RevBrasAnestesiol.2017;67(4):415---417
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Tension
pneumothorax
during
peroral
endoscopic
myotomy
for
treatment
of
esophageal
achalasia
under
general
anesthesia
Tsung-Shih
Li
a,
Tsung-Yang
Lee
b,
Kate
Hsiurong
Liao
b,∗aCheng-ChingGeneralHospital,Ping-TienBranch,DepartmentofAnesthesia,Taiwan bChinaMedicalUniversityHospital,DepartmentofAnesthesiology,Taichung,Taiwan
Received2October2014;accepted28November2014 Availableonline19November2015
KEYWORDS
Peroralendoscopic myotomy;
Tension pneumothorax; Esophagealachalasia; Generalanesthesia
Abstract Moreandmoreendoscopicallygastrointestinalproceduresrequireanesthesiologists toperform generalanesthesia,such as‘‘peroral endoscopicmyotomy’’. Peroralendoscopic myotomyisanovelinvasivetreatmentfortheprimarymotilitydisorderofesophagus,called esophagealachalasia.Despiteofitsminimallyinvasivefeature,therearestillcomplications duringtheprocedurewhichdeveloptocriticalconditionsandthreatpatients’lives.Hereinwe describeacaseabouttensionpneumothoraxsubsequenttoesophagealruptureduringperoral endoscopicmyotomy.Theemergentmanagementofthecomplicationisstatedindetail.The pivotalpointsofgeneralanesthesiaforpatientsundergoingperoralendoscopicmyotomyare emphasizedanddiscussed.Also,intraoperativeandpost-operativecomplicationsmentioned byliteratureareintegrated.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Miotomiaendoscópica porviaoral;
Pneumotórax hipertensivo; Acalasiaesofágica; Anestesiageral
Pneumotóraxdetensãodurantemiotomiaendoscópicaporviaoralparatratamento
demegaesôfagosobanestesiageral
Resumo Cadavezmaisosprocedimentosgastrointestinaisfeitosporendoscopia,taiscomoa miotomiaendoscópicaporviaoral(MEVO),exigemanestesiologistasparaadministrar aneste-sia geral. A MEVO é um novotratamento invasivo para o distúrbio de motilidade primária doesôfago, denominadoacalasia esofágica (AE).Apesar desuacaracterísticaminimamente
∗Correspondingauthor.
E-mail:hiphopdance100@gmail.com(K.H.Liao).
http://dx.doi.org/10.1016/j.bjane.2014.11.020
0104-0014/©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC
416 T.-S.Lietal.
invasiva,existemcomplicac¸õesduranteoprocedimentoqueevoluemparacondic¸õescríticase deriscoàvida.Descrevemosaquiumcasodepneumotóraxdetensãoapósarupturadoesôfago duranteumaMEVO.Otratamentodeemergênciadacomplicac¸ãoérelatadoemdetalhes.Os pontoscruciaisdaanestesiageralparapacientessubmetidosàMEVOsãoenfatizadose discu-tidos.Alémdisso,ascomplicac¸õesmencionadaspelaliteraturanosperíodosintraoperatórioe pós-operatóriosãointegradas.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
In the era of minimally invasive gastrointestinal surgery, manyproceduresrelyonanesthesiologiststoprovidevarying degrees of sedation or anesthesia, such as esophagogas-troduodenoscopy. Peroral endoscopic myotomy (POEM) is anovel treatment for esophageal achalasia (EA) in which clinicaltrialsyieldgoodresults.1,2Generalanesthesia usu-ally offers better cooperation and compliance when the surgeon manipulates the esophagus with an endoscope and also eliminates perioperative gut discomfort due to gas insufflation. In addition, positive pressure ventilation with endotracheal intubation provides better respiratory mechanicsunder increased intra-abdominal pressure gen-eratedbyinsufflatedgas.However,complicationsresulting from surgical intervention may develop, e.g., pneumoth-orax, mediastinal emphysema, subcutaneous emphysema, andpneumoperitonium.3,4Thesecomplicationshavechance to develop to critical ones. In the following article we report a patient who encountered tension-pneumothorax whileundergoingPOEMundergeneralanesthesia.
