Unusual occurrence of massive subcutaneous emphysema during ...

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Brief Communications

foetal monitoring is crucial, while intraoperative monitoring is no longer recommended.[1,2] These surgeries should be performed in well‑equipped centres due to the potential for complications. We recommend pharmacological DVT prophylaxis and obstetric backup. The protocol practiced in our centre is shown in Figure 2.

8.

Bassil S, Steinhart U, Donnez J. Successful laparoscopic management of adnexal torsion during week 25 of a twin pregnancy. Hum Reprod 1999;14:855‑7. 9. ACOG Committee Opinion No. 474: Nonobstetric surgery during pregnancy. ACOG Committee on Obstetric Practice. Obstet Gynecol. 2011;117:420‑1. 10. Rizzo AG. Laparoscopic surgery in pregnancy: Long‑term follow‑up. J Laparoendosc Adv Surg Tech A 2003;13:11‑5. Access this article online

Limited studies on long‑term foetal effects have reported no adverse events.[10] DDST II assessed yearly in our children up to 5‑years‑revealed no abnormalities until now. Limitations of our study are that it is a retrospective analysis with only eight patients, with no control arm for mothers and babies and further assessment of babies is ongoing and not complete yet.

Conclusion Laparoscopic surgeries during pregnancy may be a viable alternative to open surgery provided it is performed in centres with multidisciplinary facilities and recommendations are followed.

Nisha Rajmohan, Hassy Prakasam, J Simy Department of Anaesthesiology, PVS Memorial Hospital, Kaloor, Kochi, Kerala, India Address for correspondence: Dr. Nisha Rajmohan, Department of Anaesthesiology, PVS Memorial Hospital, Kaloor, Kochi ‑ 682 017, Kerala, India. E‑mail: [email protected]

References 1.

Pearl J, Price R, Richardson W, Fanelli R, Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011;25:3479‑92. 2. Moreno‑Sanz C, Pascual‑Pedreño A, Picazo‑Yeste JS, Seoane‑Gonzalez JB. Laparoscopic appendectomy during pregnancy: Between personal experiences and scientific evidence. J Am Coll Surg 2007;205:37‑42. 3. Cruz AM, Southerland LC, Duke T, Townsend HG, Ferguson JG, Crone LA. Intraabdominal carbon dioxide insufflation in the pregnant ewe. Uterine blood flow, intraamniotic pressure, and cardiopulmonary effects. Anesthesiology 1996;85:1395‑402. 4. Upadhyay A, Stanten S, Kazantsev G, Horoupian R, Stanten A. Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy. Surg Endosc 2007;21:1344‑8. 5. Soper NJ, Hunter JG, Petrie RH. Laparoscopic cholecystectomy during pregnancy. Surg Endosc 1992;6:115‑7. 6. Williams JK, Rosemurgy AS, Albrink MH, Parsons MT, Stock S. Laparoscopic cholecystectomy in pregnancy: A case report. J Reprod Med 1995;40:243‑5. 7. Reitman E, Flood P. Anaesthetic considerations for non‑obstetric surgery during pregnancy. Br J Anaesth 2011;107 Suppl 1:i72‑8. Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013

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DOI: 10.4103/0019-5049.123339

Unusual occurrence of massive subcutaneous emphysema during ERCP under general anaesthesia Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is associated with retroperitoneal perforation in 2.1% of cases and is usually related to extensive sphincterotomy.[1] Not infrequently, retroperitoneal air, pneumoperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema are also reported which may or may not be associated with retroperitoneal perforation.[2‑4] Usually, these conditions respond to conservative management. Recently, we encountered a case developing subcutaneous emphysema without pneumomediastinum and pneumothorax while undergoing ERCP. This communication aims at highlighting a variant of presentation of extraluminal air during ERCP and current status of surgical approach to such situations.

Case ReporT A 62‑year‑old woman with obstructive jaundice and deranged liver function tests was referred for an elective ERCP and stenting/sphincterotomy. Her past medical history and examination were unremarkable. She was given a general anaesthetic with endotracheal intubation. During ERCP which was indeed difficult, a peripapillary mass and a narrowed common bile duct without stones was noted. A sphincterotomy was tried repeatedly without success. There were no 615



adverse anaesthetic events till late into the procedure when there was sudden drop in oxygen saturation from 99% to 88%. This prompted the anaesthesiologist to auscultate the chest who noted the presence of crepitus over the anterior as well as posterior aspect of chest. As the patient was in the semi‑prone position and draped, further closer examination of the patient’s face and neck revealed emphysematous swelling predominant on the right side, previously non‑existent [Figure 1]. Suspecting retro‑peritoneal perforation, the patient was turned supine and then she was noted to have slightly distended abdomen too. Oxygen saturation improved immediately after change of position and ventilation with 100% oxygen. A gastrointestinal surgery consultation was obtained and it was decided to undertake surgical exploration immediately. However, laparotomy did not reveal any definitive perforation even though there was minimal retro‑duodenal staining with bile. Roux‑en‑Y hepaticojejunostomy and gastrojejunostomy was performed as a palliative measure. After surgery, the patient was shifted to intensive care unit (ICU) for elective ventilation where a chest X‑ray revealed diffuse subcutaneous emphysema without any evidence of pneumothorax and pneumomediastinum [Figure 2]. She was weaned off the ventilator next morning, had a steady resolution of subcutaneous emphysema, and was discharged on day 12 without any jaundice and emphysema.

