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Iatrogenic oesophageal injury during transoesophageal echocardiography (TOE) is rare. In patients with reduced sensorium under general anaesthesia, the risk may be increased. Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical subcutaneous emphysema should alert to the possibility of oesophageal injury. This article highlights subtle presentations of this potential life-threatening condition, and the importance of early diagnosis and treatment.Case reportA 61-year-old gentleman with symptomatic severe rheumatic mitral stenosis and tricuspid regurgitation underwent mitral valve replacement and tricuspid ring annuloplasty. He has no other significant past medical history. In the anaesthetic room, the patient had a straight-forward endotracheal intubation. However, the cardiac anaesthetist commented on some difficulty in locating the jugular vein for central venous cannula insertion at the right cervical area. Subsequently, cannulation was smoothly accomplished with ultrasound guidance. No air or arterial blood aspiration was reported during the procedure.TOE probe insertion was achieved with guidance by a laryngoscope after an initial attempt with manual manipulation failed. The surgery was uneventful, and satisfactory haemostasis was achieved.In the intensive care unit, the patient was propped up and followed our cwake and extubated protocol. Shortly afterwards, increasing swelling was noted at the base of the neck, initially prompting suspicion of a growing haematoma originating from the surgical site or central venous cannulation. On further examination, cervical crepitus associated with subcutaneous emphysema was demonstrated which was confirmed on chest radiograph (Figure 1). Urgent computed tomography scan showed extensive pneumomediastinum, cervical subcutaneous emphysema, and small paraoesophageal lower neck haematoma (Figure 2).Urgent flexible bronchoscopy was unremarkable, and oesophagogastroduodenoscopy (OGD) confirmed the presence of a hematoma and tear at the level of cricopharyngeus. Endoscopic-guided nasogastric tube was inserted and the patient was managed conservatively with intravenous antibiotics.Computed tomography scan and contrast swallow performed 2 weeks following the injury demonstrated no oesophageal leakage, and complete resolution of subcutaneous emphysema. Oral diet was gradually resumed and he remained well at 6 weeks postoperative follow-up. Figure 1. Chest radiograph showing mild swelling at base of neck, and cervical subcutaneous emphysema Figure 2. Computed tomography scan demonstrating extensive cervical subcutaneous emphysema Discussion Complications from TOE is rare, with the most serious being oesophageal perforation which has a reported frequency of 0.019 to 0.008%.1,2 The mortality rate from the use of TOE is 0.0098%.2 TOE may cause injury by direct oropharyngeal and oesophageal trauma usually related to probe insertion, active manipulation, or tip flexing to acquire images. Prolonged retention of probe in the oesophagus has also been associated with oesophageal perforation.3 TOE should be avoided in patients with extensive oesophageal or gastric diseases as it carries higher risk of injury. Furthermore, it is quite plausibly that patients who are heavily sedated or under general anaesthesia with reduced sensorium may be more prone to oesophageal perforation. A less common mechanism for oesophageal injury is by thermal energy produced from the probe tip. Modern probes are designed to automatically shut off when high temperatures are reached to reduce the risk of such injury. Oesophageal perforation can be life-threatening and should be diagnosed and treated urgently, because delay is well-known to result in high mortality (16 to 35%) and morbidity.1,4Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical surgical emphysema should alert to the possibility of oesophageal injury. Chest radiograph may show the \"V\" sign of Naclerio, which is a V-shaped collection of air in mediastinum and along the diaphragm, indicating presence of pneumomediastinum and pneumothorax.4 Pleural effusion may also be found particularly when there is a delay in diagnosis. Computed tomography is usually diagnostic, although an oesophagram can confirm and demonstrate extravasation of contrast and the level of perforation.4 OGD may also be helpful but is not often necessary. Most reports of TOE oesophageal perforations have presented relatively late with infective complications of the mediastinum and pleural space.1-3 Fortunately, the