Anesth Pain Med.  2021 Apr;16(2):171-176. 10.17085/apm.20088.

Bilateral tension pneumothorax during endoscopic submucosal dissection under general anesthesia diagnosed by point-of-care ultrasound - A case report -

• Oh SK
• Cho SI
• Won YJ
• Yun JH

• KMID: 2515543
• DOI: http://doi.org/10.17085/apm.20088

Abstract

Background
Endoscopic submucosal dissection has become popular. However, this can cause serious complications. In this case, esophageal perforation caused bilateral tension pneumothorax. Case: A 60-year-old man with esophageal adenoma underwent endoscopic submucosal dissection under general anesthesia. The peak airway pressure was 25 cmH2O after induction but abruptly increased to 40 cmH2O after 30 min. Respiratory sounds were barely heard. The lack of lung sliding in either (right-dominant) lung on ultrasound. Within minutes, oxygen saturation and systolic blood pressure decreased to 52% and 70 mmHg. Emergent needle thoracostomy, followed by chest tube insertion, was performed on right chest and his vital signs stabilized. Upon transfer to intensive care unit, oxygen saturation and blood pressure decreased again; therefore, a left chest tube was inserted.
Conclusions
Pneumothorax due to esophageal perforation can lead to life-threatening tension pneumothorax. Anesthesiologists should be aware of the risks and emergency treatment. Ultrasound can be useful for immediate bedside patient-care decisions.

Keyword

Diagnostic ultrasound; Endoscopic gastrointestinal surgical procedures; Endoscopic mucosal resection; General anesthesia; Tension pneumothorax

Figure

• 

  Fig. 1. Lung ultrasound. Upper: B-mode. Lower: M-mode. The normal homogenous granular pattern generated by the lung sliding (lung sliding sign) is not visible, representing the static chest wall (barcode or stratosphere sign).

• 

  Fig. 2. Chest radiographs. (A) Intraoperative chest radiograph showing bilateral (right-dominant) tension pneumothorax. (B) Chest radiograph on postoperative day 3 showing the resolved pneumothorax with an inserted chest tube.

Reference

1. Hamada K, Kawano K, Yamauchi A, Koyanagi R, Horikawa Y, Nishida S, et al. Efficacy of endoscopic submucosal dissection of esophageal neoplasms under general anesthesia. Clin Endosc. 2019; 52:252–7.

2. Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, et al. Efficacy and safety of endoscopic submucosal dissection under general anesthesia. World J Gastrointest Endosc. 2016; 8:466–71.

3. Song BG, Min YW, Cha RR, Lee H, Min BH, Lee JH, et al. Endoscopic submucosal dissection under general anesthesia for superficial esophageal squamous cell carcinoma is associated with better clinical outcomes. BMC Gastroenterol. 2018; 18:80.

4. Lian J, Chen S, Zhang Y, Qiu F. A meta-analysis of endoscopic submucosal dissection and EMR for early gastric cancer. Gastrointest Endosc. 2012; 76:763–70.

5. Cao Y, Liao C, Tan A, Gao Y, Mo Z, Gao F. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy. 2009; 41:751–7.

6. Park YM, Cho E, Kang HY, Kim JM. The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc. 2011; 25:2666–77.

7. Yagi Kuwata N, Gotoda T, Suzuki S, Mukai S, Itoi T, Moriyasu F. Reasonable decision of anesthesia methods in patients who underwent endoscopic submucosal dissection for superficial esophageal carcinoma: a retrospective analysis in a single Japanese institution. Turk J Gastroenterol. 2016; 27:91–6.

8. Heo HJ, Lee JH, Kim YY, Baek SM, Kim KM, Jung DW. Invisible perforation during an endoscopic procedure of the esophagus under general anesthesia - a case report. Anesth Pain Med (Seoul). 2020; 15:383–7.

9. Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest. 2015; 147:1659–70.

10. Isomoto H, Yamaguchi N, Minami H, Nakao K. Management of complications associated with endoscopic submucosal dissection/endoscopic mucosal resection for esophageal cancer. Dig Endosc. 2013; 25 Suppl 1:29–38.

11. Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg. 2015; 261:1068–78.

12. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann Emerg Med. 2013; 61:207–8.

13. Denault A, Canty D, Azzam M, Amir A, Gebhard CE. Whole body ultrasound in the operating room and intensive care unit. Korean J Anesthesiol. 2019; 72:413–28.

14. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012; 38:577–91.

15. Volpicelli G, Boero E, Stefanone V, Storti E. Unusual new signs of pneumothorax at lung ultrasound. Crit Ultrasound J. 2013; 5:10.

16. Loiselle A, Parish JM, Wilkens JA, Jaroszewski DE. Managing iatrogenic pneumothorax and chest tubes. J Hosp Med. 2013; 8:402–8.

17. Mavridis S, Gnauk HG, Schumacher M, Wagner R. Bilateral pneumothoraces complicating reduction mammoplasty: a case report. BMC Surg. 2013; 13:29.