Case
report
A 56-year-old previously healthy woman (height 155cm, weight48kg)wasscheduledtoundergoperoralendoscopic myotomyfornewdiagnosedesophagealachalasia.Her lab-oratorytestswerenormal.Shewasheldnilperosfor 8h. The initial vital signs in the operating room represented bloodpressure151/68mmHg, withheartrate 78bpmand saturation95%.Duringinductionofgeneralanesthesia, pre-oxygenationwith100%oxygenvia facemaskwasdone for 5min following by intravenous fentanyl 100mcg, Propo-fol120mg,andlidocaine20mg.Rapidsequencetechnique wasappliedwithcricoidpressureafteradministrationwith rocuronium35mg.Successfulnasalendotrachealintubation wasachieved. The lung was ventilatedat a tidal volume of 10mL/kg and a rate of 10breaths/min. The patient was maintained in stable hemodynamics with sevoflu-rane. The initial plateau pressure was 21mmHg under PEEP 5mmHg. The endoscopewas then inserted intothe esophagus and a submucosal tunnel created by mucoso-tomy with blunt air dissection was made. The patient’s abdomenwasincreasinglydistendedandgraduallyelevated airway pressure (from 21mmHg to 30mmHg) occurred
duringthefirst2hoftheprocedure.Thesurgeondeflated and evacuated the air in the gut so that airway pres-sure declined to 23mmHg. The following third hour of the operation, plateau pressure rapidly rose again up to 35mmHgwithin30min,anddesaturationfrom100%down to 85% accompanied by loss of breath sounds of right lung andlossofright chestwallmovement wasdetected. Rightchestpercussion showedhyper-resonance.Her jugu-lar vein was engorged. There was obvious subcutaneous emphysemaoverherface,neck,shouldersandchestwall. Tachycardia with HR 132bpm and hypotension with BP 80/55mmHg ensued. Right tension pneumothorax result-ing from esophageal rupture was diagnosed immediately. The anesthesiologistusedemergentneedledecompression (by a16G needle)viaright second intercostalspace.The airway pressure decreased to 27mmHg and blood pres-surebecamenormalwithinfewminutes.Soonafteraright chest tube was placed, the patient’s saturation restored to 100%. The surgeon completed the treatment and the patient wastransferred to intensive care unitin the end oftheoperation.Twohoursafterthesurgeryshewas suc-cessfully extubated in the ICU. Post-operative Day 3, the patient developed mediastinitis with right empyema and underwentthoracotomy for esophagealrepair andpleural decortication.Inthefollowingdaysherconditionwasstable underantibioticadministration.Shewasdischarged10days later.
Discussion
Esophagealachalasiaisaprimarymotilitydisorder charac-terizedbyincreasedloweresophagealsphincter(LES)tone and lack of peristalsis of the esophagus.5 In recent years POEMhasbeenanovelpromisingtherapeuticmodalityfor EA. Ofcourse, miscellaneous complications of POEMhave alsobeenmentioned.
Tensionpneumothoraxduringperoralendoscopicmyotomy 417
pleural cavity. Furthermore, positive pressure ventilation under general anesthesia facilitated the development of pneumothorax.That’swhytensionpneumothoraxoccurred inthispatientfollowing2hofsurgery.Evidencesupported that the use of air had a higher rate in gas-insufflation related complications than the use of carbon dioxide.3,6 Renet al.3 reportedthreecasesasintraoperative pleural drainage for intraoperative pneumothorax resulting from carbon dioxide insufflation. The patient we described here is the first case who experienced shock due to air insufflationinducedtensionpneumothoraxandwastreated with emergent needle decompression and chest tube drainage. Because sometimes transmural openings of the esophagus into the mediastinum may occur for surgical reasons.7 We emphasize the importance of awareness in excessively elevated airway pressure during POEM, especiallythe surgeonchoosesairasinsufflationgas with a long duration. We suggest minimal gas insufflation to gut withcarbon dioxideand limitedpressure tominimize gas leakage. Abnormal findings in physical examination suchasdecreasedbreathsounds,hyper-resonanceinchest percussionandjugularvenousdistensionmayindicatethe formation of pneumothorax. Once tension pneumothorax (pneumothoraxwithcompromisedvitalsigns)isconsidered, promptdecompression should bedone without anyimage evidence for the reason of immediate rescue of unstable hemodynamics.
Post-operative complications of POEM associated with gas insufflation and gas leakage via minor esophageal tear include pneumothorax, pneumoperitonium, medi-astinal emphysema, and subcutaneous emphysema. One study detected different degrees of post-operative pleu-ral effusion and focal atelectasis by thoracic CT on POEM treated patients.6 Literature had reported these complications as common but non-life threatening ones andmostpatientscouldrecoverunderconservative treat-ment or tube drainage.3,6---9 It is to be noticed, however, eventhesecomplicationsareself-limiting,theymay dete-riorate post-operative respiratory function in patients with pulmonary diseases. An unexpected complication, atrial fibrillation, caused by left atrial compression from esophageal submucosal hematoma had been reported by Abdulazizetal.10
Thepatientwedescribedherehadsymptomsof epigas-tric fullness and regurgitation of undigested food before the surgery. During induction, the risk of pulmonary aspiration was concerned. We applied rapid sequence inductionwithcricoidpressuretothepatient.This compli-cation occurred during general anesthesia in a patient undergoing POEM reported in literature.11 Nevertheless cricoidpressure might beunnecessary afterpre-induction endoscopic clearance of esophageal contents.12 Anesthe-siologists should be alert in this risk during induction period and take well preparation and prevention strat-egy.
Conclusion
POEM is a new technique to treat esophageal achalasia andgeneralanesthesiaisusuallyneeded.Anesthesiologists should have a great understanding in intraoperative and post-operativecomplicationsofPOEMsuchastension pneu-mothorax,andapplyimmediateandcorrectmanagements. Also,anesthesiologistsmusthaveaclearconceptaboutthe risk of pulmonary aspiration when they perform general anesthesiatothesepatientsandprovidegoodprevention.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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