Letters to the Editor

fluid erosion. Dissolution generally begins as early as 30 h after ingestion even when the device is blocked in a tight stricture. A multicenter trial to assess its safety in patients with known strictures, reported no cases of retention (4). Designed to minimize risk of capsule retention, the Agile capsule failed dissolution ultimately resulting in acute SBO and ischemic enteritis. We hypothesize that acute SBO was facilitated by luminal strictures presumably due to chronic inflammation with scarring from prior bowel surgery. The occlusive Agile capsule in turn resulted in localized ischemia with pressure necrosis and ulceration. Ultimately, a surgical extraction of the deformed, occlusive capsule occurred 144 h after ingestion. The reason for this failed dissolution is not known. CONFLICT OF INTEREST

Guarantor of the article: Kiran Nakkala, MD, MPH. Specific author contributions: Data collection, interpretation, and drafting of manuscript; final draft approval: Amara Okoli. Data collection, interpretation, and drafting of manuscript; final draft approval: Nischala Ammannagari and Mohammed Mazumder. Data interpretation and drafting of manuscript; final draft approval: Kiran Nakkala. Financial support: None. Potential competing interests: None.

Fatal Gas Embolism after Endoscopic Transgastric Necrosectomy for Infected Necrotizing Pancreatitis Benjamin Bonnot, MD1, Isabelle Nion-Larmurier, MD2, Benoit Desaint, MD2, Najim Chafai, MD3, François Paye, MD, PhD3, Marc Beaussier, MD, PhD1 and Thomas Lescot, MD, PhD1 doi:10.1038/ajg.2013.473

To the Editor: Endoscopic transgastric necrosectomy is effective for removing infected necrotic tissue in patients with acute pancreatitis but can result in complications. We describe the case of a 63– year-old woman who was admitted for severe upper abdominal pain and found to have severe acute pancreatitis (Balthazar grade E) with moderate respiratory failure. On day 22, sepsis developed and new abdominal CT showed gas within peripancreatic and retrogastric heterogeneous collections consistent with infected necrosis. CT-guided percutaneous drainage was performed. Culture was positive for Enterobacter cloacae. The treatment

combined imipenem and external drainage. Persistent sepsis prompted endoscopic transgastric necrosectomy on day 29. Endoscopy with carbon dioxide insufflation under general anesthesia was performed by senior physicians. The collection was punctured under endoscopic ultrasound guidance and double-pigtail stents were placed after gastrostomy followed by stomach-wall balloon dilation (Figure 1). Endoscopic necrosectomy was repeated on days 34, 37, 47, and 55. Gas was visible in the venous portal system on day 47 but not 7 days later, when the fifth necrosectomy procedure was performed. The patient required intermittent norepinephrine therapy due to persistent sepsis despite adaptation of the antibiotic regimen to the recovered organisms. On day 63, 15 min after initiation of the sixth necrosectomy procedure, bradycardia developed abruptly, followed 15 seconds later by asystolic cardiac arrest. Cardiac massage was performed immediately, concomitantly with intravenous epinephrine infusion and ventilation with 100% oxygen. Immediate CT of the chest and abdomen showed massive gas embolism in the venous portal system and the right and left cardiac chambers (Figure 2). The patient died despite prolonged resuscitation. Necrotizing pancreatitis has been shown to complicate almost 20% of acute pancreatitis episodes. In patients with infected

REFERENCES 1. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc 2010;71:280–6. 2. Caunedo-Alvarez A, Romero-Vazquez J, Herrerias-Gutierrez JM. Patency and Agile capsules. World J Gastroenterol 2008;14:5269–73. 3. Lewis BS. Expanding role of capsule endoscopy in inflammatory bowel disease. World J Gastroenterol 2008;14:4137–41. 4. Herrerias JM, Leighton JA, Costamagna G et al. Agile patency system eliminates risk of capsule retention in patients with known intestinal strictures who undergo capsule endoscopy. Gastrointest Endosc 2008;67:902–9. 1

Department of Medicine, Bassett Medical Center, Cooperstown, New York, USA; 2Division of Digestive Disease, Bassett Medical Center, Cooperstown, New York, USA. Correspondence: Amara Okoli, MD, MPH, Department of Medicine, Bassett Medical Center, One Atwell Road, Cooperstown, New York 13326, USA. E-mail: [email protected]

© 2014 by the American College of Gastroenterology

Figure 1. Abdominal computed tomography showing a pancreatic collection containing gas and the double-pigtail stents between the stomach and pancreatic collection (arrows).

