A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.

Ten year experience of treating Boerhaave syndrome: A single centre analysis

Background: Boerhaave syndrome is a rare condition characterised by spontaneous barogenic, transmural rupture of the oesophagus. We aimed to examine a ten-year experience of Boerhaave syndrome at our centre. Method(s): Cohort analysis of Boerhaave syndrome over a ten year period (2012-2022). Univariate analysis was employed to determine risk factors associated with inferior patient survival. Result(s): During the study period, 40 patients presented with oesophageal perforation, of which 21 (52.5%) were spontaneous transmural rupture. Median age of patients with Boerhaave syndrome was 51 years, in predominantly male (15, 71.4%), non-smokers (13, 61.9%). The most common site of rupture was the lower oesophagus (12, 57.1%), although the exact site of rupture was unknown in 5 (23.8%) patients. 14 (66.7%) patients were treated conservatively with antibiotics. Three (14.3%) patients underwent endoscopic oesophageal stent insertion (either alone or in combination with surgical treatment). Five (23.0%) underwent thoracoscopic washout and drain insertion and 1 (4.8%) underwent open thoracotomy washout and drain insertion. Overall 10-year survival was 80.8%. There was no association between mortality and patient age, sex, smoking status, length of stay, location of perforation, coronavirus status or mode of nutrition on univariate analysis (p>0.05 throughout). Patient age was the greatest predictor of prolonged length of stay beyond 10 days (c-statistic 0.74). Modality of surgery also had no bearing on 1- and 10-year mortality (p=0.95). Conclusion(s): Boerhaave syndrome is an uncommon condition which may be treated with an array of approaches, including non-operative measures, endoscopic and surgical intervention, depending on individual patient characteristics. The availability of multimodal treatment at a specialist oesophagogastric centre may have contributed to favourable patient outcomes. Given the rarity of Boerhaave syndrome, identification of risk factors for poor patient outcomes is difficult to determine, due to statistical underpowering.

Esophageal Strictures in Children, a Six Year Case Series Experience in a Tertiary Center in Mexico City

Introduction: Esophageal strictures in children are in most cases associated with a benign etiology. There are multiple conditions that are associated with esophageal strictures including congenital stenosis, secondary to surgical repair of esophageal atresia, caustic burns following ingestion of acids or alcalis, radiation therapy and secondary to some pathologies as gastroesophageal reflux disease, eosinophilic esophagitis, scleroderma, epidermolysis bulllosa and idiopathic. Esophageal dilation can be performed with different techniques that include endoscope dilators, dilations performed over the wire and using the endoscope itself. Some cases require other adjunctive techniques that improve the results after failed progressive dilation. This therapies includes medical treatment and surgical derivations, with some cases known as recalcitrant. Also, esophageal strictures and its management could produce motility disorders. There is no consensus in the literature regarding the management process, especially in frequency of interventions, use of adjunctive therapies and alternatives for conservative management. This problem is more evident in developing countries. Objective(s): The objective of this study was to describe the cases of esophageal strictures and its management in children between 2016 and 2022 in the Instituto Nacional de Pediatria in Mexico City. Method(s): This was a six year retrospective study involving pediatric patients with esophageal stricture. We retrospectively reviewed the medical records of 23 pediatric patients who underwent endoscopic treatments for esophageal strictures, between January 2016 and May 2022 in the Comprehensive Pediatric Gastroenterology Diagnostic Unit in the Instituto Nacional de Pediatria in Mexico City. Result(s): The mean age at diagnosis was 24 months (Q1 15, Q3 35), 12 patients were male (52%) and 11 patients were female (48%). The most prevalent etiology was caustic strictures in 10 patients (43%). Six patients (26%) had esophageal atresia (4 type III, 1 type I and 1 type V), all whose received surgical management in the first days of life. All required repeated pneumatic dilation (between 1 and 11) for the management of postsurgical stenosis. Other etiologies that were found include Schatzki Ring, congenital stenosis, esophageal fibrosis associated with congenital dyskeratosis, epidermolysis bullosa, graft-versus-host disease and gastroesophageal reflux disease (one patient for each cause). In one patient the etiology remains unknown. Seventeen patients had one stricture, 5 patients had two strictures and 1 had 3 strictures. Ten patients had esophageal pseudodiverticula and two had mucosal fold. Six patients underwent dilation with Savary-Guilliard dilators combined with pneumatic balloon dilation. Four patients received mitomycin- C as an adjuvant therapy during dilations. The average diameter of stenosis was increased from 7 mm (range 4-15 mm) to 13,5 mm (range 8-18mm). Two patients had severe complications, one had a esophageal perforation associated with dilation. The other one had a pneumothorax related with anesthetic management. In the outcome 6 patients are asymptomatic, 1 patient persist with dysphagia after completed treatment, 9 patients are under treatment, 1 patient died secondary to its underlying disease and 6 patients lost follow up. Conclusion(s): Post-corrosive esophagitis and post-esophageal atresia anastomotic strictures were the most frequent types of cicatricial esophageal strictures. The conservative treatment was the first management strategy in the majority of patients, being the endoscopic balloon dilation the first choice. The SARS-COV-2 sanitary emergency limited the progressive intervention rate and appropriate clinical follow up of patients, reason why there is an important loss of follow up in the described group. A number of patients are currently on management, reason why their outcomes will be assessed in the future.

