Fatal outcome due to CO<sub>2</sub> emboli during direct cholangioscopy

Hann, Alexander; Zizer, Eugen; Egger, K; Allescher, Hans–Dieter; Meining, Alexander

doi:10.1136/gutjnl-2017-313988

Cited by 14 publications

(10 citation statements)

References 12 publications

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“…However, there are several limitations to evaluating suspected malignant biliary stricture using POC systems, including high costs and the possibility of adverse event (cholangitis, pancreatitis). Also, the standardization of endoscopic techniques and prevention of air or carbon dioxide embolization are still required for direct POC using an ultraslim endoscope [11,21,25,26]. In addition, clear criteria guiding the choice of POC systems for individual patients are lacking.…”

Section: Totalmentioning

confidence: 99%

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

et al. 2018

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Background Although endoscopic retrograde cholangiopancreatography (ERCP) is a first-line diagnostic modality for suspected malignant biliary stricture (MBS), the diagnostic yield of ERCP-based tissue sampling is insufficient. Peroral cholangioscopy-guided forceps biopsy (POC-FB) and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) are evolving as reliable diagnostic procedures for inconclusive MBS. This study aimed to evaluate the usefulness of a diagnostic approach using POC-FB or EUS-FNAB according to the stricture location in patients with suspected MBS. Methods Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with transpapillary forceps biopsy (TPB) was performed initially. When malignancy was not confirmed by TPB, POC-FB using a SpyGlass direct visualization system or direct POC using an ultraslim endoscope was performed for proximal strictures, and EUS-FNAB was performed for distal strictures as a follow-up biopsy. Results Among a total of 181 patients, initial TPB showed malignancy in 122 patients, and the diagnostic accuracy of initial TPB was 71.8 % (95 % confidence interval [CI] 65.3 % – 78.4 %]. Of the 59 patients in whom TPB was negative for malignancy, 32 had proximal biliary strictures and underwent successful POC. The remaining 27 patients had distal strictures and underwent successful EUS-FNAB. The accuracy of malignancy detection using POC-FB for proximal biliary strictures and EUS-FNAB for distal biliary strictures was 93.6 % (95 %CI 84.9 %−100 %) and 96.3 % (95 %CI 89.2 %−100 %), respectively. The overall diagnostic accuracy for the combination of TPB with either POC-FB for proximal strictures and EUS-FNAB for distal strictures was 98.3 % (95 %CI 95.9 %−100 %) and 98.4 % (95 %CI 95.3 %−100 %), respectively. Conclusions An approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS.

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Section: Totalmentioning

confidence: 99%

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

et al. 2018

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“…[ 10 ] Therefore, the use of CO 2 , but not of air, is strictly recommended to reduce the incidence of emboli. [ 12 ] Early diagnosis of air embolism is very important. The most beneficial therapy in eliminating the gas bubbles is HBOT.…”

Section: Discussionmentioning

confidence: 99%

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy

Guo

Wang²,

Wang³

et al. 2021

Medicine

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Introduction: Air embolism has the potential to be serious and fatal. In this paper, we report 3 cases of air embolism associated with endoscopic medical procedures in which the patients were treated with hyperbaric oxygen immediately after diagnosis by transesophageal echocardiography. In addition, we systematically review the risk factors for air embolism, clinical presentation, treatment, and the importance of early hyperbaric oxygen therapy efficacy after recognition of air embolism. Patient Concerns: We present 3 patients with varying degrees of air embolism during endoscopic procedures, one of which was fatal, with large amounts of gas visible in the right and left heart chambers and pulmonary artery, 1 showing right heart enlargement with increased pulmonary artery pressure and tricuspid regurgitation, and 1 showing only a small amount of gas images in the heart chambers. Diagnoses: Based on E T CO 2 and transesophageal echocardiography (TEE), diagnoses of air embolism were made. Interventions: The patients received symptomatic supportive therapy including CPR, 100% O 2 ventilation, cerebral protection, hyperbaric oxygen therapy and rehabilitation. Outcomes: Air embolism can causes respiratory, circulatory and neurological dysfunction. After aggressive treatment, one of the 3 patients died, 1 had permanent visual impairment, and 1 recovered completely without comorbidities. Conclusions: While it is common for small amounts of air/air bubbles to enter the circulatory system during endoscopic procedures, life-threatening air embolism is rare. Air embolism can lead to serious consequences, including respiratory, circulatory, and neurological impairment. Therefore, early recognition of severe air embolism and prompt hyperbaric oxygen therapy are essential to avoid its serious complications.

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“…Although CO 2 is an inert, noncombustible gas that is rapidly absorbed and is highly soluble in water and blood, there have been case reports of fatal embolic events occurring with CO 2 during endoscopy. 7 For this reason, endoscopy should be avoided if there is any concern for AEF. 1 Patients presenting with sepsis due to AEF also tend to grow Gram-positive organisms in their blood culture, most likely attributed to oral flora, very similar to our patient who had bacteremia with S. mitis .…”

Section: Discussionmentioning

confidence: 99%

Acute Stroke After Upper Endoscopy in a Patient With a Suspected Atrioesophageal Fistula

2019

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Atrioesophageal fistula (AEF) is a rare complication of atrial fibrillation ablation. We present a man with sepsis and frank hematemesis 3 weeks after atrial fibrillation ablation. Thoracic computed tomography showed no definitive evidence of AEF. He underwent esophagogastroduodenoscopy and subsequently developed an embolic stroke. In the operating room, he was found to have AEF. This case highlights the importance of maintaining a high index of suspicion for AEF because of its nonspecific presentation and difficulty in diagnosing with imaging or endoscopy. Once AEF is suspected, esophagogastroduodenoscopy should be avoided because of the risk of precipitating embolic events.

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Fatal outcome due to CO₂ emboli during direct cholangioscopy

Cited by 14 publications

References 12 publications

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy

Acute Stroke After Upper Endoscopy in a Patient With a Suspected Atrioesophageal Fistula

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Fatal outcome due to CO2 emboli during direct cholangioscopy

Cited by 14 publications

References 12 publications

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy

Acute Stroke After Upper Endoscopy in a Patient With a Suspected Atrioesophageal Fistula

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Fatal outcome due to CO₂ emboli during direct cholangioscopy