The present report described the successful conservative management of TEE-associated gastric perforation. The unexpectedly large echo-free space and continuous bleeding from the nasogastric tube were indicative of perforation. EGD and CT were useful imaging modalities for establishing a definite diagnosis. We selected conservative management to avoid highly invasive procedures and minimize the risk of a potential intraperitoneal infection spreading to the mediastinum, implanted mechanical valve, and mitral ring. Furthermore, the patient presented no typical abdominal symptoms including pain, muscular guarding, or Blumberg’s sign, and the perforation site was covered by the lesser omentum and inferior surface of the liver. Conservative management was considered successful, as the patient had recovered sufficiently to resume oral intake by postoperative day 12.
TEE is widely used in cardiac surgery. Although TEE is considered minimally invasive, some complications have been reported. The overall incidence of TEE-associated morbidity and mortality is 0.2 and 0%, respectively [2]. The most common complication is severe odynophagia (0.1%), followed by dental injuries (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%) [2]. In addition, one report described splenic injury caused by the TEE probe [6]. While upper gastrointestinal perforation is an unusual complication in TEE, it can often become severe. In the present case, the perforation may have been caused by the TEE probe being advanced and withdrawn repeatedly to maintain an anteflexed position in the stomach, allowing visualization of the venous cannula in the IVC. In order to prevent such complications, it is necessary to select the appropriate TEE probe size, as well as to insert and operate the TEE probe gently.
Min et al. reported that the risk factors for TEE-associated perforation were advanced age, prolonged CPB or ventilatory support, intracardiac procedures, post-CPB hypotension, low cardiac output, use of vasopressors or an intra-aortic balloon pump, emergency operations, and systemic anticoagulation or aspirin therapy [7]. Several of these risk factors were present in the case reported here, including advanced age, prolonged CPB (154 min), and anticoagulation therapy (warfarin).
Many reports have described upper TEE-associated gastrointestinal perforation [8,9,10,11]. Here, we report on TEE-related perforation of the stomach. Gastric perforation is a clinical condition different from esophageal perforation. Several cases involving esophageal perforation by TEE were reported, including a few cases with successful conservative management of the perforation [8, 9]. On the other hand, gastric perforation is a very rare complication in TEE, with only three such cases being reported, all treated via surgical intervention [10, 11]. Therefore, to the best of our knowledge, the present case report is the first to describe the successful conservative management of iatrogenic gastric perforation by TEE. In previously reported cases, open or laparoscopic surgery was performed for iatrogenic gastric or esophageal perforation by TEE [10, 11], in an effort to prevent severe infection-related complications such as mediastinitis, peritonitis, and septic shock, which may occur when treatment for upper gastrointestinal perforation by TEE is delayed.
The surgical management of gastrointestinal tract perforations is now often replaced by conservative therapy [12]. For example, Merchea et al. reported that non-operative management of EGD-associated upper gastrointestinal perforation can be successful when there is no evidence of contrast extravasation or free fluid on radiographic studies [13]. According to the European Society of Gastrointestinal Endoscopy Position Statement, conservative management of iatrogenic gastric perforation by EGD is recommended as a first-line treatment when the following criteria are satisfied: late recognition of perforation (> 12 h), asymptomatic presentation, and no signs of peritoneal effusion or sepsis [14]. Clipping under EGD or surgery may also be recommended in some cases of EGD-associated gastric perforation, depending on clinical symptoms or the size of the perforation site [14]. The incidence of perforation is very similar between TEE and EGD examinations [2, 7, 8, 14], as such examinations have much in common, including the size of the probe and the period of fasting. Therefore, as with EGD-associated perforation, TEE-associated gastric perforation may also be amenable to conservative management. In the present case, asymptomatic iatrogenic perforation was diagnosed at > 12 h following mitral valve repair. Moreover, open abdominal surgery was considered too invasive and might have allowed a potential intraperitoneal infection to spread to the implanted mechanical valve. Thus, we decided to perform conservative management in an effort to reduce the risk of severe complications. Had the patient presented abdominal symptoms of peritonitis (abdominal pain, Blumberg’s sign, muscular defense, fever, tachycardia), an invasive procedure to repair the perforation would have been required, per the current guidelines [14].
In conclusion, based on our experience with the patient described in this report, iatrogenic TEE-associated gastric perforation, which is a very rare complication of TEE, can be successfully managed conservatively even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis.