Crit Care Shock (2019) 22:72-75 Images in clinical medicine Unusual presentation of tension pneumoperitoneum during endo- scopic submucosal dissection of early gastric tumor Phui Sze Au Yong, Gek Kim Sharon Ong Introduction aesthesia was maintained with an air-oxygen Tension pneumoperitoneum is a well-known but mixture and desflurane with boluses of fentanyl for rare complication of upper gastrointestinal endo- analgesia. She was put on continuous mandatory scopy. It is defined as the massive accumulation of volume-control ventilation. A bite guard was also air in the peritoneal cavity, which results in a inserted to facilitate endoscope movement. sudden increase in intraabdominal pressure Sixty minutes into the procedure, blood pressure resulting in hemodynamic or ventilatory decreased to 80/60 mmHg requiring intermittent compromise. (1) The presentation varies from boluses of ephedrine, followed by a marked intense abdominal pain and tenderness to imminent increase in peak airway pressure from 17 cmH2O collapse. (2) to 23 cmH2O despite adequate paralysis. Obstruc- tion, kinking, and bronchospasm were ruled out. The patient’s position was found to have flopped Case description forward onto her abdomen. While repositioning, The patient was a 72-year-old Burmese lady, 57.2 her abdomen was found moderately distended and kg, 159 cm, American Society of Anaesthesiol- the procedure was halted for nasogastric tube ogists (ASA) 2 with a past medical history of decompression. The airway pressure decreased to Sjogren’s syndrome. She was diagnosed with early 17 cmH2O and the procedure continued. antral gastric adenocarcinoma in October 2017. Seventy five minutes later, the airway pressure The lesion was 3 cm at the antrum lesser curve. again gradually increased to 30 cmH2O with She was electively admitted for endoscopic accompanying hypotension requiring more boluses submucosal dissection in the endoscopy suite. The of ephedrine and phenylephrine, and gross abdo- procedurist was amenable for the procedure to be minal distension. This was suspected that to be due done under sedation or general anaesthesia. to the gas insufflation from the endoscope. The However, as the duration was scheduled for 3 procedurist verbalized that he had changed to air hours, a general anaesthesia technique with for insufflation instead of carbon dioxide to intubation, paralysis, and positive pressure improve his visualization but did not inform the ventilation was chosen. Induction of anaesthesia anaesthetist. Due to persistent ventilatory compro- was uneventful. The patient’s airway was secured mise, needle aspiration using a 50 ml saline-filled with a size 7 standard endotracheal tube (ETT). syringe with was performed to decompress the She was positioned in a left lateral position and an- . abdomen. (2) At least 500 ml of air was aspirated before the abdominal distension resolved. Bladder catheterization was also performed to reduce risk of perforation during needle aspiration. The proce- dure resumed and was completed in the next 15 From Division of Anaesthesiology and Perioperative Medicine, Department of Surgical Intensive Care, Singapore minutes, and the stomach walls were examined General Hospital (Phui Sze Au Yong, Gek Kim Sharon Ong). carefully for gross macro perforation before withdrawing the scope. The total duration of the procedure was 4 hours 46 minutes. Address for correspondence : Postoperative chest and abdominal X-ray were Dr. Phui Sze Au Yong done after uneventful extubation ( Figure 1 ), Division of Anaesthesiology and Perioperative Medicine, revealing moderate pneumoperitoneum and Department of Surgical Intensive Care, Singapore General subcutaneous emphysema. The patient remained Hospital stable in recovery for 1 hour and was sent to high Tel: +65 94366422 Email: phuisze.auyong@mohh.com.sg dependency unit overnight. She had no complaints . 72 Crit Care Shock 2019 Vol. 22 No. 2
of abdominal pain or breathlessness and vitals re- time and intense pain caused by distension and mained stable. Broad spectrum antibiotic coverage dissection of the gastric wall necessitate a deeper with ceftriaxone and metronidazole was com- level of sedation, however this is associated with menced in view of the possibility of inadvertent increased rates of aspiration. In a retrospective pin-point gut perforation during dissection. Serial study, Yurtlu found that the incidence of nausea, X-rays showed resolution of the pneumoperitone- cough, number of oropharyngeal suctioning, and um and emphysema. She was able to tolerate liq- desaturation episodes were significantly higher in uids on postoperative day 1, progressed to full diet the propofol sedation group versus those in the 2 days later, and