Open Journal of Surgery Case Reports

Case Report

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Kamparoudi Pagona1, Kiroplastis Konstantinos2*, Serchan Paschalitsa1, Panteleou Kyriaki1, Sakellaris Vasileios1 and Kambaroudis Apostolos2

1Anesthesiology Department, “Ippokratio” General Hospital of Thessaloniki, Greece

25th Surgical Department, Aristotle University of Thessaloniki, “Ippokratio” General Hospital of Thessaloniki, Greece

Received: 26 June 2019

Accepted: 16 September 2019

Version of Record Online: 30 September 2019

Citation

Kamparoudi P, Kiroplastis K, Serchan P, Panteleou K, Sakellaris V, et al. (2019) Cervical Esophagus Perforation Following Nasogastric Tube Insertion. Open J Surg Case Rep 2019(1): 15-21.

Correspondence should be addressed to
Kiroplastis Konstantinos, Greece

E-mail: kostas.kiroplastis@gmail.com
DOI: 
10.33513/OJSC/1901-07

Copyright

Copyright © 2019 Kiroplastis Konstantinos et al. This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and work is properly cited.

Abstract

Nasogastric tubes are routinely inserted in clinical practice, followed by rare though possibly serious and life-threatening complications.

Objective: To review the management of esophageal injury as a result of nasogastric tube insertion, we report the case of a 78-year-old critically ill male, who suffered massive subcutaneous emphysema as a result of inadvertent nasogastric tube insertion. Computed tomography and simple radiography confirmed nasogastric tube misplacement and left-side cervical esophageal perforation, which was surgically repaired.

Results: This report outlines that even though the nasogastric tube placement technique is apparently simple, major complications, such as esophageal perforation, may occur. The risk increases in cases of difficult nasogastric tube insertion, where, even though several techniques are described, there is no consensus for a standard approach. Overall, early diagnosis is crucial and a multidisciplinary approach is essential to successfully manage the injury, thus reducing patients’ morbidity and mortality.

Introduction

Esophageal perforation is a serious and acute clinical condition. Its causes are mostly iatrogenic (70%), such as endoscopic procedures or nasogastric tube insertion. Other possible causes are non-traumatic perforation (15%), presence of foreign objects (8%) and trauma (5%) [1-3]. Mortality is high, reaching 65%. That is because of the complexity of surgically identifying and dissecting the esophagus with safety, the lack of esophageal serosal layer and its proximity to other vital organs. The esophageal blood supply is rich and complex, consisting of a group of arteries from disparate sources, depending on the esophagus level. However, improper esophageal dissection or resection can cause esophageal leakage [2,3]. Furthermore, doctors’ inexperience and the absence of specific clinical symptoms could delay diagnosis and further increase mortality [4].

Case Report

A 78-year-old male was transferred to our institution’s emergency department with the diagnosis of acute abdomen due to obstructive ileus, as a result of sigmoid-anal tumor. A nasogastric tube was inserted and its correct position was confirmed both by performing abdominal radiography and suctioning gastric content. Afterwards, the patient was transferred to the operating theatre, where after rapid sequence induction to anesthesia, the stomach was emptied and the nasogastric tube was retracted. The patient was easily intubated (Cormack- Lehane 2 C-L2). Several unsuccessful attempts to place a nasogastric tube were performed, using frozen nasogastric tubes and Magill’s forceps. When the surgical procedure was completed, the patient had an uneventful recovery and was transferred to the surgical department. However, four hours later, the patient presented massive subcutaneous emphysema and crepitation on palpation extending from the left supraclavicular region up to the face and both orbital regions (Figure 1). Airway was not obstructed and the Glasgow Coma scale was 15. Chest and neck radiographs were immediately performed (Figure 2) where air bubbles were identified in the superior mediastinum and the neck’s soft tissue, while the nasogastric tube was folded and its tip was at the level of the left atrium. Neck computed tomography was performed, confirming the presence of air bubbles in the neck’s soft tissue (in anterior and posterior neck triangles), at the anterior vertebrae region towards the supraclavicular region, as well as at the tracheal anterior region. Moreover, the nasogastric tube’s transmural course was illustrated, indicating the probable site of perforation and the surrounding soft tissue hematoma (Figure 3). Gastrografin was orally administrated and a new neck radiography was performed. Leakage was documented at the left side of the cervical esophagus, just below the pharyngoesophageal junction (Figure 4). The patient was urgently transferred to the operating room where the nasogastric tube was retracted. The patient remained stable, without difficulty in breathing, having patent airway and a perfect level of consciousness. Rapid sequence induction of anesthesia was performed; however, tracheal intubation was difficult and was only achieved at the second attempt, assisted by a gum-elastic endotracheal introducer (bougie), due to the extended tracheal deviation caused by soft tissue edema. Finally, an endotracheal tube No7 was inserted. Intraoperatively, surgeons assisted in inserting a nasogastric tube. The site of perforation was identified at the esophageal left lateral upper third, just below the pharyngoesophageal junction. Mucosal deficit was less than two centimeters long and was sutured in a single layer fashion with interrupted sutures, accompanied by surgical debridement and adequate drainage of the region (Figure 5). By surgery completion, the edema was substantially less and the patient’s recovery was uneventful. The patient had a post-operative course without further complications and was discharged on the 7th post-operative day.

