REAL EMERGENCIES IN INTERVENTIONAL GASTROENTEROLOGY – MASSIVE PNEUMOMEDIASTINUM AND PNEUMOPERITONEUM AFTER ARGON PLASMA COAGULATION OF BARRETT'S OESOPHAGUS

Background: therapeutic gastrointestinal endoscopy is typically performed under moderate or deep sedation. Endoscopy complications are a rising concern on the quality of endoscopic care, given the technical advances and the complexity of therapeutic procedures, over the entire gastrointestinal and bilio-prancreatic tract (1). In a small percentage, as in case of hollow organ perforation, there can be real emergency conditions with real vital compromise.
Case report: We report a case of esophageal and gastric perforation in a generally healthy 45-year-old woman who underwent upper endoscopy and argon plasma coagulation (APC) for ablation of Barrett's esophagus (2,3), performed in the Department of Interventional Gastroenterology of University Hospital Setting. We observed endoscopically a long segment – more than 3cm Barrett's esophagus, a substenotic cardia with irregular mucosa and a large sliding hiatus hernia; stomach and duodenum were normal. As a treatment modality, APC was chosen and performed under deep sedation with Propofol – 1,5mg/kg as a loading dose, followed by infusion of 4mg/kg/h and Ketamine – 0,5mg/kg. The entire procedure lasted 12 min. During awaking the patient complained severe chest pain, respiratory distress, became cyanotic, poorly responsive, and pulseless, while oxygen saturation dropped to 60 %. After gentle Ambu balloon ventilation and catecholamine supplementation, a radial pulse reappeared, oxygen saturation rose and patient regained consciousness. Respiratory drama reappeared (severe chest pain and tachydyspnea), but also at that moment extensive subcutaneous emphysema was observed over the chest, neck, whole right upper extremity and face with complete closing of the right eye. Oxygen saturation dropped again after a few minutes, breathing sounds were markedly reduced, and the abdomen became tense. The patient was placed in orthopneic position, titration of Morphine and high flow O2 therapy were instituted. Stepwise the patient status improved, which permitted transferring in ICU and soon later in operative theatre. At surgery (thoracotomy and laparotomy), a 3-mm-wide perforations of the posterior wall of the esophagus and cardia were found, esophageal and gastric resections with gastro-esophageal anastomosis was performed. The patient was discharged 2 weeks later.
Discussion: Obviously the procedure caused hollow organ perforation, cardiac syncope, pneumo-mediastinum, extensive subcutaneous emphysema over the chest, neck, face and right antebrachium, but also pneumoperitoneum, as was confirmed by the X-ray and computed tomography. We suppose that during endoscopy, pressurized air that was inflated into a mechanically produced esophageal perforation caused mediastinal distension, subcutaneous emphysema and the first syncope. Further rising of intra-gastric pressure, generated by Ambu-ventilation thereafter, aggravated progressive dilatation of the stomach and subsequent air diffusion into the peritoneal cavity and mediastinum, leading to a second rapid patient status deterioration. Given the unknown source of perforation, which was confirmed during surgery, we tried to avoid forced ventilation and maximally keep the normal breathing of the patient. The clinical presentation and the increase in intra-abdominal pressure suggested a perforation in the peritoneal cavity without direct connection with the pleura, but there could be an indirect communication with intrapleural space. In face of aggressive ventilation by endotracheal tube, high peak inspiratory pressures, could cause developing of tension pneumothorax and death of the patient in a few minutes.  
In conclusion, we report an uncommon case of simultaneous esophageal and gastric perforation determining syncope, pneumoperitoneum and pneumomediastinum. The awareness of the operator and anesthesiologist for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome.
Keywords: GI Endoscopy complications; GI emergencies; perforation; Argon Plasma Coagulation.
Learning points: Emergency conditions with real vital compromise are possible complications of interventional gastroenterology. Their possibility rise a question were, in which settings these procedures could be done? Also, these complications highlight the possible risk that aggressive resuscitation maneuvers may aggravate a clinical picture of hollow organ perforation.

1. ASGE Standards of Practice Committee. Adverse events of upper GI endoscopy. Gastrointest Endosc. (2012); 76(4):707-718.

2. Manner H, Argon Plasma Coagulation in Barrett’s Esophagus. Video Journal and Encyclopedia of GI Endos-copy (2013),1:4–6

3. Williamson JML, Almond LM, Shepherd NA, Barr H, Current management of Barrett’s esophagus. Br J Hosp Med (Lond) (2012); 73:271–77.


09 / Real emergencies in interventional gastroenterology – massive pneumomediastinum and pneumoperitoneum after argon plasma coagulation of Barrett’s oesophagus.