oesophageal tear was diagnosed very early in this patient, which led to immediate damage limiting management. More commonly, the perforations have occurred at the lower third of the oesophagus.1-3 Our case of an upper oesophageal tear is rare, and the level of injury explains the unusual presentation of neck swelling and subcutaneous emphysema.1-3 Treatment of oesophageal perforations can be conservative and surgical, involving thoracoscopic or open repairs. More recently, endoscopic stenting has been successfully employed to seal off the leak in selected cases.1 Early recognition and treatment of oesophageal perforation is paramount in achieving the best clinical outcome. Clinicians should have a high index of suspicion for oesophageal injury following TOE, particularly when the clinical presentation may be quite variable depending on the time interval to diagnosis and level of tear.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Nana AM, Stefanidis C, Chami JP, et al. Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting. Ann Thorac Surg. 2003;75:1955-7.Elsayed H, Page R, Agarwal S, Chalmers J. Oesophageal perforation complicating intraoperative transoesophageal echocardiography: suspicion can save lives. Interact Cardiovasc Thorac Surg. 2010;11:380-2.Kallmeyer IJ, Collard CD, Fox JA, et al. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001;92:1126-30.Ng CSH, Mui LM, Yim APC. Barogenic Esophageal Rupture: Boerhaave Syndrome. Can J Surg. 2006;49:438-9.

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Iatrogenic oesophageal injury during transoesophageal echocardiography (TOE) is rare. In patients with reduced sensorium under general anaesthesia, the risk may be increased. Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical subcutaneous emphysema should alert to the possibility of oesophageal injury. This article highlights subtle presentations of this potential life-threatening condition, and the importance of early diagnosis and treatment.Case reportA 61-year-old gentleman with symptomatic severe rheumatic mitral stenosis and tricuspid regurgitation underwent mitral valve replacement and tricuspid ring annuloplasty. He has no other significant past medical history. In the anaesthetic room, the patient had a straight-forward endotracheal intubation. However, the cardiac anaesthetist commented on some difficulty in locating the jugular vein for central venous cannula insertion at the right cervical area. Subsequently, cannulation was smoothly accomplished with ultrasound guidance. No air or arterial blood aspiration was reported during the procedure.TOE probe insertion was achieved with guidance by a laryngoscope after an initial attempt with manual manipulation failed. The surgery was uneventful, and satisfactory haemostasis was achieved.In the intensive care unit, the patient was propped up and followed our cwake and extubated protocol. Shortly afterwards, increasing swelling was noted at the base of the neck, initially prompting suspicion of a growing haematoma originating from the surgical site or central venous cannulation. On further examination, cervical crepitus associated with subcutaneous emphysema was demonstrated which was confirmed on chest radiograph (Figure 1). Urgent computed tomography scan showed extensive pneumomediastinum, cervical subcutaneous emphysema, and small paraoesophageal lower neck haematoma (Figure 2).Urgent flexible bronchoscopy was unremarkable, and oesophagogastroduodenoscopy (OGD) confirmed the presence of a hematoma and tear at the level of cricopharyngeus. Endoscopic-guided nasogastric tube was inserted and the patient was managed conservatively with intravenous antibiotics.Computed tomography scan and contrast swallow performed 2 weeks following the injury demonstrated no oesophageal leakage, and complete resolution of subcutaneous emphysema. Oral diet was gradually resumed and he remained well at 6 weeks postoperative follow-up. Figure 1. Chest radiograph showing mild swelling at base of neck, and cervical subcutaneous emphysema Figure 2. Computed tomography scan demonstrating extensive cervical subcutaneous emphysema Discussion Complications from TOE is rare, with the most serious being oesophageal perforation which has a reported frequency of 0.019 to 0.008%.1,2 The mortality rate from the use of TOE is 0.0098%.2 TOE may cause injury by direct oropharyngeal and oesophageal trauma usually related to probe insertion, active manipulation, or tip flexing to acquire images. Prolonged retention of probe in the oesophagus has also been