Management of a life-threatening esophageal perforation during laparoscopic sleeve gastrectomy: a case study of an Ecuadorian patient Open Access

Abstract

Introduction

Bougie insertion for gastric calibration is routinely done during laparoscopic sleeve gastrectomy (LSG) with low expected risk. Esophageal perforation (EP) is a rare, but life-threatening and high morbidity complication [1]. We present a case of late diagnosis (>24 h) EP that was successfully managed with surgery.

Case description

A 46-year-old woman with a history of type 2 obesity underwent a planned sleeve gastrectomy, cholecystectomy, and hiatoplasty. Intraoperatively, an iatrogenic esophageal perforation occurred. Approximately 30 h after the procedure, the patient developed epigastric pain radiating to the retrosternal region, accompanied by dyspnea. A torpid clinical evolution followed.

A barium esophagogram revealed a leak in the distal third of the esophagus, and a contrast-enhanced CT scan demonstrated findings consistent with mediastinitis. The patient was promptly taken to the operating room. Upper endoscopy identified a 1 × 2 cm defect on the anterior and right lateral wall of the esophagus, ⁓1 cm proximal to the gastroesophageal junction.

The cardiothoracic and general surgery team operated on the patient’s thoracic and abdominal cavities, respectively. A Kehr’s T tube was placed for drainage. Three drains were placed on the left thorax and a right thoracic tube was inserted. All thoracic drains were connected to a vacuum system. Lastly, a cervical esophagostomy was performed for proximal diversion.

Meanwhile, an abdominal laparotomy allowed the lavage of the cavity and a jejunostomy was fabricated. Additional drains were placed in the hepatorenal recess and left subphrenic space.

During surgery, the patient developed refractory hypotension, unresponsive to intravenous crystalloids, fresh frozen plasma, and albumin. Vasopressor support with norepinephrine was initiated. After almost 5 h of surgery, the patient was transferred to the intensive care unit (ICU).

The patient required mechanical ventilation and vasopressor therapy for the first 24 h postoperatively. A total of 48 h later, preliminary cultures from intra-abdominal abscesses identified Enterobacter cloacae (AmpC-producing), Streptococcus anginosus (milleri group), and Candida albicans. Empiric antibiotic therapy was escalated to meropenem, vancomycin, and fluconazole.

Despite aggressive surgical and medical management, the patient exhibited persistent systemic inflammatory response syndrome, necessitating an ICU stay of 12 days. After stabilization, she was transferred to the medical ward and eventually discharged 2 weeks later without further complications.

The drainage tubes and vacuum system were removed after a couple months and the cervical esophagostomy was repaired a year after the incident.

Discussion

Esophageal perforation, although rare, is a serious and potentially life-threatening complication in bariatric surgery. The time lapsed from EP to its treatment has been reported as having a statistical impact on patient mortality. Delayed therapy instauration—defined as initiation of therapy ˃24 h after perforation, as in our patient’s case—is associated with a mortality rate of ⁓20.3% [2]. However, prompt diagnosis is hindered by its rarity and widely variable clinical presentation.

Regarding its management, according to the World Society of Emergency Surgery (WSES) Guidelines, the criteria for nonoperative management (NOM) by Altorjay et al. and Pittsburgh perforation severity score, might be helpful for treatment selection. For this patient, a surgical approach was elected as NOM criteria were not met. Moreover, the WSES suggests that direct esophageal repair is not recommended in hemodynamically unstable patients, such as ours; and an esophageal exclusion, diversion or resection should be performed (Grade 1C recommendation) [3]. Accordingly, our surgical strategy included aggressive mediastinal drainage and debridement, esophageal diversion, and creation of a feeding enterostomy to support nutritional needs.

Lovence et al., reported a case of early diagnosis of perforation after LSG due to bougie insertion located in the upper third of the esophagus. In their hemodynamically stable patient, they performed a primary repair using a sternocleidomastoid muscle flap via a cervical approach. The patient received broad-spectrum antibiotics, avoided sepsis, initiated oral intake on postoperative day six, and was discharged on day eight [4].

In contrast, Thoeurou et al., reported a case of a late diagnosis of perforation in the middle third of the esophagus after an adjustable gastric band placement. They opted for a total esophagectomy with esophagostomy. The patient required two units of red blood cells concentrates and broad spectrum antibiotics, developed septic shock and died 18 days after surgery [5].

These contrasting cases, when compared to ours, underscore the wide spectrum of clinical presentations, therapeutic approaches, and outcomes associated with esophageal perforation.

Conclusions

The study of esophageal perforations and their management is difficult due to low prevalence of this condition and the high heterogeneity in causation and treatment. As of now, treatment selection is guided by the surgeon’s criteria and ranges from conservative approaches to esophagectomy, or esophageal exclusion. More research regarding this complication, specifically in bariatric patients, is needed so standardized management guidelines can be established.

Conflict of interest statement

None declared.

Funding

None declared.

References