Case Reports: Case Report
During laparoscopic Heller myotomy, the esophageal “bougie” dilator is an instrument placed in the esophagus and advanced through the gastroesophageal junction to ascertain whether the surgical wrap repair is too tight. A potential complication of esophageal dilator placement is the possibility of perforation through a mucosal barrier. Injury to the esophagus is a recognized complication; injury to other mucosal walls is also possible. We describe a retropharyngeal mucosal injury as a complication in a patient undergoing laparoscopic Heller myotomy with Dor fundoplication. This patient has given written consent for publication of this case report.
A 54-year-old woman with progressive achalasia (American Society of Anesthesiologists physical status II) presented for laparoscopic Heller myotomy with Dor fundoplication. The case began with uneventful induction and oral intubation of general endotracheal anesthesia. Because the patient did not have risk factors for delayed gastric-emptying and NPO status was adequate, neither an orogastric nor nasogastric tube was inserted. During the surgery, the surgeon requested the placement of a 50-French esophageal dilator in the esophagus and its advancement to the gastroesophageal junction. The anesthesiologist encountered difficulty inserting the esophageal dilator, encountering resistance along several trajectories. Coiling of the dilator was observed in the oropharynx. On further repositioning, the dilator was advanced without resistance and guided under laparoscopic visualization from the surgical team into the gastroesophageal junction. The remainder of the operation proceeded uneventfully. At conclusion, the patient was extubated and admitted to the medical–surgical unit. On postoperative day 1, the patient was scheduled for a routine barium swallow study, which demonstrated cervical retropharyngeal mucosal injury and possible perforation. This was further evaluated with computerized tomography (CT) of the head and neck (Figures 1 and 2 sagittal plane; Figure 3 transverse plane), which demonstrated a contained posterior pharyngeal wall perforation as well as retained retropharyngeal contrast from the previous barium swallow study. Figure 1 is a CT slice illustrating the retropharyngeal contrast collection. Figure 2 illustrates retropharyngeal gas collection in relation to the esophageal lumen. No evidence of abscess was appreciated. The patient did report midline throat pain and cleared a scant amount of blood-tinged secretions on postoperative day 1. The patient was started on IV piperacillin–tazobactam and fluconazole for antibiotic coverage. On postoperative day 3, the patient was able to tolerate oral intake. A follow-up CT scan confirmed stable appearance of the mucosal injury. The patient was transitioned to an oral antibiotic regimen of ampicillin–sulbactam and fluconazole. At a 1-month follow-up evaluation, the patient was tolerating a diversified soft diet without dysphagia or pain. A follow-up barium esophagram performed at the patient’s 1-month follow-up visit did not demonstrate any ongoing leakage or change in the area of previously extravasated barium.
Perforation of the esophagus is a recognized complication with placement of an esophageal dilator. However, injury to other mucosal barriers is also possible.1 Such injury may be more likely in the setting of lessened mucosal wall strength such as a Zencker diverticulum. However, this was not felt likely given that the patient had a gastrointestinal endoscopy 3 months before surgery, which was negative for such pathology. The oropharynx and esophagus are surrounded by loose areolar tissue, which can lead to severe mediastinitis and sepsis because of passage of bacteria from the esophagus into this area.2 Treatment should be individualized to the patient based on severity of symptoms. In the presence of systemic inflammatory response symptoms and evidence of septic shock, early surgery may be more beneficial than conservative therapy with IV antibiotics.2 In this case, the patient was able to tolerate oral intake without significant discomfort and repeated imaging on follow-up visits did not demonstrate evidence of abscess formation. For lesions larger than a few centimeters, for symptoms suggestive of sepsis, or for patients who do not tolerate oral intake, early esophageal repair via thoracotomy may be indicated.2 Key components of successful placement of an esophageal dilator include lubrication of the dilator, achieving adequate opening of the oropharynx, and assessing for resistance to passage of the esophageal dilator. Utilization of direct or indirect laryngoscopy may also be helpful to visualize correct trajectory of esophageal devices. Close communication with the surgery team and advancement of the dilator under visualization by the surgery team are also important for advancement of the esophageal dilator. If resistance or coiling is encountered like in this case, a high index of suspicion for malposition should be maintained. Early imaging as was performed in this case may help to confirm or rule down the possibility of mucosal injury.2
Name: Gregory J. Blair, MD.
Contribution: This author helped write the manuscript.
Name: Robert Hsiung, MD.
Contribution: This author helped write the manuscript.
This manuscript was handled by: Raymond C. Roy, MD.
1. Salo JA, Eero IT Sihvo. Instrumental perforation of the esophagus. Surgical Treatment: Evidence-Based and Problem-Oriented. 2001. Munich, Switzerland: Zuckshwerdt; Available at: http://www.ncbi.nlm.nih.gov/books/NBK6892/
. Accessed August 15, 2016.