Two Cardiac Arrests Because of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography: A Case Report

When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography

Air embolism (a result of direct communication with the vasculature and an external pressure gradient from the gastrointestinal or the biliary tract), although rare, is a potentially devastating adverse event seen in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Whether venous, arterial, or paradoxical, the clinical presentation ranges from asymptomatic patients to cardiorespiratory arrest. This is of particular importance because it makes the diagnosis of air embolism even more difficult in an already sedated patient. Since early recognition increases the chances of patients' survival, endoscopists should be highly motivated and trained to recognize this complication as early as possible. With only 60 cases of air embolism reported (and even fewer related to paradoxical air embolism), we aimed to report a case of paradoxical cerebral air embolism in a patient undergoing ERCP due to a common bile duct stricture and to provide a mini-review of this clinical entity that can serve as a bedside quick reference guide for endoscopists worldwide.

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure that is widely used by endoscopists and has a robust therapeutic profile. It uses endoscopy and imaging for a variety of diagnostic as well as therapeutic purposes. It is used for the management of a lot of pancreaticobiliary diseases such as obstructive jaundice, obstruction related to bile ducts, pancreatic biliary tumors, and traumatic or iatrogenic damage to the bile ducts. Other therapeutic interventions that can be done via ERCP include sphincterotomy, dilation of strictures, removal of biliary stones and placement of stents. Air embolism presents with cardiovascular, pulmonary, and neurologic signs and symptoms. Treatment of air embolism should be started early in suspected cases, and it should be in the differential diagnoses of various complications secondary to high risk of ERCP, especially if a cardiopulmonary compromise is present. Air embolism is rare but a serious complication associated with ERCP. The physicians must keep this in mind while performing ERCP in patients with predisposing risk factors. This review highlights the mechanism, causes, risk factors, pathophysiology, clinical signs, diagnostic modalities, treatment, and preventive measures to deal with this catastrophic complication.

Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and management

Air embolism is rarely diagnosed and is often fatal. The diagnosis is often not made in a timely manner given the rapid and severe clinical deterioration that often develops, frequently leading to cardiac arrest. Many patients are only diagnosed post-mortem. With the increasing use of endoscopic retrograde cholangiopancreatography, air embolism should be considered in the differential diagnosis in patients who experience sudden clinical deterioration during or immediately after the procedure. Clinical suspicion is key in the diagnosis and management of air embolism. Use of precordial Doppler ultrasound and transesophageal echocardiogram can aid in the diagnosis of air embolism. Once the diagnosis is made, supportive management of airway, breathing and circulation is pivotal. Advanced cardiac life support should be initiated when necessary. Fluid resuscitation and vasopressors can improve cardiac output. Hyperbaric oxygen therapy should be considered when possible in cases of suspected cerebral air embolism cases to improve neurological outcome. A multidisciplinary team approach and effective communication with experts, potentially including an anesthesiologist, cardiologist, intensivist, radiologist and surgeon, can improve the outcome in air embolism.

Risk Factors and Management for Biliary Complications Following Adult Living-Donor Liver Transplantation

BACKGROUND Biliary complications (BCs) following liver transplantation are very serious. Nevertheless, it is still uncertain which components influence the incidence of BCs the most. MATERIAL AND METHODS A consecutive sample of 74 adult recipients who underwent living-donor liver transplantation were enrolled in this study. BCs that were Clavien-Dindo classification grade II or higher were determined as BCs. RESULTS There were 11 out of the 74 recipients who experienced BCs. There were no differences in preoperative background factors between the BCs+ and BCs- group. Unexpectedly, the number of bile duct orifices did not contribute to the BCs (p=0.722). In comparison with the BCs- group, the frequency of post-operative bleeding requiring re-operation was relatively higher (27.3% vs. 7.9%, p=0.0913) and this complication was the only independent risk factor (p=0.0238) for the onset of BCs. Many of the BCs+ recipients were completely treated by endoscopic or radiological intervention (81.8%). However, surgical revision was required for 2 recipients (18.2%). CONCLUSIONS Given these results, it is reasonable to believe that definite hemostasis is required to prevent future BCs. In addition, bile duct multiplicity was not associated with BCs.

Risk Factors and Management for Biliary Complications Following Adult Living-Donor Liver Transplantation

BACKGROUND Biliary complications (BCs) following liver transplantation are very serious. Nevertheless, it is still uncertain which components influence the incidence of BCs the most. MATERIAL AND METHODS A consecutive sample of 74 adult recipients who underwent living-donor liver transplantation were enrolled in this study. BCs that were Clavien-Dindo classification grade II or higher were determined as BCs. RESULTS There were 11 out of the 74 recipients who experienced BCs. There were no differences in preoperative background factors between the BCs+ and BCs- group. Unexpectedly, the number of bile duct orifices did not contribute to the BCs (p=0.722). In comparison with the BCs- group, the frequency of post-operative bleeding requiring re-operation was relatively higher (27.3% vs. 7.9%, p=0.0913) and this complication was the only independent risk factor (p=0.0238) for the onset of BCs. Many of the BCs+ recipients were completely treated by endoscopic or radiological intervention (81.8%). However, surgical revision was required for 2 recipients (18.2%). CONCLUSIONS Given these results, it is reasonable to believe that definite hemostasis is required to prevent future BCs. In addition, bile duct multiplicity was not associated with BCs.