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Oesophageal perforation

Case study: Oesophageal perforation following LSG

Oesophageal perforations are a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential

The risks related to the use of bougie during bariatric surgery should not be underestimated and inserted with extreme caution in order to prevent oesophageal perforations, according to researchers from Karolinska University Hospital, Stockholm, Sweden, who noted that oesophageal perforations are a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

The paper, ‘Cervical oesophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy: a case report and review of the literature’, published in BMC Surgery, reports on the rare case of a cervical oesophageal perforation caused by a bougie during laparoscopic sleeve gastrectomy (LSG).

The complication occurred in a 42-year old woman who underwent LSG (BMI31) in a private hospital in October 2018. The LSG lasted 37 minutes and there were no obvious intraoperative complications. However, immediately after the operation the patient complained about pain in the throat, mild difficulty swallowing and pain when moving her neck.

The next morning, the pain had increased, her throat was swollen and she suffered from marked sialorrhea. A subsequent laryngoscopy revealed no issues. Later, the patient developed subcutaneous emphysema and underwent an emergency CT scan, which showed free air outside the oesophageal lumen, up to the neck and along the entire intrathoracic oesophagus. The patient was still hemodynamically stable and in good general condition and was transferred to our hospital, which is a tertiary referral centre for oesophageal surgery, for further management.

She was taken to the operating room and a gastroscopy was performed under general anaesthesia revealing a 3cm long perforation located 14–1 cm from the incisors on the posterior wall of cervical oesophagus, estimated to be at exactly the level of the thoracic inlet. The false lumen extended more distally, and the prevertebral space at the time of surgery was filled with purulent fluid (Figure 1). The authors noted that due to the proximity to the cricopharyngeal muscle, sealing of the perforation by placement of a fully covered oesophageal stent was not possible. Because of the large size of the defect using an endoluminal vacuum therapy system was unfeasible.

Gastroscopy captures showing a big perforation on the posterior wall of the cervical esophagus. a. Large communication with the prevertebral space which is filled with purulent fluid. b–c. The prevertebral fascia is visible, marked with an asterisk (*). d. A nasogastric tube is inserted under direct vision for decompression

The investigators needed access to the upper mediastinum to achieve satisfactory drainage and, repair the defect at the same time if possible. A right-sided thoracoscopy was performed and the intrathoracic oesophagus was mobilised by incising the mediastinal pleura and a large mediastinal fluid collection was evacuated. Although the lower border of the perforation high up on the posterior wall of the oesophagus at the level of thoracic inlet could be visualised, suturing was technically not possible thoracoscopically.

After placing two drains in the thoracic cavity and the cervical oesophagus was approached through a left-sided neck incision. The proximal oesophagus was mobilised and rotated giving access to the posterior side, the defect was visualised and repaired with interrupted 4/0 PDS sutures. Further reinforcement was applied by a muscle flap constructed from the sternal head of the sternocleidomastoid muscle. Due to neck oedema, delayed extubation was performed as a precaution and the patient spent the first post-operative day in the Intensive Care Unit and was discharged and transferred to the ward the following day. Further treatment with nil by mouth, broad-spectrum antibiotics and parenteral nutrition was carried out. The recovery was uneventful; the patient could start an oral diet on post-operative day six and was discharged from the hospital two days later (post-operative day 8).

Literature

A systematic web-based search revealed 62 articles, but only two case reports describing iatrogenic perforations caused by the use of a bougie during bariatric surgery, both described more distal lesions located in the middle and lower oesophagus, respectively. Furthermore, a retrospective descriptive study on thoracic complications after bariatric surgery had reported on three patients where thoracic oesophageal perforation occurred due to bougie advancement during LSG.

The authors state that the most important principles of the management of an oesophageal perforation include:

  • resuscitation of the patient
  • assessment of the defect and;
  • timely decision-making regarding operative or non-operative management

If the patient is hemodynamically stable and the mediastinal or abdominal contamination limited, an endoscopy can be performed to assess the perforation and if appropriate treat it with the placement of an oesophageal stent, endoscopic clips or Eso-SPONGE in case of small defects.  In such cases, a conservative approach can be attempted, consisting of nasogastric decompression, parenteral nutrition, adequate drainage of mediastinal and pleural collections and broad-spectrum antibiotics.

In cases where non-surgical management is not feasible, due to the location or size of the perforation or the extent of the contamination, patients should be treated with emergency surgery. Firstly, the surgeon should suture the defect, sometimes with an intercostal or other muscle flap to reinforce the repair. If not possible, due to severe sepsis with hemodynamic instability, large size of the defect or friability of the surrounding tissues, the best choice is a damage control approach, e.g. oesophageal diversion, which gives the patient the best chance of survival. In these cases, reconstruction of the oesophagus is typically performed six months to one year following the perforation, pending full recovery. In addition to infection source control, adequate external drainage of all mediastinal and thoracic collections is mandatory.

“In conclusion, this is the first reported case, to our knowledge, of a cervical oesophageal perforation caused by the bougie during LSG. We present it in order to underline that the risks inherited in the use of a bougie (or any other oesophageal tube) during surgery should not be underestimated and that the insertion must be done with extreme caution,” the authors write. “Oesophageal perforation is still a challenging, life threatening, complication. Once the suspicion of a perforation arises all available tests (CT scan with orally administered water-soluble contrast and gastroscopy) should be performed without delay, as prompt diagnosis and initiation of adequate treatment is the key to a favourable outcome.”

To access this paper, please click here

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