Respiratory and Circulatory Failure From Abscess-Related Pneumomediastinum and Overflow Pneumoperitoneum

SESSION TITLE: Fellow Case Report Slide: Disorders of the Mediastinum SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 25, 2016 at 07:30 AM - 08:30 AM INTRODUCTION: Gastroesophageal perforation is an infrequent but serious complication following laparoscopic hiatal hernia repair1, which can lead to mediastinal abscess. CASE PRESENTATION: A 64 year old male presented with esophageal food impaction from an intrathoracic gastric volvulus. Four days following disempaction and laparoscopic hiatal hernia repair he developed hypoxia and sepsis. After intubation he had unanticipated severe hypotension. Testing confirmed a large gas-forming mediastinal abscess from a gastric perforation, which was treated with endoscopic stitching and stenting with complete defect closure. The next day he had worsening abdominal distention, rising airway pressures, and hypotension. CT scan showed enlargement of the mediastinal abscess with pneumomediastinum and new pneumoperitoneum from the diaphragm to the scrotum (Figure). Surgical debridement, mediastinal chest tube placement, and needle paracentesis for abdominal air dramatically improved peak airway pressures and hemodynamics. DISCUSSION: The patient suffered an iatrogenic gastric perforation with a large gas-producing mediastinal abscess. While intrathoracic displacement explains his respiratory failure, the hemodynamic collapse after positive pressure ventilation was likely from a critical increase in intrathoracic pressure impeding venous return. Perforation closure exacerbated this problem by eliminating the enteral drainage mechanism resulting in overflow pneumoperitoneum and further decline in respiratory mechanics, finally relieved by definitive external drainage. Historically, most iatrogenic gastroesophageal perforations merit surgical management, especially when recognized >24 hours after the injury2, but endoscopic drainage techniques can be considered in primary management of mediastinal abscess3. CONCLUSIONS: Without adequate drainage, gas-forming mediastinal abscess can rapidly expand causing pneumomediastinum and overflow pneumoperitoneum leading to respiratory and circulatory collapse, which is exacerbated by positive pressure ventilation. Reference #1: Brinster, Clayton J., et al. “Evolving options in the management of esophageal perforation.” The Annals of Thoracic Surgery 77.4 (2004): 1475-1483. Reference #2: Bufkin, Bradley L., Joseph I. Miller, and Kamal A. Mansour. “Esophageal perforation: emphasis on management.” The Annals of Thoracic Surgery 61.5 (1996): 1447-1452. Reference #3: Wehrmann, Till, et al. “Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series.” Gastrointestinal Endoscopy 62.3 (2005): 344-349. DISCLOSURE: The following authors have nothing to disclose: Matthew Nolan, John Park No Product/Research Disclosure Information