Conservative management of esophageal perforation caused by misplacement of endotracheal tube

Esophageal perforation remains a potentially fatal disease with mortality rates of 10% to 40% [1, 2]. Today it is accepted that the method for the treatment of esophageal perforation plays an important role in the mortality rate. There are also several reports of non-operative treatments, by stopping all oral intake and providing intravenous nutrition or using a covered stent in patients with small ruptures localized to the mediastinum [3].
We report a case of esophageal perforation caused by misplacement of the endotracheal tube. The diagnosis and management strategy are discussed here.
The patient is a 65-year-old woman candidate for coronary artery bypass grafting. During the induction of anesthesia, intubation of the patient was difficult and the tracheal tube was inadvertently placed in the esophagus. We noticed the presence of blood secretions in the NG tube and decreased arterial oxygen saturation. The operation was halted by the order of the anesthetist. The patient was reversed and transferred to recovery for further investigation. She complained of central chest pain with radiation to her back. On examination, the chest breathing sounds were equal bilaterally and her vital signs were: pulse rate 98/min, blood pressure (BP) 142/72 mm Hg, SaO2 = 91% on air and temperature 37.5°C.
Investigations including chest radiography, electrocardiography (ECG), full blood count, and biochemistry screen were performed. In radiography, free air under the diaphragm and widened mediastinum were observed (Fig. 1). Lab work showed white blood count cells count (WBC) = 11.1, neutrophils = 78%, and trigger point injection (TPI) = 20.
In order to examine the air below the diaphragm, upper gastrointestinal Gastrografin contrast study was performed but no contrast leak was seen (Figs. 2, 3). Thoracic and abdominal computed tomography (CT) scan were performed to rule out other diagnoses, but they were normal except for bilateral pleural effusion (Fig. 4).
The patient was transferred to the coronary care unit (CCU) department. Because of good general condition and lack of esophageal contrast leak, a conservative approach was suggested for patient management. Nil per os (NPO) regimen and parenteral nutrition were selected. Antibiotic therapy with ceftriaxone 1 g/q 12 h, metronidazole 500 mg/q 8 h, with pantoprazole 40 mg/q 12 h, and anticoagulant therapy were started. Daily examinations were performed by physical examinations and vital...


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