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