Cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy: a case report and review of the literature

Andrea Lovece, Ioannis Rouvelas, Masaru Hayami, Mats Lindblad, Andrianos Tsekrekos, Andrea Lovece, Ioannis Rouvelas, Masaru Hayami, Mats Lindblad, Andrianos Tsekrekos

Abstract

Background: Obesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy.

Case presentation: The complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m2) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful.

Conclusions: We made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

Keywords: Bougie; Case report; Esophageal perforation; Laparoscopic sleeve gastrectomy.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
CT scan findings: a–b. Extensive emphysema in the soft tissues of the neck. Free air is also visible in the upper mediastinum (white arrows). c–d. Sagittal sections showing communication between the esophagus and a false lumen corresponding to the cervical and upper thoracic prevertebral space, containing air and small amounts of fluid (white arrows). e–g. Free air in the upper and middle mediastinum, along the intrathoracic esophagus and around the big mediastinal vessels (white arrows)
Fig. 2
Fig. 2
Gastroscopy captures showing a big perforation on the posterior wall of the cervical esophagus. a. Large communication with the prevertebral space which is filled with purulent fluid. b–c. The prevertebral fascia is visible, marked with an asterisk (*). d. A nasogastric tube is inserted under direct vision for decompression
Fig. 3
Fig. 3
Intraoperative picture showing the perforation on the posterior wall after mobilization of the cervical esophagus. The tip of the thoracic drain that was placed thoracoscopically is visible in the operative field. E: esophagus. P: perforation, with forceps inserted in the defect. EM: esophageal mucosa. PF: prevertebral fascia. SM: sternocleidomastoid muscle

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