

Case Report was uneventful. The patient was transferred to the recovery room. She was fully awake and asymptomatic. A 79 year old, 70 kg lady known hypertensive On post-op day one, the patient complained and dyslipidemic presented for laparoscopic of dry cough and dyspnea after her first meal. On cholecystectomy and intraoperative cholangiogram physical exam, she had scattered wheezes and right secondary to an acute cholecystitis. The patient denied field crakles. She was afebrile. Chest X ray (CXR) any symptoms or history of dysphagia, odynophagia, revealed opacification on the right lower and right gatroesophageal reflux or chest pain. Difficult middle fields. A diagnosis of pulmonary aspiration intubation was anticipated due to short neck and a was suspected and Solumedrol, Combivent, pulmicort glidescope assisted intubation was planned. and Tazocin were started. The CXR improved in the In the operating room, after lung denitrogenation afternoon. However, clinically the patient was getting with 100% oxygen, rapid sequence induction was worse the following day with progressive desaturation performed using lidocaine 100 mg (1.5 mg/kg), down to 90% and became hypotensive with systolic propofol 140 mg (2 mg/kg) and succinylcholine 100 pressure of 80 mmHg. The patient was transferred mg (1.5 mg/kg) intravenously. No bag ventilation to the intensive care unit and Tazocin was shifted was performed. The trachea was intubated by an to broad spectrum antibiotic coverage consisting of endotracheal tube (ETT) size 8.0 using the Glidesscope Meropenem, Levofloxacin and Metronidazole. The and a 10Fr intubating stylet (Unomedical). Several patient symptoms improved, however the cough and attempts to insert a well lubricated 14 Fr suction wheezes persisted. A CT chest was done on post op catheter failed (Bicakcilar, suction catheter w/ day 7 revealing an air pocket posterior to the carina vakon connector ideal tip 4.7 mm x 600mm). The in continuity with the right lower lobe. A diagnosis catheter would not advance even with an index finger of esophageo-pleural fistula in the lower esophagus inserted in the patient mouth guiding the catheter was suspected and was confirmed with Gastrograffin into the pharynx. After multiple attempts using the swallow. On post-op day 9, a thoracotomy for right laryngoscope to have better visualization, the insertion lung decortication and closure of fistula was performed. of the orogastric tube was not successful. During The patient was kept intubated and extubation was the procedure, the surgeon noted that the stomach done on the following day. Antibiotics were continued was inflated and insisted on the placement of an for 14 days post-op. The radiological findings on CXR orogastric tube to suction the stomach. We elected resolved on post-op day 17. then to place an ETT size 7.0 that we advanced in the A repeated gastrograffin swallow was performed esophagus and inserted the orogastric tube through it. on post-op day 20 showing an outpouching at the The advancement of the catheter would always stop level of the fistula but no leak. Another gastrograffin at the same level as previously tried with or without swallow was performed on post-op day 27 showed no the laryngoscope attempts. The resistance upon the leak. insertion of the catheter was encountered at a distance of about 25 cm from the lips. No forceful maneuvers The patient was discharged from the hospital on were performed and no blood was recovered over the post-op day 33. suction catheter. We decided to abort the placement of the orogastric tube and the surgeon was advised so. His Discussion concern was a fully inflated stomach that he is showing us on the video camera. We explained that placement Perforation of the esophagus due to of orogastric tube was difficult, and will treat his instrumentation in the adult is a rare yet potentially concern by extubating the trachea when the patient is devastating event associated with high morbidity and fully awake. mortality3. The mortality has decreased from 38.7% After the surgical procedure ended, extubation in the 1970s to 8.3% today18. The leading cause of Esophageal perforation in laparoscopy 119 esophageal perforation is mainly iatrogenic with However if delayed diagnosis beyond 48h was made, perforations at the thoracic level being the highest19. no patient with esophageal perforation should be Most of perforations occur during instrumentation deprived from surgical repair28. Mortality is decreased of the esophagus i.e. endoscopy procedures, in surgical repair versus conservative treatment29, for transesophageal echocardiography, esophageal varices that reason, our patient underwent thoracotomy for sclrerotherapy, stricture dilatation, using relatively fistula closure and repair of esophageal tear. large stiff probes (endoscope, TEE probe, Sengstaken- In any patient with a recent history