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Figure 1: Subcutaneous emphysema at the left supraclavicular region, at the face and both orbital regions (black arrows).

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Figure 2: Chest radiography/Presence of air bubbles at superior mediastinum and neck’s soft tissue. Nasogastric tube is misplaced and folded (red arrow).

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Figure 3: Neck and chest computed tomography. A) Presence of air bubbles in neck’s soft tissue (in anterior and posterior neck triangles), at the anterior vertebrae region towards supraclavicular region and tracheal anterior region as well; B) nasogastric tube’s transmural course and surrounding soft tissue hematoma (red arrows).

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Figure 4: Neck radiographs after gastrografin oral administration. Contrast media is identified at the left cervical region (red arrows).

Cervical Esophagus Perforation Following Nasogastric Tube Insertion

Figure 5: Surgical procedure. Suturing the perforated cervical esophagus.

Discussion

The esophagus is mainly a midline structure, deviating initially to the left of the trachea as it passes through the neck, then to the right to accommodate the arch of the aorta and is finally pushed anteriorly by the descending thoracic aorta. There are three physical constrictions (cricopharyngeal, broncho-aortic, esophagogastric). The most common sites of esophageal perforation are at its normal narrowings. Perforations of the hypopharynx or the cervical esophagus are usually secondary due to exertion of force during the attempts of passing the instrument through the cricopharynx.

It is a common practice for anesthesiologists to blindly insert a nasogastric tube (Levin tube) in patients under general anesthesia, in order to empty the stomach and reduce its volume, post-operative nausea and vomiting. It is an apparently simple procedure. However, serious complications may occur at a rate of 0.3-0.8%. The tracheal-bronchial route, the upper gastro-intestinal tract, the head and the surrounding vessels are usually injured with a mortality rate reaching 0.3% (Table 1) [2,5-9]. Philip Ryom et al., [2] retrospectively studied periods 1997-2001 and 2002-2005 and reported that nasogastric tube insertion was the cause of esophageal perforations which occurred at 8% and 3% rate, respectively.

System/ Organ

Complication

Respiratory System

Intra tracheal-bronchial insertion causing:

Larynx injury, vocal cords paresis/paralysis.

Tracheal/bronchial/pleural perforation resulting to pneumothorax, hydrothorax, hemothorax, empyema, bronchial-pleural fistula, mediastinitis, sepsis.

Atelectasis, pneumonia, pneumonitis and abscess. Haemorrhage due to lung or trachea-bronchial tree.

Upper gastrointestinal tract

Nasogastric tube insertion perforating posterior nasopharyngeal wall

Esophageal perforation (cervical, thoracic, abdominal esophagus) with/without haemorrhage and mediastinitis, pneumoperitoneum or peritonitis

Stomach perforation with pneumoperitoneum and peritonitis

Duodenum peroration with pneumoperitoneum and peritonitis or posterior pneumoperitoneum and retroperitoneal soft tissue infection - sepsis

Facial bones

Insertion to:

Eustachian tube

Intracranial vault following maxillofacial injury

Vessels

Injury of:

Internal jugular vein

Subclavian artery

Right atrium

 Table 1: Nasogastric tube insertion complications (Levin tube).

There are several factors contributing to the risk of nasogastric tube misplacement, such as several unsuccessful attempts or head and neck position (Table 2) [8,10,11]. It is important to mention that the presence of blood implies trauma, the site of which must be identified. Presence of strictures, cancer, diverticulum, mucosal injury or perforation are some of the potential causes. In the case presented above, three risk factors were present; endotracheal intubation, several attempts using Magill’s forceps and the use of frozen non-flexible nasogastric tube. The tube’s successful placement can be confirmed either by insufflating air while auscultating its flow at the epigastrium, or by estimating the content’s pH (pH<5) and bilirubin levels [2].

Risk Factors

Nasogastric tube

  • Small diameter
  • No contrast marker
  • Nasogastric tube design
  • Inflexible nasogastric tube

Technique

  • Doctor’s inexperience
  • Patient’s wrong position
  • Blind insertion
  • Wrong tube’s size
  • Several attempts
  • Inadequate lubricant use

Patient

  • Patient with altered consciousness
  • Critically ill patient
  • Endotracheal intubation / tracheostomy
  • Sedation or neuromuscular blockage
  • Facial anatomic disorders
  • Esophageal injury / abnormalities
  • Esophageal paracentesis
  • Rhinopharyngeal pathology
  • Cervical osteophyte
  • Lung transplantation
  • Cardiomegaly

Table 2: Nasogastric tube misplacement risk factors. 

