Imaging: Student/Resident Case Report Poster - Imaging |

Pneumopericardium Due to Delayed Esophageal Leak After Per Oral Endoscopic Myotomy (POEM) FREE TO VIEW

Dennisdhilak Lourdusamy, MD; Shil Patel, DO; Braghadheeswar Thyagarajan, MD; Squillaro Anthony J, MD; Steven Gorcey, MD; Violet Kramer, MD
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Monmouth Medical Center, Long Branch, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):671A. doi:10.1016/j.chest.2016.08.765
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SESSION TITLE: Student/Resident Case Report Poster - Imaging

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: POEM is generally considered a safe and efficacious procedure in treating achalasia. Some findings such as pneumomediastinum can be considered to be normal postoperative changes, however in the context of clinical instability, a high index of suspicion for severe complications must be maintained. We describe an esophageal leak diagnosed by CT scan after oral contrast causing critical illness.

CASE PRESENTATION: A 39 year old female presented 3 weeks after POEM with cough, dyspnea, and weakness. She was afebrile, tachycardic and tachypneic. Physical exam revealed mild distress with tachypnea, distant heart sounds, and cool, mottled feet. Laboratory data (see table) was suggestive of sepsis. Initial CT of the chest and neck showed pneumopericardium. Initial upper GI gastrograffin series showed no evidence of extraluminal contrast. However, given her worrisome clinical presentation, a repeat CT chest was obtained, which revealed contrast in the pericardial space, confirming the leak. The patient underwent pericardial drainage and chest tube placement for parapneumonic effusion with improvement of her hemodynamic parameters. She had a protracted course in the ICU with vent-dependent respiratory failure requiring tracheostomy. She required broad spectrum antibiotics and inotropic support for left ventricular dysfunction from sepsis which subsequently resolved. She was weaned from the ventilator, decannulated and discharged home successfully, tolerating oral nutrition.

DISCUSSION: Most complications of POEM including subcutaneous emphysema, mediastinal emphysema and pneumopericardium are managed conservatively (1). The common occurrence of these complications is explained by the lack of serosa in the esophageal wall and minor disruption of the outer longitudinal fibers could lead to air leak into the thoracic cavity during the procedure. The above mentioned complications are regarded as normal post-operative radiological changes, given their rapid resolution with conservative treatment (2). As long as the esophageal mucosal integrity is preserved, these findings can be managed conservatively. In this case, the delayed esophageal leak was likely due to the loss of integrity of the esophageal wall, causing pneumopericardium with hemodynamic compromise.

CONCLUSIONS: A high index of suspicion is required to diagnose esophageal leak and differentiate it from regular post-op radiologic changes. Early diagnosis and aggressive supportive care is crucial, as the mortality rate for mediastinitis is very high.

Reference #1: Barbieri LA, Hassan C, Rosati R, Romario UF, Correale L, Repici A. Systematic review and meta-analysis: Efficacy and safety of POEM for achalasia. United European Gastroenterol J. 2015 Aug;

Reference #2: Chung CS1,2, Lin CK1, Hsu WF1, Lee TH1, Wang HP3, Liang CC1. Gastroenterology: Pneumomediastinum and pneumoperitoneum after peroral endoscopic myotomy: Complications or normal post-operative changes? J Gastroenterol Hepatol. 2015 Oct;

DISCLOSURE: The following authors have nothing to disclose: Dennisdhilak Lourdusamy, Shil Patel, Braghadheeswar Thyagarajan, Squillaro Anthony J, Steven Gorcey, Violet Kramer

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