Esophageal perforation during laparoscopic sleeve gastrectomy: Complication of bougie insertion

Piriform Fossa Injury during Calibration Tube Insertion in Laparoscopic Sleeve Gastrectomy

Piriform fossa and/or esophageal injuries caused by calibration tubes are relatively rare and remain unelucidated. Herein, we report the case of a 36-year-old woman with morbid obesity, sleep apnea, and menstrual abnormalities who was scheduled to undergo laparoscopic sleeve gastrectomy (LSG). We inserted a 36-Fr Nelaton catheter made of natural rubber as a calibration tube during the surgery. However, excessive resistance was observed. We confirmed a submucosal layer detachment approximately 5 cm from the left piriform fossa to the esophagus using intraoperative endoscopy. Additionally, LSG was performed using an endoscope as the guiding calibration tube. We inserted a nasogastric tube under endoscopy with a guidewire before completing the surgery, hoping for a guiding effect on the saliva flow. After 17 months, the patient had successfully lost weight postoperatively without complaints of neck pain or discomfort during swallowing. Therefore, in cases where the damage is limited to the submucosal layer, as in this case, conservative therapy should be considered; this is similar to the concept of endoscopic submucosal dissection not requiring suture closure. This case highlights the risk of iatrogenic injuries to the piriform fossa and/or esophagus during LSG and the importance of careful calibration tube insertion to prevent them.

The impact of esophageal device insertion on cuff pressure of endotracheal tube: a literature review and meta-analysis

The impact of intraoperative esophageal device insertion (EDI) on endotracheal tube (ET) cuff inflation pressure remains unclear. Electronic databases including Medline, Embase, Google scholar, Web of Science™ and Cochrane Central Register of Controlled Trials were searched for studies involving EDI after placement of ETs from inception to July 7, 2022. The primary outcome was risk of high cuff pressure, while the secondary outcomes were increases in cuff pressure following EDI. Difference between adults and children was investigated with subgroup analysis. There were ten eligible studies (observation study, n = 9, randomized controlled study, n = 1) involving a total of 468 participants. EDI notably increased the risk of high cuff pressure (n = 7, risk ratio: 12.82, 95% confidence interval: 4.9 to 33.52, subgroup analysis: p = 0.008). There were significant elevations in cuff pressure in adults and children both during (13.42 and 7.88 cmH₂O, respectively, subgroup analysis: p = 0.15) and after (10.09 and 3.99 cmH₂O, respectively, subgroup analysis: p = 0.0003) EDI. Our results revealed an over 12-fold increase in the risk of high endotracheal tube cuff pressure in patients, especially adults, receiving EDI under endotracheal anesthesia. There were significant increases in both adults and children despite a higher increase in the former after device insertion.