Symptoms vary depending on the level of esophageal perforation. Cervical subcutaneous emphysema, crepitation on palpation, dyspnea and dysphagia may be reported in cervical esophageal perforation. Posterior sternal pain, dyspnea, dysphagia and mediastinitis follow thoracic esophageal injury. Finally, epigastric pain or clinical signs of peritonitis are observed after abdominal esophageal perforation. Delayed diagnosis (more than 24 hours after injury) is reported at 60% of the cases. The main causes making diagnosis difficult are the non-specific symptoms and the variety of their intensity [12]. At the case reported, subcutaneous emphysema and crepitation at palpation at the left cervical region were the main clinical findings and diagnosis was performed within four hours after injury.

Diagnoses demand imaging tests. Flexible endoscopy may contribute to diagnosis; the entire esophagus can be directly inspected, identifying the exact site and kind of injury, noting the possible presence of haemorrhage. However, air insufflation is followed by the risk of enlarging the perforation and as a result, its use remains controversial. Simple neck radiography combined with orally administrated contrast media (gastrografin), apart from the presence of air bubbles in the neck’s soft tissues, can also indicate the injury’s level, as contrast media leaks out of the esophagus. Furthermore, chest radiographs are used to identify the presence of hemothorax, pneumothorax or subcutaneous emphysema. Finally, computed tomography confirms the diagnosis and contributes to documenting the tube’s course [12-14]. In our case, diagnosis was confirmed by the presence of air bubbles in the superior mediastinum and the neck’s soft tissue and the abnormal tube’s position. As there were no signs of respiratory disorders or pneumothorax, the injury was more likely to be extraglottical. Iatrogenic injuries due to instrumentation usually occur in the level of the cricopharynx. Chest and neck computed tomography that followed indicated the former mentioned findings and the extent of the cervical esophageal injury. Neck radiographs, following oral gastrografin administration, located the perforation site at the cervical esophagus’ left side, just below the pharyngoesophageal junction.

The treatment approach could be surgical, conservative or endoscopic. However, most of the times, a combination of techniques is essential. The main principles constitute of limiting injury contamination, suturing perforation site, draining injured region and providing dietary support to the patient. Cervical perforations due to the neck’s anatomy, are usually restrained in Killian’s triangle and as a result, conservative treatment in cases of iatrogenic limited perforation in stable patients without signs of ongoing sepsis may apply. Close patient follows up, intravenous antibiotics administration, parenteral nutrition, nil per os and radiologically guided drainage can be effective, having better outcomes when injury is treated within 6 hours of occurrence [15,16]. Endoscopy, apart from exactly locating and visualizing the injury, can be also used to repair mucosal defects by clipping, inserting plastic or metal self-expanding stents, applying tissue sealants and endoscopic sutures [16,17]. Lately, endoscopic vacuum sponge therapy has been used to treat a healing esophageal leakage or perforation with success rates over 70% [16,17].

In cases that the diagnosis was delayed for more than 24 hours or clinical symptoms of infection were present, there was a higher risk of failure of a conservative approach. Surgical treatment outcomes depend on injury extent and location, the surrounding soft tissue necrosis and the time elapsed since the moment of injury. Early diagnosis of a complication after nasogastric tube insertion is the best predictive factor of a surgical treatment outcome. An injury occurring more than 24 hours before admission and extensive tissue necrosis are followed by a greater post-operative complication risk [14,18,19]. The injury in the presented case was early diagnosed and treated in less than six hours from the time it occurred. Surgical exploration and primary interrupted suturing in single layer fashion of the perforation was performed, followed by surgical debridement and drainage.

The vast majority of the studies state post-operative hospital stay of 14 to 30 days [20]. Our patient had an uneventful post-operative course. He was re-evaluated with a neck computed tomography and was discharged on the 7th post-operative day.

It can be easily deduced that all possible measures should be taken, in order to prevent an esophageal iatrogenic injury. Many techniques have been described in reports of difficult nasogastric tube insertions, using special equipment, that is not available at all times. A technique, based on the use of an endotracheal tube, can assist doctors in cases of difficult nasogastric tube insertion. Direct laryngoscopy is used to identify the esophagus. Afterwards, an endotracheal tube cut longitudinally to its entire length, is inserted in the esophagus. As soon as a nasogastric tube is inserted through the endotracheal tube, the latter can be withdrawn with safety [21].

Conclusion

Nasogastric tube insertion in a generally anaesthetised patient is not such a simple procedure as it is thought to be. There is a risk of several complications, such as cervical esophageal perforation. Early diagnosis and meticulous treatment are of great importance to minimize morbidity and mortality, despite the fact that they remain challenging. Conservative management may apply to some patients in stable condition with small, contained perforations, without any signs of sepsis, while endoscopy may be of use either for the diagnosis or treatment of the injury. Surgical therapy is used in complex cases with larger defects and with septic patients where extended drainage and debridement are necessary. Due to the rare nature of the injury, it is difficult for individual doctors to gain enough experience. Therefore, early transfer to centres of expertise must be available. Furthermore, more studies are needed to improve patients’ management, with novel techniques. Last but not least, it is more than apparent, that a multidisciplinary approach is essential to limit the mortality and morbidity rates interlinked with such a serious complication after nasogastric tube misplacement.

Conflicts of Interest

All authors declare no conflicts of interest in this article.

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