Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection

DOI: https://doi.org/10.21203/rs.3.rs-37167/v2

Abstract

Background: Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave's syndrome (BS), is rare after chest surgery.

Case Presentation: A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment.

Conclusions: Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Background

Spontaneous rupture of the esophagus, also known as Boerhaave’s syndrome (BS), typically occurs after severe emesis as a highly morbid emergency condition [1]. BS accounts for about 15% of esophageal perforations, and the tears are usually located in lower third of the esophagus [2]. Contrast esophagram and computed tomography (CT) are sufficient for the diagnosis of BS.

Non-intubated video-assisted thoracoscopic surgery (VATS) can be utilized to avoid ventilation-associated adverse effects, which has been reported to be technically feasible and safe [3]. The major complications of non-intubated procedure include intraoperative hypoxia, hypercapnia, and cough.

To our knowledge, the onset of contralateral esophageal rupture after lung resection without lymph node dissection is rare. Herein we presented a case of BS following severe emesis after non-intubated lung surgery. Meanwhile, the current evidence regarding the safety of non-intubated/tubeless thoracic surgery was reviewed briefly.

Case Presentation

The clinical data of the patient were treated anonymously for privacy concern. A 60-year-old previously healthy female non-smoker was admitted because the CT revealed a ground-glass nodule (GGN) about 0.5 cm in the left upper lobe (Fig. 1A). The serum neuron-specific enolase, cytokeratin-19 fragment, carcinoembryonic antigen, and squamous cell carcinoma were in normal range. After a preoperative workup, the patient was assigned to lung resection. Fast-track protocol was introduced. Preoperative three-dimensional CT angiography (3D-CTA) was established by OsiriX [4]; therefore, invasive labeling of the GGN by microcoil or hook-wire was avoided. Non-intubated uniportal VATS pulmonary wedge resection was performed under internal intercostal nerve block and targeted sedation [5, 6]. The operation time was 30 minutes, without obvious blood loss. Mediastinal lymph node sampling wasn’t performed because the frozen-section reported atypical adenomatous hyperplasia (AAH). Ultrasound-guided serratus anterior plane block (SAPB) using a bolus of 0.2% bupivacaine was utilized for postoperative analgesia.

Next-day discharge was scheduled because air leak was not recorded. Postoperative pathological staining of the specimen confirmed the diagnosis of AAH. The patient complained of nausea and emesis about 3h after the operation, which was alleviated gradually after intravenous ondansetron (4mg, once). However, 6h after the surgery, she developed sudden tachycardia, tachypnea, dyspnea and hypotension after oral feeding. Emergency CT revealed right-sided hydropneumothorax (Fig. 1B). The turbid, yellow fluid drained from the chest tube further confirmed the diagnosis of BS.

The patient refused a timely surgical intervention. Besides antibiotics and tube feeding, endoscopy-guided naso-leakage drainage of the pleural effusion was utilized, which had been reported to be effective to rinse vomica [7]. Finally, the esophagus was healed 40d after the treatment (Fig. 1C). During the 1-year follow up, tumor recurrence or metastasis was not recorded.

Discussion And Conclusions

We identified a patient with BS after severe emesis following minimally invasive lung surgery. Severe emesis is a stressful complication of anesthesia or analgesia. A retrospective study presented 10 patients with esophageal perforation after emesis associated with large volume of food and alcohol intake [8]. Moreover, every perforation was longitudinal tears (about 1-4 cm), locating in the left lower-third of the esophagus. Then the authors hypothesized that esophageal perforation probably resulted from emesis through a pathophysiological reaction within the upper digestive tract. Furthermore, they proposed that BS should be defined as post-emetic esophageal perforation. Therefore, we concluded that the present BS was probably secondary to the uncontrolled emesis rather than the surgical procedure itself.

The incidence of post-discharge emesis after ambulatory surgery is approximately 30% [9]. Chest pain and emesis always suggest the onset of BS, but the patients don't always present with typical clinical features. The major treatment options for BS were conservative, endoscopic and surgical approach; whereas the survival rate of the patients using these treatments was 75%, 100% and 81%, respectively [10]. Surgery should be considered especially for those who are admitted within 24 hours of perforation [11]. In addition, endoscopy also plays a role in the treatment of transmural defects [12], although an evidence-based recommendation is still lacking. Besides surgical and endoscopic interventions, naso-esophageal extraluminal drainage has been reported to be effective for the treatment of esophageal leaks and subsequent mediastinal abscess [13].

