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Fatal pharyngoesophageal perforation caused by extraction of duodenal mass
Journal Pre-proof Fatal pharyngoesophageal perforation caused by extraction of duodenal mass Augustin Attwell, MD, AGAF, FASGE, Jennifer Kolb, Augustin Attwell PII:
S0016-5107(20)30048-1
DOI:
https://doi.org/10.1016/j.gie.2020.01.022
Reference:
YMGE 11938
To appear in:
Gastrointestinal Endoscopy
Received Date: 20 August 2019 Accepted Date: 15 January 2020
Please cite this article as: Attwell A, Kolb J, Attwell A, Fatal pharyngoesophageal perforation caused by extraction of duodenal mass, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/ j.gie.2020.01.022. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
August 20, 2019
Drs. Douglas Adler and Mohamed Othman At the Focal Point Section Editors, Gastrointestinal Endoscopy Dear Drs. Adler and Othman: We would like to submit this case report titled, “Fatal pharyngoesophageal perforation caused by extraction of duodenal mass” for the At the Focal Point section of your journal. Herein we present a rare and unfortunate case of iatrogenic esophageal and pharyngeal perforation caused by extraction of a benign duodenal Brunner gland hamartoma after snare removal. Needless to say, this tragic case was emotional and devastating for the patient and her family. It was also thought-provoking, sobering, and emotional for us as physicians. However, we feel it is best to share this case with the GI Endoscopy readership in order to stimulate discussion and learning that would otherwise be missed. We hope that you find this case interesting and educational and consider it for publication. If not, we would welcome your input regarding other journals or sections that may welcome a discussion of this case or its thought-provoking consequences.
Sincerely,
Augustin Attwell MD, AGAF, FASGE Jennifer Kolb MD
University of Colorado School of Medicine Department of Internal Medicine Mail Stop B177 12631 E 17th Ave Aurora, CO 80045 303-602-5418 office 303-602-5055 fax [email protected]
Fatal pharyngoesophageal perforation caused by extraction of duodenal mass Jennifer Kolb and Augustin Attwell Department of Internal Medicine, Division of Gastroenterology and Hepatology University of Colorado School of Medicine, Aurora, Colorado Dr. Kolb retrieved and edited the images. Dr. Attwell drafted the text and edited the images. Both authors performed the endoscopic procedures and cared for the patient throughout her hospital stay. Correspondence: Augustin Attwell MD Department of Internal Medicine, Division of Gastroenterology University of Colorado-Denver School of Medicine Mail Stop B-177 12631 E 17th Ave Aurora, CO 80045 Phone 303-602-5418 Fax: 303-602-5055 Email: [email protected] Conflicts of Interest: The authors report no conflicts of interest
An 85-year-old female with postprandial epigastric pain and weight loss was referred for EUS to evaluate a duodenal mass seen on CT. EGD revealed a pedunculated, subepithelial mass in the duodenal bulb (A). EUS showed a 3 cm, mixed solid and cystic mass in layer III and avascular stalk (A, arrows). Given her symptoms and nondiagnostic EUS, the mass was snare removed after clipping the stalk. The mass was retrieved with a Roth net, and moderate resistance was noted during extraction through the upper esophageal sphincter. Pathology showed a soft, fully excised brunner gland hamartoma (B). She reported dysphagia the next day, and neck CT showed pneumomediastinum (C). EGD showed a deep, 4-cm-long, linear tear from the left pharynx to the upper esophagus (D). It was closed with 7 endoclips, and a nasogastric tube was placed. A limited esophagram showed no leak. Three days later she developed coughing, followed by respiratory distress and confusion. CT showed bilateral pneumonia and empyema, and repeat esophagram showed a large leak communicating with the mediastinum. Despite surgical exploration of the neck, drains, repeat EGD, and bilateral chest tubes, her course deteriorated. While lucid, the patient refused further aggressive measures. She died comfortably with family present, 9 days after the original EGD/EUS.
S0016-5107(20)30048-1
DOI:
https://doi.org/10.1016/j.gie.2020.01.022
Reference:
YMGE 11938
To appear in:
Gastrointestinal Endoscopy
Received Date: 20 August 2019 Accepted Date: 15 January 2020
Please cite this article as: Attwell A, Kolb J, Attwell A, Fatal pharyngoesophageal perforation caused by extraction of duodenal mass, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/ j.gie.2020.01.022. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
August 20, 2019
Drs. Douglas Adler and Mohamed Othman At the Focal Point Section Editors, Gastrointestinal Endoscopy Dear Drs. Adler and Othman: We would like to submit this case report titled, “Fatal pharyngoesophageal perforation caused by extraction of duodenal mass” for the At the Focal Point section of your journal. Herein we present a rare and unfortunate case of iatrogenic esophageal and pharyngeal perforation caused by extraction of a benign duodenal Brunner gland hamartoma after snare removal. Needless to say, this tragic case was emotional and devastating for the patient and her family. It was also thought-provoking, sobering, and emotional for us as physicians. However, we feel it is best to share this case with the GI Endoscopy readership in order to stimulate discussion and learning that would otherwise be missed. We hope that you find this case interesting and educational and consider it for publication. If not, we would welcome your input regarding other journals or sections that may welcome a discussion of this case or its thought-provoking consequences.
Sincerely,
Augustin Attwell MD, AGAF, FASGE Jennifer Kolb MD
University of Colorado School of Medicine Department of Internal Medicine Mail Stop B177 12631 E 17th Ave Aurora, CO 80045 303-602-5418 office 303-602-5055 fax [email protected]
Fatal pharyngoesophageal perforation caused by extraction of duodenal mass Jennifer Kolb and Augustin Attwell Department of Internal Medicine, Division of Gastroenterology and Hepatology University of Colorado School of Medicine, Aurora, Colorado Dr. Kolb retrieved and edited the images. Dr. Attwell drafted the text and edited the images. Both authors performed the endoscopic procedures and cared for the patient throughout her hospital stay. Correspondence: Augustin Attwell MD Department of Internal Medicine, Division of Gastroenterology University of Colorado-Denver School of Medicine Mail Stop B-177 12631 E 17th Ave Aurora, CO 80045 Phone 303-602-5418 Fax: 303-602-5055 Email: [email protected] Conflicts of Interest: The authors report no conflicts of interest
An 85-year-old female with postprandial epigastric pain and weight loss was referred for EUS to evaluate a duodenal mass seen on CT. EGD revealed a pedunculated, subepithelial mass in the duodenal bulb (A). EUS showed a 3 cm, mixed solid and cystic mass in layer III and avascular stalk (A, arrows). Given her symptoms and nondiagnostic EUS, the mass was snare removed after clipping the stalk. The mass was retrieved with a Roth net, and moderate resistance was noted during extraction through the upper esophageal sphincter. Pathology showed a soft, fully excised brunner gland hamartoma (B). She reported dysphagia the next day, and neck CT showed pneumomediastinum (C). EGD showed a deep, 4-cm-long, linear tear from the left pharynx to the upper esophagus (D). It was closed with 7 endoclips, and a nasogastric tube was placed. A limited esophagram showed no leak. Three days later she developed coughing, followed by respiratory distress and confusion. CT showed bilateral pneumonia and empyema, and repeat esophagram showed a large leak communicating with the mediastinum. Despite surgical exploration of the neck, drains, repeat EGD, and bilateral chest tubes, her course deteriorated. While lucid, the patient refused further aggressive measures. She died comfortably with family present, 9 days after the original EGD/EUS.