Esophageal Perforation Caused by Misplaced Minnesota Tube

Abstract

48-year-old man with decompensated alcoholic Acirrhosis (Model for End-Stage Liver Disease 14) was admitted to an outside hospital with a 1-day history of hematemesis and melena. Upon arrival, the patient was hemodynamically unstable and his laboratory test results showed a hemoglobin level of 5.9 g/dL. Initial management included resuscitation with packed red blood cells and fresh-frozen plasma, in addition to combined continuous infusion of proton-pump inhibitor and octreotide therapy. An emergent esophagogastroduodenoscopy (EGD) was performed, which showed bleeding from distal esophageal varices. Four bands were placed successfully for endoscopic variceal ligation. Shortly thereafter, the patient had recurrent hematemesis and a repeat EGD proved unsuccessful in banding of a distal esophageal varix. The patient then was intubated for airway protection and a Minnesota tube was placed before transfer to our facility for further care. On arrival to our hospital, the patient’s respiratory status deteriorated acutely and a chest radiograph showed a misplaced Minnesota tube with the gastric balloon inflated within the distal esophagus (Figure A). Both gastric and esophageal balloons subsequently were deflated and the Minnesota tube was removed. A chest computerized tomography showed a new, large, left-sided pleural effusion concerning for hemothorax. Emergent chest tube placement was performed. An EGD showed a large esophageal perforation that tracked into the pleural cavity, extending from 29 to 39 cm from the incisors. Endoscopic placement of 2 fully covered (23mm 15 cm) esophageal metal stents (Boston Scientific, Galway, Ireland) was performed and a follow-up esophagogram showed no contrast extravasation (Figure B). Subsequently, a 10 mm 8 cm Viatorr (GORE, Flagstaff, AZ) transjugular intrahepatic portosystemic shunt was placed by interventional radiology. After a prolonged hospital course, the patient’s condition improved. Two months after presentation, a repeat EGD permitted removal of all stents and fluoroscopy confirmed complete closure of the esophagopleural fistula (Figure C). To prevent this complication, we recommend the following: (1) passage of the tube to at least 50 cm from the incisors, (2) injection of air into the gastric aspiration port while auscultating over the stomach, and (3) radiographic confirmation before complete inflation of the gastric balloon whenever possible.