On the other hand, non-intubated thoracic surgery under minimal sedation with regional anaesthesia is useful to avoid nausea and emesis [14]. However, the evidence supporting non-intubated VATS as the preferred approach for lung surgery is still limited. Previous meta-analyses show that non-intubated procedures could attenuate surgery-related stress responses and decrease postoperative complications compared to intubated surgery [15, 16]. Moreover, for patients who are considered as high-risk under intubated general anesthesia due to their compromised lung function, non-intubated procedure could be considered [17]. A meta-analysis indicates that non-intubated VATS may be a better alternative to intubated surgery [18], although it requires extra vigilance to ensure the safety of the patients [19]. The disadvantages of non-intubated thoracic surgery include cough and poor maneuverability due to the movements of diaphragm and lung [20].

We searched PubMed, Web of Science, Scopus, Embase, Europe PMC, Cochrane Library and Google Scholar for randomized controlled trials (RCTs) up to June 2020 according to the PRISMA Protocol for updated evidence of nonintubated lung surgery. Key words in title or abstract include “non-intubated” or “tubeless” or “awake” and “pulmonary” or “lung” and “surgery”. Finally a total of 13 RCTs were obtained (Table 1), which covered 627 patients who underwent non-intubated or tubeless VATS. Among them, 11 (1.8%) morbidities due to gastrointestinal reactions were recorded. Based on these findings, non-intubated VATS is technically feasible and safe; however, the results should be interpreted with caution due to small samples in the trials and potential publication bias. Well-designed studies are warranted. The registered trials of non-intubated thoracic surgery were listed in Table 2, which might further elucidate the specific indications and contraindications of tubeless thoracic surgery.

In summary, perioperative antiemetic with strict supervision should be considered as an indispensable item of fast-track thoracic surgery. Moreover, the occurrence of BS and a timely intervention should be kept in mind when the patients report chest distress after severe emesis following lung surgery.

List Of Abbreviations

CT, computed tomography; BS, Boerhaave's syndrome; VATS, video-assisted thoracoscopic surgery; AAH, atypical adenomatous hyperplasia; SAPB, serratus anterior plane block; RCTs, randomized controlled trials

Declarations

Ethics approval and consent to participate

This report was approved by the Institutional Review Board of Xuzhou Central Hospital.

Consent for publication

Written informed consent was obtained from the patient for publication of this report and any accompanying images.

Availability of data and materials

The data used in this report are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

MZ performed the surgery and wrote this paper. LL contributed to the preparation of the figures and tables. All authors contributed to preparation of the paper and to the perioperative treatment of the patient. All authors approved the final manuscript.

Acknowledgements

Not applicable.

References

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Tables

Table 1 The reported randomized clinical trials regarding non-intubated thoracoscopic lung surgery

First author, year

Sample

Age, year

Anaesthesia method

Surgical procedure

Conversion to intubation

Postoperative analgesia

Morbidity due to gastrointestinal reactions

Pompeo, 2004 [21]

30

60 (45–68)

TEA at T4-T5

Pulmonary nodule resection

4 (13.3%)

TEA

NR

Pompeo, 2007 [22]

21

28 ± 14

Locoregional anaesthesia

Bullectomy

0

TEA

1 (4.8%)

Vanni, 2010 [23]

25

57 (51–62)

TEA

NR

0

PCIA

0

Tacconi, 2010 [24]

11

48 (43–55)

TEA

Lung nodule resection, bullectomy, pleura-lung biopsy 

0

PCIA

0

Pompeo, 2011 [25]

32

64 ± 9

TEA at T4-5

Lung volume reduction

2 (6.3%)

NR

0

Pompeo, 2013 [26]

20

67 ± 12

TEA at T4

Pleurodesis

0

NR

0

Cai, 2013 [27]

30

23.5 ± 10.6

Laryngeal mask anesthesia

Bullectomy

0

PCIA

3 (10.0%)

Wang, 2014 [28]

50

43.2 ± 14.7

General anesthesia; laryngeal mask

Bullectomy, lobectomy, biopsy, mediastinal mass excision

0

NR

0

Liu, 2015 [29]

167

NR

TEA

Wedge resection, lobectomy 

0

NR

4 (2.4%)

Chen, 2016 [30]

85

23.3 ± 6.8

Intravenous anesthesia

Sympathectomy

0

NR

0

Mao, 2018 [31]

30

21 ± 3.2

General anesthesia + laryngeal mask

NUSS procedure

0

PCIA

3 (10.0%)

Hwang, 2018 [32]

21

17 (17-45)

Sedation anesthesia

Bullectomy

0

Local analgesia

0

Mogahed, 2019 [33]

35

42.9 ± 9.6

General anaesthesia

Lung resections, excision/biopsy of mediastinal mass, foreign body extraction and pericardial window.

