Acute Intraoperative Airway Emergency During Submucosal Tunnel Endoscopic Resection for an Esophageal Lesion: A Report of an Unusual Case

Introduction

With the increasing adoption of gastrointestinal endoscopic procedures, the utilization of high-risk interventions such as endoscopic submucosal dissection (ESD) and submucosal tunnel endoscopic resection (STER) is also on the rise. Anesthesiologists play a critical role in maintaining airway safety and monitoring respiratory and circulatory parameters during these procedures. Life-threatening complications such as abdominal compartment syndrome (ACS), which is defined as a sustained intra-abdominal pressure (IAP) >20 mmHg that is associated with new-onset organ dysfunction or failure according to the 2013 World Society of the Abdominal Compartment Syndrome consensus guidelines, due to severe pneumoperitoneum and increased airway pressures, must be promptly recognized and managed [1,2]. Although mediastinal emphysema, pneumothorax and other complications have been reported in the gastroenterology literature [3,4], thoracic compression, ventilation obstruction and hypoxemia caused by severe increase in abdominal pressure during esophageal endoscopic surgery have not been reported and discussed. This case report describes a patient undergoing STER who developed severe pneumoperitoneum due to abdominal esophageal perforation, leading to thoracic compression, ventilatory compromise, and critical hypoxemia. Rapid identification of the underlying cause and timely, targeted intervention were crucial in managing this intraoperative airway emergency. This case highlights the intersection between gastroenterological interventions and anesthesia-related emergencies, underscoring the need for anesthesiologists to maintain vigilance during STER procedures and implement effective multidisciplinary management strategies [5]. Moreover, the systematic reporting of such rare yet critical events can contribute to the development of evidence-based monitoring protocols and perioperative guidelines, reinforcing the shared responsibility of endoscopists and anesthesiologists in preventing and managing procedure-related ACS.

Case Report

A 60-year-old woman with no previous medical history was admitted after esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) revealed an esophageal submucosal protruding lesion, suspected to be a leiomyoma (Figure 1). Upon examination, vital signs were within normal ranges (BP: 144/76 mmHg; temperature: 36.6°C (97.9°F); respiratory rate: 15 breaths/min; SpO2: 97%). The patient was 150 cm in height and weighed 62 kg. Physical examination revealed no abnormalities. There was no recent history of travel, camping, hiking, or vaccinations. Routine laboratory tests were all within normal ranges. Chest computed tomography (CT) showed poor esophageal filling and mild thickening of the lower esophageal wall. She was scheduled for endoscopic submucosal tunnel resection (STER) under general anesthesia with endotracheal intubation. Upon entering the operating room, her vital signs were monitored, and anesthesia was induced with propofol (125 mg), sufentanil (30 μg), and rocuronium (50 mg). During rapid sequence induction, the patient was preoxygenated. A reinforced 7.0-mm endotracheal tube was successfully inserted, and after intubation she remained hemodynamically stable (BP: 130/77 mmHg; HR: 70 bpm; SpO2: 99%; PETCO2: 32 mmHg). The ventilator settings were tidal volume (VT): 450 mL, respiratory rate (f): 13 breaths/min, FiO2: 60%. At the beginning of the surgery, endoscopic observation revealed a 1-cm elevated lesion in the lower esophagus. A submucosal tunnel was created 4 cm proximal to the lesion, and the submucosal tissue was gradually dissected toward the tumor. Approximately 20 min into the procedure, she developed acute respiratory and hemodynamic compromise: BP decreased to 95/50 mmHg, HR remained 71 bpm, SpO2 dropped to 89%, PETCO2 increased to 59 mmHg, and peak airway pressure (Paw) progressively increased from 14 cmH2O to 40 cmH2O. The tidal volume (VT) gradually decreased to nearly zero. Immediate interventions included increasing FiO2 to 100%, switching to manual ventilation, encountering significant resistance, but end-tidal CO2 waveforms persisted, with PET CO2 further rising to 65 mmHg. The manual ventilation rate was increased, stabilizing PET CO2 at 50 mmHg. Auscultation revealed weakened but coarse bilateral breath sounds, confirming proper endotracheal tube placement. At this time, BP dropped further to 78/50 mmHg, requiring dopamine (2 mg) administration for blood pressure support. SpO2 remained around 94%, but airway resistance remained extremely high, prompting an immediate request to halt the procedure. Further examination revealed significant abdominal distension with extreme abdominal wall tension, and percussion of the abdomen produced a tympanic sound, suggesting massive pneumoperitoneum. Gastric auscultation revealed an absence of air movement sounds, ruling out accidental gastric insufflation. These findings strongly suggested pneumoperitoneum-induced abdominal compartment syndrome (ACS), leading to severe thoracic compression, impaired ventilation, and hemodynamic compromise. In response, we performed an emergency percutaneous abdominal decompression procedure. After disinfecting the right lower abdomen (McBurney point), a large-bore (needle diameter 1.6×38 mm) syringe containing 5 ml of normal saline was inserted vertically into the skin approximately 2 cm deep, until a distinct feeling of empty space was felt, When bubbles emerged from the syringe, it confirmed that there was inert gas in the abdominal cavity (Figure 2). During the entire decompression and venting process, which lasted about 10 min, no obvious bubbles were observed. Then, the needle was removed and a sterile patch was applied to cover the needle site. Meanwhile, manual lung recruitment maneuvers were applied. Mechanical ventilation was resumed, and the patient’s airway pressure and tidal volume gradually returned to normal, abdominal wall tension resolved, and vital signs stabilized (BP: 95–100/61 mmHg, HR: 80 bpm, SpO2: 98%, PETCO2: 36 mmHg). The total intervention time from the onset of respiratory distress to patient stabilization was approximately 20 min.