The American Journal of GASTROENTEROLOGY

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Letters to the Editor

and design, supervision, and drafting of the article. All authors approved the final draft. Financial support: Funding was provided solely from institutional and departmental sources. Potential competing interests: None.

REFERENCES

Figure 2. Computed tomography performed immediately after sudden cardiac arrest during endoscopic transgastric necrosectomy: massive gas embolism in the right cardiac chamber (arrows).

necrosis, the treatment combines antibiotics and drainage of pancreatic collections according to a step-up approach, starting with the least invasive techniques. (1) Endoscopic transgastric necrosectomy is effective in removing infected necrotic material, thereby ensuring resolution of the collection without surgical debridement (2,3) and diminishing the pro-inflammatory response compared to conventional surgery (4). In our patient, endoscopic transgastric necrosectomy was complicated by fatal gas embolism documented by CT, which showed massive amounts of gas in the systemic and venous portal systems. Gas embolism results from a direct communication between a source of gas and the bloodstream. The gastroenterologist and carbon dioxide insufflator who provided care to our patient were highly experienced and scrupulously followed proper technique. Mobilization of the inflammatory necrotic tissues may have ruptured a blood vessel, thereby allowing the passage of carbon dioxide into the bloodstream. Gas embolism has been previously reported as a complication of gastrointestinal endoscopy. Risk factors included the use of interventional techniques and local inflammation (5), which were both present in our patient. Three observational studies of endoscopic transgastric necrosectomy were published recently. Of the total populaThe American Journal of GASTROENTEROLOGY

tion of 254 patients with acute pancreatitis included in these studies, 4 experienced gas embolism, which was fatal in 3 cases (2,3,6). The relatively small number of patients included in these studies may indicate underreporting of gas embolism. Clinicians should bear in mind the rare, albeit not exceptional, complications of endoscopic transgastric necrosectomy when choosing among the various available treatment options. Gas embolism should be considered promptly if cardiovascular and / or respiratory symptoms develop abruptly during the procedure, and protocols should be available to manage these critical situations. Gas in the venous portal system may contraindicate additional endoscopic necrosectomy. Further research aimed at identifying the risk factors for gas embolism are necessary to allow optimal individual tailoring of the treatment strategy for infected necrosis in acute pancreatitis. CONFLICT OF INTEREST

Guarantor of the article: Thomas Lescot, MD, PhD. Specific author contributions: Benjamin Bonnot: project conception/design; Isabelle Nion-Larmurier, Benoit Desaint, and Najim Chafai: critical revision; François Paye and Marc Beaussier: critical revision and supervision; Thomas Lescot: project conception

1. van Santvoort HC, Besselink MG, Bakker OJ et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491–502. 2. Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58:1260–6. 3. Gardner TB, Coelho-Prabhu N, Gordon SR et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter US series. Gastrointest. Endosc. 2011;73:718–26. 4. Bakker OJ, van Santvoort HC, van Brunschot S et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012;307: 1053–61. 5. Donepudi S, Chavalitdhamrong D, Pu L et al. Air embolism complicating gastrointestinal endoscopy: A systematic review. World J Gastrointest Endosc 2013;5:359–65. 6. Yasuda I, Nakashima M, Iwai T et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study. Endoscopy 2013;45:627–34.

1

Anesthesiology and Critical Care, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie, Paris, France; 2Gastroenterology, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie, Paris, France; 3Digestive Surgery; Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris and Université Pierre et Marie Curie, Paris, France. Correspondence: Thomas Lescot, MD, PhD, Département d’Anesthésie Réanimation, Hôpital Saint-Antoine, 75012 Paris, France. E-mail: [email protected]

Ulcerative Colitis and Electronic Cigarette: What’s the Matter? Marine Camus, MD, MSc1,2, Glaire Gallois, MD1,2 and Philippe Marteau, MD, PhD1,2 doi:10.1038/ajg.2013.439

VOLUME 109 | APRIL 2014 www.amjgastro.com

Fatal gas embolism after endoscopic transgastric necrosectomy for infected necrotizing pancreatitis.

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