Ann Thorac Surg 2003;75:1955-1957
© 2003 The Society of Thoracic Surgeons
Case report
Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting
Albert M. Nana, MDa,
Constantin Stefanidis, MDa,
Jean-Pierre Chami, MDb,
Jacques Deviere, MD, PhDc,
Luc Barvais, MD, PhDd,
Jean-Marie De Smet, MDa*
a Department ofCardiac Surgery, , Brussels, Belgium
b Department ofInfectious Diseases, , Brussels, Belgium
c Department ofGastroenterology, , Brussels, Belgium
d Department ofAnesthesiology, Erasme Hospital, University of Brussels, Brussels, Belgium
Accepted for publication November 14, 2002.
* Address reprint requests to Dr De Smet, Erasme Hospital, University of Brussels, 808, Route de Lennik 1070 Brussels, Belgium
e-mail: jean-marie.de.smet{at}ulb.ac.be
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Abstract
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The usefulness and safety of transesophageal echocardiography during cardiac surgery have been well described in the literature. However, rare complications of this procedure can occur and should be familiar to surgeons and anesthesiologists. A case of esophageal perforation by echoprobe during coronary artery bypass grafting treated successfully by endoscopic stenting is reported.
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Introduction
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Transesophageal echocardiography (TEE) is routinely used during cardiac surgery to monitor cardiac hemodynamics, removal of air, weaning off bypass and alve function. Complications such as esophageal perforations are reported with a frequency of 0.008% [1, 2], and can be treated conservatively or surgically, with a mortality ranging from 16% to 35% [6]. More recently, endoscopic stenting has been proposed as an alternative and less invasive treatment of esophageal leaks [7].
A 70-year-old obese (71 kgs, 160 cm) woman with a past history of diabetes and hypertension was admitted in our department for progressive coronary artery disease. She underwent coronary artery bypass grafting under TEE control of the cardiac function. No difficulties were encountered during the multiplane probe insertion (Hewlett Packard Sonos 5500 6,2/5 Mhz probe, Andover, MA).
During bypass, the probe was withdrawn to the lower third of the esophagus and was left in a neutral (nonflexed) position. On the second postoperative day, the patient complained of fever, myalgia, and cough. On clinical examination she was pale and sweating. Dullness and a diminished vesicular murmur were found at the left lung base. Hemoglobin was 7.4 g/dL, white blood cell count was 11.9 cells/mm3 and c = reactive protein (CRP) 33.3 mg/dL. Chest roentgenogram revealed a massive pleural effusion and a small loculated pneumopericardium. Laboratory analysis of the pleural fluid showed colonies of Streptococcus viridans, Enterococcus faecalis and Candida albicans. An esophageal perforation was suspected and antibiotherapy was started (clavulanic acid, amoxicillin, fluconazole). A thoracic computed tomographic scan with gastrografin (Fig 1)
and esophagoscopy confirmed a large esophageal perforation, 2 cm proximal to the Z line. No other anomalies were found.
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Fig 1. Thoracic computed tomographic scan showing leakage (arrow) within the distal part of the esophagus.
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An esophageal coated stenting (Ultraflex, 2.2 cm of diameter and 13 cm long; Boston Scientific, Natick, MA), was placed without difficulties. Two days later, oral intake was allowed. Ten days after stenting, no leakage was found on endoscopic and thoracic computed tomographic scan control (Fig 2).
The pleural drain was removed. Seventeen days after coronary artery bypass grafting, the patient was discharged home. Nine months later, she is still free of complaints, without dysphagia or angina. She declined further endoscopic examination, but a plain chest and abdominal roentgenogram showed no migration of the stent.
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Comment
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During the past decade, TEE has been intensively used for the management of cardiac surgical patients. Although it is considered to be safe and semi-invasive, cases of oropharyngeal, esophageal, and gastric damages by echoprobe during cardiac surgery have been reported [1].
Traumatic, ischemic, and thermal theories are evoked to explain esophageal damage during TEE. Direct trauma may be associated with blind insertion and advancement of the probe, the large size of the probe tip relative to the esophagus, and the wide range of probe tip flexion and manipulations required to obtain good images. Indirect trauma may be related to excessive and prolonged continuous pressure at TEE probe-mucosal interface, resulting in tissue ischemia and necrosis [1, 2, 3]. Although esophageal thermal injury have been reported in patients, no histopathologic changes have been observed in animals after manipulation and retention of the echoprobe [3, 4].