0

Intramuscular ketoprofen

NR

35

43.5 ± 10.5

General anaesthesia + TEA

35

44.0 ± 9.3

General anaesthesia + intercostal block infiltration

Abbreviations: TEA, thoracic epidural anesthesia; PCIA, patient controlled intravenous analgesia; NR, not reported.

 

Table 2 The registered trials of non-intubated or tubeless thoracoscopic lung surgery

Registration identifier

Year

Disease

Anaesthesia method

Estimated enrollment

Major outcomes

Status

Country

NCT00566839

2007

Emphysema

TEA

60

Mortality, FEV1, dyspnea index

Completed

Italy

NCT01469728

2011

NR

TEA

40

Grade of medical care

Completed

Italy

NCT01677442

2011

NR

TEA at the T5/T6

500

Recovery time

Unknown

China

NCT01533233

2012

Lung cancer

NR

100

Complication and morbidity

Unknown

China

NCT02109510

2014

Pneumothorax

Sedation anesthesia +  intercostal nerve block

40

Postoperative discomforts

Completed

Korea

NCT02123173

2014

Lung neoplasms

NR (one lung ventilation)

71

Cardiac output

Completed

China

NCT02393664

2015

Lung neoplasms

General anesthesia + intercostal/vagal blocks

300

Quality of recovery

Unknown

China

NCT02817048

2016

Solitary lung nodule

NR (Tubeless)

100

Postoperative hospital stay

Not yet recruiting

China

NCT03275428

2017

Lung nodule

Intravenous sedation

40

Arterial oxygen pressure

Unknown

China

NCT03083080

2017

NR

Intercostal nerve plane block

30

Pain, time to lose skin sensation

Unknown

China

NCT03086213

2017

NR

Paravertebral/intercostal nerve block

48

The change of stress response markers

Unknown

China

NCT03016858

2017

Bulla

Intravenous anesthesia

320

Complications

Recruiting

China

NCT03137576

2017

Lung neoplasms

Erector spinae plane block/paravertebral block and sedation

172

Percentage of sedation escalation

Recruiting

Italy

ChiCTR-INR-17012747

2017

Thoracic diseases

General anesthesia

30

Length of hospital stay

Recruiting

China

ChiCTR-IPR-17013325

2017

Lung nodule

Intravenous anesthesia

120

CD3+, CD8+,                CD4+, CD19+, NK cell concentration

Not yet recruiting

China

NCT03711461

2018

NR

NR

32

Impedance changes (swallowing)

Recruiting

China

NCT03432637

2018

Lung cancer

Spontaneous ventilating anesthesia

450

Hypoxemia or hypercapnia

Recruiting

China

NCT03471884

2018

Lung cancer

General anesthesia

82

Lung function

Recruiting

China

NCT03469323

2018

NR

NR (one-lung spontaneous breathing)

30

Quality of lung collapse

Recruiting

China

ChiCTR1800018198

2018

NR

Paravertebral nerve block + laryngeal mask

110

Glottal injury, sore throat

Recruiting

China

NCT03653494

2018

NR

General anesthesia + paravertebral block + surface spray anesthesia + vagus block with or without phrenic block

80

Anesthetic drugs needed

Enrolling by invitation

China

ChiCTR1800018204

2018

NR

Serratus anterior plane/erector spinae plane/paravertebral block

90

Nerve block time

Not yet recruiting

China

ChiCTR1800017854

2018

T1a (2cm) peripheral lung adenocarcinoma

NR (Tubeless)

200

Complications

Not yet recruiting

China

NCT03874403

2019

NR

Intercostal nerve block

60

The density spectral array

Recruiting

China

NCT04057586

2019

NR

NR (one lung ventilation)

240

Intraoperative cerebral oxygenation

Recruiting

China

ChiCTR1900027350

2019

Lung cancer

Intercostal/paravertebral nerve block + general anesthesia using laryngeal mask

80

Hemodynamics, general anesthetic dose, recovery time

Recruiting

China

ChiCTR1900022020

2019

Thoracic disease

General anesthesia

120

Glottal injury incidence, lung collapse score

Recruiting

China

NCT03958162

2019

Interstitial lung disease

NR (tubeless)

60

Diagnostic yield after biopsy

Not yet recruiting

China

NCT03902470

2019

Lung cancer

TEA

30

Recovery time

Not yet recruiting

Egypt

TEA, thoracic epidural anaesthesia; FEV1, Forced expiratory volume in one second; NR, not reported.