discharged on postoperative day general anaesthesia group. (6) 4. Remote locations are often cramped with limited access to patients under drapes and often patients Discussion are positioned facing away from the anaesthetist. Endoscopic submucosal dissection (ESD) of gas- For the anaesthetist, it is important to consider pa- tric tumors is a minimally invasive, curative tech- tient access, duration of procedure and risk factors nique employed for early gastric tumors. It was for bleeding and perforation in deciding on the an- developed in Japan in the mid-1990s. It has also aesthetic technique. In this patient, general anaes- been described for lesions of the esophagus, duo- thesia with endotracheal intubation, paralysis and denum, and colon. The technique involves enuclea- controlled mechanical ventilation helped to detect tion of the tumor with submucosal injection of di- and manage respiratory compromise from a tension luted epinephrine and a diathermic electrosurgical pneumoperitoneum. This may have been missed if knife, starting along the lower border of the lesion a sedation technique had been used as the patient’s and extending circumferentially until it can be dis- abdomen was not visible under the drapes. Moreo- sected away from the muscular layer and removed ver, any increase in respiration or movement may with an endoscopic bag. (3) be interpreted as patient discomfort and sedation Procedural complications include bleeding and would have been increased to obviate this. The perforation. A meta-analysis found that the perfo- possible sequelae could be desaturation with res- ration rate for ESD was 4.5 percent. (3) Risk fac- piratory or cardiac arrest, (5) and potential aspira- tors for perforation include operator factors e.g. tion. Hence, it is important to check the abdomen precise technique, experience, and volume; lesion- regularly, and entertain a differential diagnosis of related factors e.g. size, luminal distribution, and tension pneumoperitoneum if increased airway accessibility. The specimens retrieved in our case pressure and hypotension were encountered. The included a main specimen of 45x32 mm and small- immediate management of tension pneumoperito- er specimens of 21x8 mm and 9x4 mm, and proce- neum is a needle decompression, while supporting dure took a total of 4 hours 46 minutes. Chaves et ventilation and hemodynamics simultaneously. In al (4) reported a mean specimen diameter of 1.6 addition, the airway should be secured, due to the mm (0.6-3.5 mm) and a mean procedure duration risk of respiratory collapse. For severe macro per- of 85 minutes (20-160 minutes). For this patient, forations, an exploratory laparotomy for more def- the procedure took a longer time and the lesion inite management is warranted. was large. Hence, the risk of perforation was high- er. Pneumoperitoneum can occur due to micro or Conclusion macroperforations. (5) Micro perforations are usu- Advances in technology have necessitated the in- ally detected as free air on postoperative imaging volvement of the anaesthetist beyond the familiar due to the escape of air through invisible perfora- confines of the operating theatre. Awareness of the tions in a wall thinned by cautery under insuffla- procedure and its potential complications, choice tion pressure, whereas macro perforations are usu- of anaesthetic technique, increased vigilance in ally obvious to the procedurist and results from monitoring and good inter-professional communi- inadvertent deep cautery during incision or dissec- cation can help to increase patient safety and min- tion phase. Pneumoperitoneum may progress to imize a poor outcome. abdominal compartment syndrome if there is a rap- id escape of gas through a perforation and has Acknowledgment caused sudden cardiovascular collapse, tissue hy- Financial disclosure: none. poperfusion, multiorgan dysfunction, and death. Conflict of interest: none. This has become infrequent since routine use of Our institution does not require Institute of Re- carbon dioxide. search Board approval for case reports. Informed Both sedation and general anaesthesia have been written consent for publication of the case report described for gastric ESD. Prolonged procedure has been given by the patient. . Crit Care Shock 2019 Vol. 22 No. 2 73
Figure 1 . (A) Abdominal X-ray immediately postop (left), showing subcutaneous emphysema in right lateral abdominal wall; (B) Abdominal X-ray on postoperative day 1 (right), showing resolu- tion of subcutaneous emphysema; (C) Chest X-ray immediately postoperative showing free under both hemidiaphragms indicated moderate pneumoperitoneum A B C 74 Crit Care Shock 2019 Vol. 22 No. 2
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