Oesophageal perforation following perioperative transoesophageal echocardiography

Abstract

Transoesophageal echocardiography (TOE) is being used more often by cardiothoracic anaesthetists for the perioperative management of cardiac problems. Reports of iatrogenic oesophageal perforation by instrumentation of the oesophagus are increasing. Although TOE is considered safe, it may be more risky during surgery, because the probe is passed and manipulated in an anaesthetized patient. It may be in place for several hours so the risk of mucosal pressure and thermal damage is increased. Patients on cardiopulmonary bypass are also fully anticoagulated. We describe a case of oesophageal perforation following insertion of the TOE probe in a patient with gross cardiomegaly. Oesophageal distortion by cardiac enlargement may increase the risk of oesophageal perforation. Difficulty in passage of the TOE probe should be regarded with suspicion and withdrawal should be contemplated because the symptoms of oesophageal perforation are often delayed and non-specific. Delay in investigation, diagnosis and treatment will increase morbidity and mortality.

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“…Important limitations to TEE include the fact that certain regions of the heart and great vessels cannot be well visualized (most of these limitations may be overcome by more advanced technology, 3D echo and new imaging planes). The procedure is usually safe, but insertion and manipulation of the TEE probe can directly traumatize the airway and oesophagus, leading to orodental or laryngo pharyngeal trauma, oesophageal bleed, perforation, dysphagia, hoarseness and bacteraemia [57][58][59][60][61][62][63]. Upper airway obstruction by a TEE probe [61] and average 8cm H 2 O increase in tracheal cuff pressure(so that cuff pressure exceeded 35cm H 2 O in 17 out of 38 patients) during routine TEE probe insertion [63] has also been reported.…”

“…Upper airway obstruction by a TEE probe [61] and average 8cm H 2 O increase in tracheal cuff pressure(so that cuff pressure exceeded 35cm H 2 O in 17 out of 38 patients) during routine TEE probe insertion [63] has also been reported. Indirect effects of TEE include haemodynamic changes and pulmonary effects of airway manoeuvring and distraction of new TEE operator from intraoperative patient care [57][58][59][60][61][62][63]. Atrial and ventricular arrhythmias due to direct cardiac irritation from the probe may occasionally occur.…”

Transesophageal echocardiography-related complications

“…In patients with total or partial gastrectomy, TEE is not contraindicated as long as the probe is manipulated within the esophagus. 32 Normal anatomical variants, such as an aortic impression, a large left atrium and left main bronchus, or pathological conditions, such as an enlarged heart, a mediastinal tumour, 33 or esophageal duplication, can compress the esophagus, distort its imaging, and complicate esophageal intubation. 34 Esophageal vascular abnormalities, such as prominent venous plexus or varices associated with cirrhosis and portal hypertension, may cause bleeding during TEE; therefore, TEE should either not be used at all, or should be used with great caution during hepatic transplantation.…”

“…42 It can be caused by poor patient cooperation, inadequate technical skills, unexpected anatomical characteristics (GI abnormalities, extrinsic compression of the esophagus from enlarged left atrium, 33,43,44 a large calcified lymph node, 45 a cervical spur), or mucosal damage (due to motion, local ischemia, or pressure and heat by the probe). The hypopharynx and upper esophagus are the regions most vulnerable to perforation, 41 because the esophageal wall has an intrinsic weakness caused by fibres crossing from the pharyngeal constrictor and the cricopharyngeal muscles.…”

Unerkannte Hypopharynxperforation mit tiefem Halsabszess und Mediastinitis infolge trans�sophagealer Echokardiographie

“…[1,9,15]. [11]. So stellt das frühzeitige Erkennen einer Perforation im Aerodigestivtrakt und die sofortige Einleitung der Therapie einen der wichtigsten Faktoren zur Senkung der Mortalitätsrate dar,da auch bei vermeintlich stabilen Zuständen durch Ausbreitung einer Mediastinitis oder Abszedierung schnell eine erhebliche Verschlechterung der Situation eintreten kann.Sepsis und Multiorganausfall stellen häufige Todesursachen dar [15].…”