Cardiac Arrest Due to Pneumomediastinum following Esophagojejunal Anastomotic Fistula: A Case Report.

Background (cid:0) Cardiac arrest due to pneumomediastinum following esophagojejunal anastomotic stula is one of the most severe postoperative complications. However (cid:0) It presents with insidious symptoms and easy to be ignored. Case presentation: A 59-year-old man had total laparoscopic radical gastrectomy for gastric cardia adenocarcinoma (GCA). Since then, He began to appear shortness of breath and dyspnea gradually. The image reported severe pneumomediastinum due to esophagojejunal anastomotic stula. Sudden cardiac arrest developed. Immediate cardiopulmonary resuscitation (CPR) and epinephrine rescue were carried out. Stents were placed to plug the stula and drainage was performed. Conclusions: Pneumomediastinum is easily overlooked as a complication of esophagojejunal anastomotic stula after subtotal gastrectomy. A delay in diagnosis increases the rate of cardiac arrest. At present, the treatment of esophagojejunal anastomotic stula mainly adopts conservative treatment such as drainage and interventional therapy. But the death rate is extremely high. Early positive identication is the life-saving procedure and should not be delayed.

Background Cardiac arrest due to pneumomediastinum following esophagojejunal anastomotic stula is one of the most severe postoperative complications. However It presents with insidious symptoms and easy to be ignored.
Case presentation: A 59-year-old man had total laparoscopic radical gastrectomy for gastric cardia adenocarcinoma (GCA). Since then, He began to appear shortness of breath and dyspnea gradually. The image reported severe pneumomediastinum due to esophagojejunal anastomotic stula. Sudden cardiac arrest developed. Immediate cardiopulmonary resuscitation (CPR) and epinephrine rescue were carried out. Stents were placed to plug the stula and drainage was performed.
Conclusions: Pneumomediastinum is easily overlooked as a complication of esophagojejunal anastomotic stula after subtotal gastrectomy. A delay in diagnosis increases the rate of cardiac arrest. At present, the treatment of esophagojejunal anastomotic stula mainly adopts conservative treatment such as drainage and interventional therapy. But the death rate is extremely high. Early positive identi cation is the life-saving procedure and should not be delayed.

Background
Esophagojejunal anastomotic stula (EJF) is one of the most common and fearful complications of Laparoscopy-assisted radical gastrectomy(LAG) for gastric cancer [1,3]. It can induce pneumomediastinum. Pneumomediastinum in turn could lead to hemodynamic instability and circulatory collapse. This complication has insidious onset which could be easily ignored. A delay in diagnosis increases the risk of death [4,5]. We report a case of pneumomediastinum with EJF after LAG. The importance of early diagnosis and treatment strategy to avoid major complications was discussed.

Case Presentation
A 59-year-old man was admitted to hospital after "physical examination showed gastric cardia adenocarcinoma(GCA) for 6 days". The man had no signi cant medical history and the preoperative examination was normal. Under general anesthesia, the patient underwent total laparoscopic radical gastrectomy, routine pneumoperitoneum was established, total gastrectomy was performed, and roux-Y anastomosis was performed for the esophagus and jejunum. Since then, the patient began to appear shortness of breath and dyspnea gradually. On 6 days after operation (day 6), enhanced CT scan of chest, abdomen and pelvis (Fig. 2) showed that both lungs were scattered with few in ammation. Gas accumulation was widespread in mediastinum. Pneumomediastinum due to EJF occurred and conservative treatment was initiated. On day 9, He was transferred to the ICU after developing dyspnea where tracheal intubation was performed. Immediately, blood pressure (BP) dropping to 63/43 mmHg and sudden cardiac arrest developed. Immediate cardiopulmonary resuscitation (CPR) and epinephrine rescue were carried out. After 4 minutes, the patient's spontaneous heartbeat recovered. Due to the unstable vital signs of the patient, no external examination or surgical intervention was required. On day 17, follow-up CT reexamination (Fig. 3) demonstrated that pneumatosis increased in mediastinum.
Interventional therapy was performed at the EJF of the patient, stents were placed to plug the stula and drainage was performed. However, the patient was died from the hospital 3 months later after an multifunctional organ failure.

Discussion And Conclusions
Pneumomediastinum is de ned by the deleterious effects on the cardiovascular and pulmonary systems [8]. The increased intra-mediastinum pressure and gas compresses trachea, bronchi and lungs, damage ventilation, decreases cardiac output and large blood vessels dilation, which may lead to respiratory and circulatory failure. Anastomotic stula after GCA can easily lead to pneumomediastinum.
At present, EJF is diagnosed mainly through CT and pleural puncture to extract the contents entering the thoracic cavity through the digestive tube [9]. However, EJF patients with pneumomediastinum is di cult to go to the radiology department for radiographic examination. Therefore, It is important to emphasize that postoperative patients need to closely observe the respiratory condition, and regularly review the chest and abdomen CT examinations, so as to identify pneumomediastinum in time.
At present, the treatment of EJF mainly adopts conservative treatment such as drainage and interventional therapy [2,6,7]. But the death rate is extremely high. early positive identi cation is the lifesaving procedure and should not be delayed.

Abbreviations
GCA gastric cardia adenocarcinoma CPR cardiopulmonary resuscitation EJF esophagojejunal anastomotic stula LAG Laparoscopy-assisted radical gastrectomy Declarations Ethics approval and consent to participate This report was prepared in accordance with the ethical standards of the institutional ethics committee and with the 1964 Helsinki Declaration.

Consent for publication
Written informed consent for the publication of their clinical details was obtained from the patient. A copy of the consent form is available for review by the editor of this journal.

Availability of data and materials
All data generated or analysed during this study are included in this published article. Figure 1 Enhanced CT angiography of chest, abdomen and pelvis. Transverse section. Gas accumulation was widespread in mediastinum.