Ann Thorac Surg 2007;84:1034-1036
© 2007 The Society of Thoracic Surgeons
Case Reports
Esophageal Stents for Iatrogenic Esophageal Perforations During Cardiac Surgery
Ahmed S.E. Ramadan, MDa,*,
Constantin Stefanidis, MDa,
William Ngatchou, MDa,
Olivier LeMoine, MD, PhDb,
Didier De Canniere, MD, PhDa,
Jean-Luc Jansens, MDa
a Department of Cardiac Surgery, Erasme Hospital, University of Brussels, Brussels, Belgium
b Department of Gasteroenterology, Erasme Hospital, University of Brussels, Brussels, Belgium
Accepted for publication April 13, 2007.
* Address correspondence to Dr Ramadan, Department of Cardiac Surgery, Erasme Hospital, Free University of Brussels, Lennik Road 808, Brussels, 1070, Belgium (Email: ahmad_sabry_cts{at}yahoo.com).
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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 series of two cases of esophageal perforation by echoprobe during cardiac surgery treated successfully by endoscopic stenting are reported.
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Introduction
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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% [3]. More recently, endoscopic stenting has been proposed as an alternative and less invasive treatment of esophageal leaks [4, 5].
We report a case of an 83-year-old man (81 kgs, 170 cm) with a past history of chronic atrial fibrillation, chronic ischemic cardiomyopathy, hypertension, and mitral valve prolapse. He was admitted in our department for mitral valve repair with annuloplasty. During the procedure no difficulties were encountered in introducing the multiplane probe for transesophageal echocardiography (Hewlett Packard Sonos 5500 6, 2/5 Mhz probe [Hewlett Packard Sonos, Andover, MA]). On postoperative day 3 in the intensive care unit the patient started to have a fever dyspnea, and cough develop. Dullness and a diminished vesicular murmur were found at the right lung base. Hemoglobin was 7.9 g/dL, white blood cell count was 16.9 cells/mm3 and C-reactive protein was 30.3 mg/dL. A chest roentgenogram revealed a bilateral pleural effusion (mainly on the right) and a small loculated pneumopericardium. Laboratory analysis of the pleural fluid showed colonies of Staphylococcus epidermis, Staphylococcus aureus, and Enterococcus faecalis. An esophageal perforation was suspected and antibiotics (piperacillin-tazobactam, meropenem, fluconazole) were started. A thoracic computed tomographic scan with gastrografin (Fig 1) and an esophagoscopy confirmed a large lower third esophageal perforation with signs of reflux esophagitis grade A (Fig 2). No other anomalies were found. An esophageal expansile plastic stenting (Polyflex, 2.5 cm of diameter and 10-cm long [Boston Scientific, Natick, MA]) was placed without difficulty (Fig 3). Oral intake was stopped for 3 weeks under cover of total parenteral nutrition. After that, endoscopic and radiographic follow-up showed no leakage. The pleural drain and the plastic esophageal stent were removed. One month after surgery the patient was discharged home without any complaint. With the same manner, we have been treating a 70-year-old obese woman (71 kg, 160 cm) who underwent coronary artery bypass grafting, and until now she was doing well.
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Comment
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During the past decade, transesophageal echocardiography (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 the TEE probe-mucosal interface, resulting in tissue ischemia and necrosis [1, 2, 6].
Although esophageal thermal injuries have been reported in patients, no histopathologic changes have been observed in animals after manipulation and retention of the echoprobe [6, 7]. Clinical findings of iatrogenic esophageal perforation are nonspecific. Patients are usually asymptomatic for several hours or days, and 33% of initial chest roentgenograms are normal [8]. 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 occur in patients with an unknown esophageal or gastric pathology [2]. Patients with cardiomegaly are also at risk of esophageal trauma during TEE [8]. 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 cases reported, the first patient did not have any past history of gastric or esophageal disease and did not complain of dysphasia or odynophagia, but the second patient did have a history of a mild degree of reflux esophagitis.
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 the clinical states and chest roentgenogram are often suggestive of esophageal perforation with subcutaneous emphysema, pneumothorax, or pleural effusion as seen in our patients. 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 [8].
The thoracic computed tomographic scanner with gastrografin was used in our patients, 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 a minimal surgical approach. Despite advances in surgery, the overall mortality of esophageal perforation remains high [3]. The most important factor influencing outcome is the time interval between the onset of symptoms and treatment. In the cases described, the age of the patients, vicinity of 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 [4] described stent treatment of TEE-induced esophageal perforation in the context of emergency abdominal surgery in a patient with acute myocardial infarction. Nana and colleagues [5] described endoscopic stenting after esophageal perforation during coronary artery bypass grafting.
In conclusion, in highlight of our two cases, we believe that endoscopic esophageal stenting after echoprobe perforation in perioperative cardiac surgery is the first line of management. This approach offers several advantages to open thoracotomy and minimizes the postoperative morbidity and mortality in life-threatening conditions.
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References
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- Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative oesophageal echocardiographyA case series of 7200 cardiac surgical patients. Anesth Analg 2001;92:1126-1130.[Abstract/Free Full Text]
- Kharasch ED, Sivarajan M. Gastero-esophageal perforation after intraoperative transoesophageal echocardiography Anesthiology 1996;85:426-428.
- Attar S, Hankins JR, Suter CM, Couphlin TR, Squeira A, McLaughin JS. Esophageal perforation a therapeutic challenge Ann Thorac Surg 1990;50:45-51.[Abstract]
- Zalunardo MP, Bimmler D, Grob UC, Stocker R, Pasch T, Sapahn DR. Late esophageal perforation after intraoperative transesophageal echocardiography Br J Anaesth 2002;88:595-597.[Abstract/Free Full Text]
- Nana A, Stefanidis C, Chami JP, Devière J, Barvais L, De Smet JM. Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting Ann Thorac Surg 2003;75:1955-1957.[Abstract/Free Full Text]
- Urbanowicz JH, Kernoff RS, Oppenhiem G, Parnagain E, Billingham ME, Ropp RL. Transesophageal echocardiography and its potential for esophageal damage Anesthiology 1990;72:40-43.
- O’Shea JP, Southern JF, D’Ambra MN, et al. Effects of prolonged transesophageal echocardiography imaging and probe manipulation on the esophagus—an echocardiographic pathologic study J Am 1991;17:1426-1429.
- Massey SR, Pitsis A, Mehta D, Callaway M. Oesophageal perforation following perioperative transesophageal echocardiography Br J Anaesth 2000;84:643-646.[Abstract/Free Full Text]
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Abstract
Introduction
