Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy

Corresponding author: Hyeon Ju Shin, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Anam-dong 5-ga, Sungbuk-gu, Seoul 136-705, Korea. Tel: 82-2-920-5632, Fax: 82-2-928-2275, E-mail: [email protected] This manuscript was presented as an E-poster in the 88th the Korean society of anesthesiologists which was held in grand Hilton hotel, Seoul, Korea on November 4, 2011. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Intramural esophageal dissection is a rare disorder that occurs spontaneously or iatrogenically. Iatrogenic causes are endotracheal intubation [1], gastrointestinal endoscopy [2], nasogastric tube insertion [3]. Lately, as laparoscopy or robot-assisted total gastrectomy is performed through an intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien, Mansfield, MA, USA), anesthesiologists are required to insert the OrVil transorally [4]. The OrVil has an anvil assembly mounted on a 90 cm long polyvinylchloride delivery tube and the anvil head is secured to the tube with a suture in the tilted position. First, the distal tip of the delivery tube should be inserted transorally after the esophagus is clamped. The anvil head should be passed through the oral cavity as the convex surface of the anvil head is directed at the posterior wall of the esophagus. The tilted anvil head facilitates the passage of the anvil through the mouth and the esophagus, and untilts automatically when combined with the circular stapler intracorporeally. After the anvil head arrives to the lower esophageal sphincter, the delivery tube is cut and circular stapling esophagojejunostomy is performed. But the OrVil can induce esophageal injury. A 37-year-old female patient (height, 161.5 cm; weight, 49.5 kg) was scheduled to undergo robot-assisted total gastrectomy for early gastric cancer. Her past medical history and physical examination were unremarkable. In the operation room, the patient was induced with 2.0-3.0 vol% sevoflurane after receiving 110 mg of propofol by intravenous injection. Tracheal intubation using a 7.0 mm internal diameter endotracheal tube was performed without difficulty 3 minutes after the patient received 10 mg of cisatracurium by intravenous injection. A 16 French silicone nasogastric tube (Levin tube, Yushin Medical, Bucheon, Korea) was inserted through the left nostril with some difficulty. The nasogastric tube was passed to 55 cm and was noted to drain a small amount of turbid fluid. Twenty minutes after induction of anesthesia, a skin incision was made. The duodenum was resected, the esophagus was clamped and stomach was removed. One and a half hours later, the nasogastric tube was removed. The surgeon made a request to insert the OrVil transorally and said that the anvil head should be passed as the convex surface of the anvil head is directed at the posterior wall of the esophagus. At first, the OrVil was not passed through the mouth into the esophagus on blind approach. Therefore, the tip of the OrVil was inserted through the exposure of the vocal apparatus and esophageal entrance using the laryngoscope with some resistance. But, the OrVil was reinserted because the anvil head was not positioned properly. Finally, the OrVil arrived to the end of esophagus and an esophagojejunostomy with a circular stapler was performed intracorporeally. An hour later, the surgeon doubted the stricture of the anastomosis site, so a 16 French silicone nasogastric tube was reinserted. Even after several attempts, the nasogastric tube seemed to be entrapped at the level of the