associated with oesophageal perforation.3 TOE should be avoided in patients with extensive oesophageal or gastric diseases as it carries higher risk of injury. Furthermore, it is quite plausibly that patients who are heavily sedated or under general anaesthesia with reduced sensorium may be more prone to oesophageal perforation. A less common mechanism for oesophageal injury is by thermal energy produced from the probe tip. Modern probes are designed to automatically shut off when high temperatures are reached to reduce the risk of such injury. Oesophageal perforation can be life-threatening and should be diagnosed and treated urgently, because delay is well-known to result in high mortality (16 to 35%) and morbidity.1,4Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical surgical emphysema should alert to the possibility of oesophageal injury. Chest radiograph may show the \"V\" sign of Naclerio, which is a V-shaped collection of air in mediastinum and along the diaphragm, indicating presence of pneumomediastinum and pneumothorax.4 Pleural effusion may also be found particularly when there is a delay in diagnosis. Computed tomography is usually diagnostic, although an oesophagram can confirm and demonstrate extravasation of contrast and the level of perforation.4 OGD may also be helpful but is not often necessary. Most reports of TOE oesophageal perforations have presented relatively late with infective complications of the mediastinum and pleural space.1-3 Fortunately, the oesophageal tear was diagnosed very early in this patient, which led to immediate damage limiting management. More commonly, the perforations have occurred at the lower third of the oesophagus.1-3 Our case of an upper oesophageal tear is rare, and the level of injury explains the unusual presentation of neck swelling and subcutaneous emphysema.1-3 Treatment of oesophageal perforations can be conservative and surgical, involving thoracoscopic or open repairs. More recently, endoscopic stenting has been successfully employed to seal off the leak in selected cases.1 Early recognition and treatment of oesophageal perforation is paramount in achieving the best clinical outcome. Clinicians should have a high index of suspicion for oesophageal injury following TOE, particularly when the clinical presentation may be quite variable depending on the time interval to diagnosis and level of tear.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Nana AM, Stefanidis C, Chami JP, et al. Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting. Ann Thorac Surg. 2003;75:1955-7.Elsayed H, Page R, Agarwal S, Chalmers J. Oesophageal perforation complicating intraoperative transoesophageal echocardiography: suspicion can save lives. Interact Cardiovasc Thorac Surg. 2010;11:380-2.Kallmeyer IJ, Collard CD, Fox JA, et al. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001;92:1126-30.Ng CSH, Mui LM, Yim APC. Barogenic Esophageal Rupture: Boerhaave Syndrome. Can J Surg. 2006;49:438-9.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Iatrogenic oesophageal injury during transoesophageal echocardiography (TOE) is rare. In patients with reduced sensorium under general anaesthesia, the risk may be increased. Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical subcutaneous emphysema should alert to the possibility of oesophageal injury. This article highlights subtle presentations of this potential life-threatening condition, and the importance of early diagnosis and treatment.Case reportA 61-year-old gentleman with symptomatic severe rheumatic mitral stenosis and tricuspid regurgitation underwent mitral valve replacement and tricuspid ring annuloplasty. He has no other significant past medical history. In the anaesthetic room, the patient had a straight-forward endotracheal intubation. However, the cardiac anaesthetist commented on some difficulty in locating the jugular vein for central venous cannula insertion at the right cervical area. Subsequently, cannulation was smoothly accomplished with ultrasound guidance. No air or arterial blood aspiration was reported during the procedure.TOE probe insertion was achieved with guidance by a laryngoscope after an initial attempt with manual manipulation failed. The surgery was uneventful, and satisfactory haemostasis was achieved.In the intensive care unit, the patient was propped up and followed our cwake and extubated protocol. Shortly afterwards, increasing swelling was noted at the base of the neck, initially prompting suspicion of a growing haematoma originating from the surgical site or