Clinical findings of iatrogenic esophageal perforation are nonspecific. Patients are usually asymptomatic for several hours or days, 33% of initial chest roentgenogram is normal [5]. The common symptoms and signs are chest pain, dyspnea, vomiting, and fever. The clinical course depends on the mechanism of the perforation. Patients reporting difficulties during the echoprobe insertion were all associated with immediate or early presentation of obvious signs of injury [2]. In all other patients, there was a delay of days between TEE and the onset of symptoms when patients resumed oral intake.
The majority of iatrogenic esophageal damages occurs in patients with an unknown esophageal or gastric pathology [2]. Patients with cardiomegaly are also at risk of esophageal trauma during TEE [5]. Many authors recommend performing an upper gastrointestinal series before TEE if a preexisting gastrointestinal disease is suspected, with TEE being contraindicated if any anomaly is found [1]. In the case reported, the patient did not have any past history of gastric or esophageal disease and did not complain of dysphasia or odynophagia.
To prevent thermal injuries, most of the current TEE probes have temperature sensors at their tip. In addition, it is recommended that the transmittance energy be turned off during periods of hypothermic bypass when the probe is not being used. Kallmeyer and colleagues [1] suggested the use of intraoperative epicardial or epiaortic probe if TEE is contraindicated.
In the majority of patients, chest roentgenogram is often suggestive of esophageal perforation with subcutaneous emphysema, pneumothorax, or pleural effusion as seen in our patient. After cardiac surgery, pleural effusion is often present and makes this diagnostic tool less specific. Upper gastrointestinal series with gastrografin is the most sensitive diagnostic test demonstrating more than 90% of esophageal perforations [5]. Thoracic computed tomographic scanner with gastrografin was used in our patient, which led to the diagnosis. It is easy to perform, reveals the level of perforation, helps to define the extent of mediastinitis and abscesses, and avoids upper gastrointestinal manipulations in unstable patients.
The management of esophageal perforation remains controversial and problematic. Treatment options include primary repair, resection and conservative treatment with minimal surgical approach. Despite advances in surgery, the overall mortality of esophageal perforation remains high [6]. The most important factor influencing outcome is the time interval between the onset of symptoms and treatment. In the case described, the age of the patient, vicinity of a major operation, and septic state inclined us to choose stent deployment therapy, which is considered a more expeditive and less invasive form of treatment. Zalunardo and colleagues [7] described stent treatment of TEE-induced esophageal perforation in the context of emergency abdominal surgery in a patient with acute myocardial infarction.
We believe that our case is the first report of stent treatment of esophageal perforation after cardiac surgery. This approach offers several advantages to open thoracotomy and could minimize postoperative morbidity and mortality in life-threatening conditions. This procedure has to be confirmed by further observations.
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References
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- Kallmeyer I.J., Collard C.D., Fox J.A., Body S.C., Shernan S.K. The safety of intraoperative transesophageal echocardiography. A case series of 7200 cardiac surgical patients. Anesth Analg 2001;92:1126-1130.[Abstract/Free Full Text]
- Kharasch E.D., Sivarajan M. Gastroesophageal perforation after intraoperative transesophageal echocardiography. Anesthesiology 1996;85:426-428.[Medline]
- Urbanowicz J.H., Kernoff R.S., Oppenheim G., Parnagian E., Billingham M.E., Popp R.L. Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology 1990;72(1):40-43.[Medline]
- O’Shea J.P., Southern J.F., D’Ambra M.N., Margo C., et al. Effects of prolonged transesophageal echocardiography imaging, and probe manipulation on the esophagus–an echocardiographic-pathologic study. J Am Cardiol 1991;17:1426-1429.
- Massey S.R., Pitsis A., Mehta D., Callaway M. Oesophageal perforation following perioperative transoesophageal echocardiography. Br J Anaesth 2000;84(5):643-646.[Abstract/Free Full Text]
- Attar S., Hankins J.R., Suter C.M., Coughlin T.R., Sequeira A., McLaughlin J.S. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;50:45-51.[Abstract]
- Zalunardo M.P., Bimmler D., Grob U.C., Stocker R., Pasch T., Spahn D.R. Late esophageal perforation after intraoperative transoesophageal echocardiography. Br J Anaesth 2002;88:595-597.[Abstract/Free Full Text]
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September 1, 2007;
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Abstract
Introduction