of esophageal Blakemore (SB) tube, bougie). Several risk factors instrumentation, the diagnosis of esophageal injury have been described for esophageal perforation such should be suspected in the presence of any of the as pre-existing esophageal abnormalities (carcinoma, symptoms encountered by our patient. Also, the stricture, diverticuli)20 and cervical osteophytes21. absence of gastric content on naso/orogastric tube or Esophagogastroduodenoscopy was the most the presence of blood on the catheter elicit a possible commonly litigated procedure, followed by intubation diagnosis of perforation. Nevertheless blood was not and Nissen fundoplication22. But there have been few noted on the suction catheter in our case. reported cases of iatrogenic esophageal perforations by a flexible nasogastric tube occurring mainly in For the first 24 hours following the laparoscopic neonates or infants4-6,9,23. cholecystectomy, our patient’s only complain was pain over the incision and a mild shoulder pain attributed to In our patient the perforation occurred the laparoscopic procedure. This pain was controlled after multiple attempts at inserting the orogastric by analgesics. She denied any complain or history suction catheter where the obstruction was faced of dysphagia, odynophagia, dysphonia or dyspnea. at 25cm distal to the lips. The most common areas However, after her first meal she complained of of instrumental esophageal perforation are the sudden dry cough and severe dyspnea. Taking into relatively narrow portions at the distal esophagus. consideration the fact that the patient was extubated The perforation is complicated by an inflammatory with a distended stomach, pulmonary aspiration was process and communication with the pleura in 80% of the most probable diagnosis. the cases24. The thin mediastinal pleura is ruptured by the inflammatory process, producing contamination It was the persistence of the cough and dyspnea of the pleural space and a pleural effusion. Then, and the worsening of these symptoms following gastric contents and fluids are drawn into the pleural meals, along with a problematic naso/orogastric tube space by the negative intrathoracic pressure resulting insertion that made the suspiscion of esophageal in further inflammation and fluid sequestration, perforation high. Because of the failure of insertion of hypovolemia, and the early appearance of tachycardia the orogastric catheter and the occurrence of resistance and systemic sepsis. In our patient the CXR revealed at 25 cm from the lips, an intrathoracic esophageal opacifications which reflect consolidation of the lungs injury in our case was suspected. The CT chest showed that is due to an accumulation of fluids that is most an air pocket adjacent to the carina in continuity with probably edema and inflammation. This explains the the right lower lobe. This prompted us to perform scattered wheezes and crackles that were heard on esophagogram to confirm the diagnosis of esophageal post op day one. In addition, esophageal perforation perforation. allows bacteria, usually polymicrobia flora to spread The presence of underlying esophageal pathology into the mediastinum and subphrenic space leading could explain the difficulty in advancing the orogastric 18,25-27 to mediastinitis . This explains the septic picture tube. As anesthesiologists we are the experts in inserting of our patient that was revealed by hypotension and orogastric tubes or suction catheters, a maneuver that progressive oxygen desaturation. we perform almost every day in our practice. The Literature showed a better outcome with primary advancement of the catheter was impossible past 25cm surgical closure if diagnosed in less than 24 hours. of the lips despite so many attempts. This could be

M.E.J. ANESTH 23 (1), 2015 120 Roland Kaddoum et. al explained by a pre-existing esophageal pouch that the Conclusion patient is unaware of or by an osteophytic compression of the esophagus due to the patient age, which made The lesson taken from this case report is not to the advancement of the catheter impossible. Forcing force the advancement of an orogastric/nasogstric the catheter insertion through multiple attempts lead suction catheter especially when different techniques to the perforation. On another note, the deviation from and multiple attempts fail. The other lesson taken is our current practice of inserting a suction catheter to have a very high threshold inserting an ETT in the through an ETT placed in the esophagus is a very rare esophagus to facilitate the suction catheter insertion maneuver that we perform in extreme situations. This by advancing the catheter through the ETT since this also could be the reason of the perforation. could also be a risk factor for esophageal perforation. Esophageal perforation in laparoscopy 121

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