central venous cannulation. On further examination, cervical crepitus associated with subcutaneous emphysema was demonstrated which was confirmed on chest radiograph (Figure 1). Urgent computed tomography scan showed extensive pneumomediastinum, cervical subcutaneous emphysema, and small paraoesophageal lower neck haematoma (Figure 2).Urgent flexible bronchoscopy was unremarkable, and oesophagogastroduodenoscopy (OGD) confirmed the presence of a hematoma and tear at the level of cricopharyngeus. Endoscopic-guided nasogastric tube was inserted and the patient was managed conservatively with intravenous antibiotics.Computed tomography scan and contrast swallow performed 2 weeks following the injury demonstrated no oesophageal leakage, and complete resolution of subcutaneous emphysema. Oral diet was gradually resumed and he remained well at 6 weeks postoperative follow-up. Figure 1. Chest radiograph showing mild swelling at base of neck, and cervical subcutaneous emphysema Figure 2. Computed tomography scan demonstrating extensive cervical subcutaneous emphysema Discussion Complications from TOE is rare, with the most serious being oesophageal perforation which has a reported frequency of 0.019 to 0.008%.1,2 The mortality rate from the use of TOE is 0.0098%.2 TOE may cause injury by direct oropharyngeal and oesophageal trauma usually related to probe insertion, active manipulation, or tip flexing to acquire images. Prolonged retention of probe in the oesophagus has also been associated with oesophageal perforation.3 TOE should be avoided in patients with extensive oesophageal or gastric diseases as it carries higher risk of injury. Furthermore, it is quite plausibly that patients who are heavily sedated or under general anaesthesia with reduced sensorium may be more prone to oesophageal perforation. A less common mechanism for oesophageal injury is by thermal energy produced from the probe tip. Modern probes are designed to automatically shut off when high temperatures are reached to reduce the risk of such injury. Oesophageal perforation can be life-threatening and should be diagnosed and treated urgently, because delay is well-known to result in high mortality (16 to 35%) and morbidity.1,4Following TOE, the presence of pneumothorax, hydropneumothorax, pneumomediastinum or cervical surgical emphysema should alert to the possibility of oesophageal injury. Chest radiograph may show the \"V\" sign of Naclerio, which is a V-shaped collection of air in mediastinum and along the diaphragm, indicating presence of pneumomediastinum and pneumothorax.4 Pleural effusion may also be found particularly when there is a delay in diagnosis. Computed tomography is usually diagnostic, although an oesophagram can confirm and demonstrate extravasation of contrast and the level of perforation.4 OGD may also be helpful but is not often necessary. Most reports of TOE oesophageal perforations have presented relatively late with infective complications of the mediastinum and pleural space.1-3 Fortunately, the oesophageal tear was diagnosed very early in this patient, which led to immediate damage limiting management. More commonly, the perforations have occurred at the lower third of the oesophagus.1-3 Our case of an upper oesophageal tear is rare, and the level of injury explains the unusual presentation of neck swelling and subcutaneous emphysema.1-3 Treatment of oesophageal perforations can be conservative and surgical, involving thoracoscopic or open repairs. More recently, endoscopic stenting has been successfully employed to seal off the leak in selected cases.1 Early recognition and treatment of oesophageal perforation is paramount in achieving the best clinical outcome. Clinicians should have a high index of suspicion for oesophageal injury following TOE, particularly when the clinical presentation may be quite variable depending on the time interval to diagnosis and level of tear.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Nana AM, Stefanidis C, Chami JP, et al. Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting. Ann Thorac Surg. 2003;75:1955-7.Elsayed H, Page R, Agarwal S, Chalmers J. Oesophageal perforation complicating intraoperative transoesophageal echocardiography: suspicion can save lives. Interact Cardiovasc Thorac Surg. 2010;11:380-2.Kallmeyer IJ, Collard CD, Fox JA, et al. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001;92:1126-30.Ng CSH, Mui LM, Yim APC. Barogenic Esophageal Rupture: Boerhaave Syndrome. Can J Surg. 2006;49:438-9.

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