Tiny batteries. big danger

Foreign body ingestion is common in the paediatric population, especially in children under five years of age. The most commonly ingested objects are coins, with batteries accounting for approximately 5% of ingestions. Most ingested batteries pass spontaneously through the gastrointestinal tract;however, those lodged in the oesophagus may lead to dangerous complications, such as oesophageal perforation and aorto-oesophageal fistula. There has been a dramatic increase in morbidity and mortality after battery ingestion worldwide in recent years. This is related to the wider use and easier availability of electronic devices and the growing popularity of more powerful 20 mm lithium button batteries, which are more likely to get impacted in the paediatric oesophagus, leading to serious injury if not promptly removed. Ingestion of these larger batteries resulted in death or serious complications in 12.6% of children. An increased incidence of battery ingestion has also been seen during the COVID-19 pandemic due to lockdown restrictions, with children spending more time at home. The main mechanism of injury is the generation of electric current between the poles of the battery. This is facilitated by the oesophagal mucosa being in contact with them and completing the circuit. The resultant caustic reaction leads to liquefactive necrosis of surrounding tissues, with clinically significant damage being reported as early as 2 hours after impaction. The time-sensitive nature of button-battery ingestion requires fast mobilisation of a multidisciplinary team and urgent removal. Clinicians must be able to recognise and manage button battery ingestion as per the latest guidelines. These patients often require anaesthesia for endoscopic battery removal;therefore, anaesthetists must familiarise themselves with the management of battery ingestion and be aware of its potential complications. This review focuses on the anaesthetic considerations and immediate management of ingested button batteries.

Purulent pericarditis can be near fatal

A previously healthy 27 years-old male presented with 2 weeks of substernal chest pain, progressive dyspnea, palpitations, dizziness, and(&) fever. On exam, he had tachypnea & tachycardia, was hypotensive with an elevated JVP & muffled heart sounds. Labs showed elevated WBC, CRP, lactate & high sensitive troponin. Negative for COVID-19, flu. EKG showed sinus tachycardia. CT showed large pericardial effusion with gas in the pericardial space. Echo (Figure 1) revealed large pericardial effusion with tamponade. Emergent pericardiocentesis was performed draining a liter of straw-colored thick fluid (fluid: serum LDH >3) (Figure 2). Cultures grew Strep. Anginosus & Propionibacterium acnes. Extensive infectious & immunological workup returned negative. He had initially improved on broad-spectrum antibiotics however declined clinically on day 5. Repeat CT (Figures 3 & 4) showed recurrent pericardial effusion & mediastinal abscess with trace extravasation of contrast from the esophagus to posterior mediastinum. We present a case of esophageal perforation leading to Pyopneumopericardium. Stephenson et al. reported a case series of 13 patients with esophagopericardial fistulas & pyopneumopericardium with a 100% mortality rate. Another case series showed survival rates of only 17% in 60 patients with pyopneumopericardium secondary to esophageal perforation. Erosion of esophageal ulcers, ingestion of foreign body, iatrogenic, trauma, malignancy, localized inflammation can lead to esophageal perforation. Streptococcus pneumoniae & Staphylococcus aureus are common pathogens involved. Constrictive pericarditis is a possible complication in up to 20 to 30%. Our patient underwent pericardial window & surgical debridement followed by EGD-guided gastro-jejunal tube placement. He did well after 4 weeks of IV antibiotics. Our case demonstrates that early recognition & intervention can favorably alter the course of this potentially fatal cardiac condition.