vcu death and complications conference. introduction complication pyriform sinus injury procedure...

VCUDEATH AND COMPLICATIONS CONFERENCE

Introduction

Complication Pyriform sinus injury

Procedure Laparoscopic roux-en-y gastric

bypassPrimary Diagnosis

Morbid obesity

50 yo female presenting for elective gastric bypass

5’5”, 295 lbs, BMI 49.2 Htn, hyperlipidemia, GERD, degenerative

joint disease PSH: c-section x3, lap chole,

appendectomy, shoulder surgery Quit smoking 6 months prior, no etoh,

ivda

To OR on 4/23/12 Pt intubated in standard fashion, however difficulty

passing OG and subsequently NG tube Mesocolic defect created JJ anastamosis performed with 50 cm biliopancreatic

limb and 60 cm alimentary limb which was advanced into lesser sac

Stomach divided and gastrojejunal anastamosis formed with partial closure

Olympus endoscope not able to be passed into the esophagus after several attempts, image appeared non mucosal and concern for perforation raised. Mild crepitus in neck

Intraoperative consult to ENT NGT was advanced into the stomach and

bypass was completed without difficulty ENT performed direct laryngoscopy and rigid

esophagoscopy revealing rent in left pyriform sinus which closed with desufflation

Recommendations: Ancef/flagyl prophylaxis npo No expiratory incentive spirometry, deep inspiration

ok, no forceful exhalation No nose blowing, Sneeze with mouth open Esophogram in 5 days

Neck tender post op with bilateral crepitus

Nonlabored breathing Pt able to swallow secretions Voice normal NGT removed POD1 Neck symptoms improved over 5 days Recovery from GBP uneventful

No leak on study Diet gradually advanced Able to be discharged on 4/30

Analysis of Complication

• Was the complication potentially avoidable?– Yes, technique

• Would avoiding the complication change the outcome for the patient?– Yes- prolonged hospitalization

• What factors contributed the complication?– Body habitus, technical error (intubation, gastric

tube insertion, endoscopy)

Pyriform Sinus injury

Means “pear-shaped” Anatomic recess in hypopharynx Just below epiglottis at the origin of

the esophagus Transition point in esophageal

intubation Iatrogenic perforation at this

location has been described with endoscopy and bougie insertion

More common in pharyngeal cancer pts

High index of suspicion required to rule out injury

Delayed identification of injury can lead to severe complication (sepsis, tracheal fistula, damage to RLN)

Teaching points

No procedure is benign and all need to be respected

Most esophageal injuries result from iatrogenic causes

Early diagnosis is important as delay leads to high morbidity and mortality.