Figure 1: Post procedure emphysema

Discussion Majority of reports of extraluminal air describe the presence of pneumothorax as well as pneumomediastinum along with subcutaneous emphysema following ERCP.[2‑6] This is expected when one looks at the mechanisms of progress of extraluminal air (vide infra). In addition, non‑surgical management is the preferred approach to such complications since all instances of extraluminal air are not associated with retroduodenal perforations. In our case, it was anomalous that massive emphysema without pneumothorax/pneumomediastinum occurred rapidly leading to presumption of a retro‑duodenal tear followed by surgical exploration with negative results. In a similar report, a patient was noted to develop right sided subcutaneous emphysema from the umbilicus upward till the forehead without evidence of extraluminal air anywhere else.[3] Besides this report, we were unable to find any report of pure subcutaneous emphysema though a case of subcutaneous emphysema of penis and scrotum and 616

Figure 2: Subcutaneous emphysema on X-ray chest

an intriguing report of isolated periorbital emphysema have been reported following ERCP.[4,5] Second aspect of this report is to highlight that the current approach to the presence of extraluminal air with suspicion of perforation is non‑surgical.[6,7] In our case, immediate surgery was contemplated as an extensive emphysema appeared in a short time. Additionally, the patient was under general anaesthesia which allowed quick surgical intervention. However surgery proved to be beneficial for her since her jaundice resolved subsequently. The absence of any tear on exploration did come as a surprise; however, extraluminal air during ERCP can occur in the absence of overt perforation as reported by Stapfer et al.[8] Ferrarra et al. and others have reported pneumomediastinum, pneumothorax, and subcutaneous emphysema after Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013



endoscopic sphincterotomy without evidence of perforation.[2] Like Ferrara, et al., we too did not find any evidence of true perforation, hence it is likely that this complication probably occurred because of prolonged air insufflation and interstitial air extravasation from the duodenum. Retroperitoneal perforation usually presents in the post‑procedure period with abdominal discomfort, difficulty in breathing, low‑grade fever and the condition is confirmed by chest and abdominal X‑rays and contrast enhanced CT. Majority of cases can be managed conservatively.[7,9] Trauma to the duodenal wall by the endoscope allows insufflated air under pressure to enter the mucosa and track along the perineural and perivascular sheaths to enter the mediastinum. Subsequent rupture of the mediastinal pleura allows air to decompress into the pleural cavity and cause a pneumothorax. In addition, the visceral space of the deep cervical fascia in the neck surrounds the trachea and oesophagus and is contiguous with the diaphragmatic/oesophageal hiatus, hilar vessel interstitium and major airways of the thorax.[10] This contiguity allows free movement of air and formation of subcutaneous emphysema around upper cervical region, which then tracks down the endothoracic fascia of the chest wall and transversalis fascia of abdomen to cause diffuse subcutaneous emphysema. Thus it is indeed baffling to observe subcutaneous emphysema without any pneumothorax or pneumomediastinum.

References 1.

Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post‑ERCP complications: A systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781‑8. 2. Ferrara F, Luigiano C, Billi P, Jovine E, Cinquantini F, D’Imperio N. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endosc 2009;69:1398‑401. 3. Seymann GB, Savides T, Richman KM. Massive subcutaneous emphysema after endoscopic retrograde cholangiopancreatography. Am J Med 2010;123:e15‑6. 4. Kaul S, Koul S, Singh H, Kachroo SL, Chrungoo RK. Post ERCP Surgical Emphysema. J K Science 2008;10:18990. 5. Borgharia S, Jindal V, Gautam V, Singh N, Thomas S, Solanki RS. Subcutaneous emphysema of the penis and scrotum mimicking gas gangrene: A rare complication of ERCP. Gastrointest Endosc 2011;73:613‑5. 6. Colemont LJ, Pelckmans PA, Moorkens GH, Van Maercke YM. Unilateral periorbital emphysema: An unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988;34:473‑5. 7. A Michelle Anderson MA, Fisher L, Jain R, Evans JA, Appalaneni V, et al. Complications of ERCP. Gastrointestinal Endoscopy 2012;75:467‑73. 8. Stapfer M, Selby RR, Stain SC, Katkhouda N, Parekh D, Jabbour N, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000;232:191‑8. 9. Enns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, et al. ERCP related perforations: Risk factors and management. Endoscopy 2002;34:293‑8. 10. Kirschner PA. Porous diaphragm syndromes. Chest Surg Clin N Am 1998;8:44‑72. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.123340

Conclusion Subcutaneous emphysema, pneumothorax and pneumomediastinum are infrequent complications of ERCP and do not appear to change the prognosis of these subjects. Subcutaneous emphysema can occur in isolation and if patient is stable, conservative treatment is an appropriate first‑line approach.

Santosh Kumar Jaiswal, Deepak Kumar Sreevastava, Rashmi Datta, Navdeep Singh Lamba Department of Anaesthesiology and Critical Care, Army Hospital (Research and Referral), Delhi Cantonment, India Address for correspondence: Dr. Santosh Kumar Jaiswal, Department of Anaesthesiology and Critical Care, Army Hospital (Research and Referral), Delhi Cantonment ‑ 110 010, India. E‑mail: [email protected]

Indian Journal of Anaesthesia | Vol. 57 | Issue 6 | Nov-Dec 2013

Airway management for tracheal stent insertion in a patient with difficult airway INTRODUCTION Airway management in a patient with a tracheal stenosis undergoing stent insertion poses a significant challenge to the anesthesiologist who has to ensure adequate ventilation in the presence of a stenotic segment and maintain adequate depth of anaesthesia to suppress the stress response. The airway management and ventilation technique for tracheal stent insertion in a patient with difficult airway is described in this case report. 617