Following stabilization, endoscopic examination revealed a 0.5-cm perforation in the lower esophagus behind the tumor (Figure 3). The endoscopic surgeon immediately applied a rotational endoscopic clip to close the defect. After repair, no further signs of intra-abdominal air accumulation were observed. The decompression needle was removed, and the puncture site was disinfected and dressed. The tumor was completely excised, retrieved using an endoscopic snare, and the submucosal tunnel was closed with endoscopic clips (Figure 4). The procedure was successfully completed. The patient was transferred to the post-anesthesia care unit for observation. Upon regaining consciousness, she was successfully extubated and demonstrated normal neurological function, with the following postoperative findings: BP: 144/76 mmHg, temperature: 36.6°C (97.9°F), respiratory rate: 14 breaths/min, SpO2: 99%, clear and symmetrical lung sounds on auscultation, and no postoperative concerns. The patient adhered to the prescribed guidelines of abstaining from both food and drink on the day of the operation. On the first postoperative day she continued to fast and did not consume any liquids. Following an abdominal X-ray on the second day (Figure 5), which revealed no significant abnormalities, she was permitted to resume a liquid diet. By the third postoperative day, after confirming that no notable issues were present, she was discharged from care. About 4 months after the surgery, she underwent a gastroscopy in the outpatient department, and the result showed that there were no abnormalities in the esophagus (Figure 6).

Discussion

Acute airway complication caused by gastrointestinal perforation is rarely described in the anesthesiology literature. While endoscopic perforation and pneumoperitoneum are documented complications of mucosal resection [6,7], reports in the context of endoscopy primarily focus on intraabdominal hypertension [8,9]. Diagnosing such airway complications perioperatively remains challenging; without prompt identification of the underlying perforation, managing the resultant acute ventilatory and hemodynamic deterioration is particularly difficult.

This case involved a rare but critical complication – abdominal compartment syndrome (ACS) after STER surgery – and this report seeks to highlight the associated clinical dilemma and enhance its recognition. In our case, the initial manifestation was a sharp increase in airway pressure, accompanied by hypotension and hypoxia. Pulmonary auscultation and examination rule out common causes such as tracheal dislocation, bronchospasm, and allergic reactions. Abdominal physical examination revealed tense abdominal muscles and abdominal distension, suggesting tension pneumoperitoneum accompanied by thoracic compression (Figure 7). This series of clinical inferences shows the crucial role of anesthesiologists in rapidly shifting the diagnostic focus from airway causes to abdominal causes, which is a key step in timely intervention.

Reducing diaphragmatic compression and restoring thoracic compliance directly addresses the fundamental pathophysiological issue [10], and the airway pressure and oxygenation of our patient immediately return to normal. Given the rapid progression of hypoxemia in our case other measures, such as increasing ventilation volume or continuing the surgery, could carry risks of severe hypoxia or respiratory failure.

This case demonstrates that in the context of advanced endoscopic surgery, although ACS is rare, it must be included in the differential diagnosis of acute intraoperative respiratory failure, and it emphasizes the importance of a multidisciplinary approach. The timely understanding of abdominal compartment physiology by anesthesiologists can guide clear surgical management and detect and repair potential perforations [11,12]. By integrating gastrointestinal surgery complications with anesthesia intensive care, this report aims to raise vigilance and provide management solutions for similar life-threatening emergencies.

Conclusions

Esophageal perforation during lower esophageal tumor dissection can lead to abdominal compartment syndrome and thoracic compression, resulting in severe hypoventilation and hypoxemia. Anesthesiologists should remain vigilant for complications such as pneumoperitoneum, elevated airway pressure, and pneumothorax. Early recognition and timely interventions, including abdominal decompression and repair of any perforations, are essential to prevent respiratory or circulatory failure and ensure patient safety during gastrointestinal endoscopic procedures.

To improve future clinical management, we recommend the development of standardized perioperative monitoring protocols such as routine intra-abdominal pressure assessment in high-risk endoscopic resections and the establishment of multidisciplinary simulation training focused on recognition and management of similar emergencies. Further studies are warranted to systematically evaluate the incidence, risk factors, and optimal treatment pathways for thoracic-abdominal compartment syndrome in endoscopic surgery, which may contribute to evidence-based guidelines and enhance collaborative preparedness across gastroenterology and anesthesiology teams.