GA4-80
Unusual complication following esophageal balloon dilation in a pediatric patient
Maler S, Kriss R
University of California, Davis Medical Center, Sacramento, CA, USA
Introduction: Esophageal dilation is an increasingly common procedure often performed in the outpatient setting. Indications in the pediatric population include esophageal atresia, strictures after caustic injury, or iatrogenic atresia after tracheoesophogeal fistula repair [1]. Although the overall complication rate per procedure is low, major ones may arise including esophageal perforation, hemorrhage, aspiration and bacteremia, all of which are of critical concern for the anesthesiologist in the perioperative setting [2,3,4]. This case demonstrates a rare complication after a balloon dilation in a pediatric patient.
Case: This case involves a patient who is a 14-month-old, 9.5 kg male. He was previously healthy until 12 months of age when he had an accidental ingestion of alkaline dishwasher detergent requiring a prolonged pediatric ICU (PICU) stay before discharge. Due to persistent secretions and dysphagia, he subsequently underwent three separate esophageal dilations under general anesthesia and was discharged home the day after. He presented to the OR at the Children’s Surgical Center at UC Davis Medical Center for his fourth dilation. After mask induction, IV access, and placement of an endotracheal tube, serial dilations were carried out with visualization of esophageal contour under fluoroscopy. At the time of insufflation during final endoscopy, tidal volumes abruptly decreased with intermittent drops of oxygen saturation, however blood pressure remained normal. Bilateral but coarse breath sounds were heard with no change in end tidal CO2. The procedure was completed, and the patient was extubated once stable. In the PACU, breath sounds were diminished and coarse, with saturations around 75%. Sternal retractions and mild crepitus of the upper chest were also noted. A stat portable chest x-ray found a large right pneumothorax with leftward mediastinal shift. He was taken emergently to the OR for placement of a right sided chest tube under general anesthesia. He emerged uneventfully and was taken to the PICU. Repeat x-ray demonstrated expansion of the right pneumothorax. Post operatively, he was treated with antibiotics and given total parenteral nutrition, with gradual advancement of his diet before discharge.
Discussion: This case presents a rare complication of a tension pneumothorax following an esophageal dilation due to an esophageal perforation. Perforation frequency is quoted from 0.02 to 0.4%, with more complex strictures such as from caustic ingestion, contributing to a higher risk of perforation due to poor tissue integrity and difficulty in dilation requiring additional interventions [2,3,5]. This patient may have exhibited early signs of a pneumothorax intraoperatively, but did not decompensate until post-operatively.
Conclusion: It is essential to anticipate and recognize impending cardiorespiratory collapse due to tension pneumothorax in a patient with a higher risk of perforation undergoing esophageal dilation.
Sources:
1. Allmendinger N, et al.J Pediatr Surg.1996; 31(3):334-336.
2. Egan JV, et al. Gastrointest Endosc.2006;63(6):755.
3. Kavic SM, et al. Am J Surg 2001;181:319.
4. Mandelstam P, et al.Gastrointest Endosc.1976; 23:16.
5. Bittencourt PF, et al. J Pediatr (Rio J).2006; 82(2):127-31.
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