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Ann Thorac Surg 2007;84:1034-1036
© 2007 The Society of Thoracic Surgeons
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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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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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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This article has been cited by other articles:
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  L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, A. M. Hutter Jr, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., December 6, 2011; 58(24): e123 - e210. [Full Text] [PDF]
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 Writing Committee Members, L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, December 6, 2011; 124(23): e652 - e735. [Full Text] [PDF]
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