Unusual occurrence of massive subcutaneous emphysema during ERCP under general anaesthesia
A 62-year-old woman with obstructive jaundice and deranged liver function tests was referred for an elective ERCP and stenting/sphincterotomy. Her past medical history and examination were unremarkable. She was given a general anaesthetic with endotracheal intubation. During ERCP which was indeed difficult, a peripapillary mass and a narrowed common bile duct without stones was noted. A sphincterotomy was tried repeatedly without success. There were no adverse anaesthetic events till late into the procedure when there was sudden drop in oxygen saturation from 99% to 88%. This prompted the anaesthesiologist to auscultate the chest who noted the presence of crepitus over the anterior as well as posterior aspect of chest. As the patient was in the semi-prone position and draped, further closer examination of the patient's face and neck revealed emphysematous swelling predominant on the right side, previously non-existent []. Suspecting retro-peritoneal perforation, the patient was turned supine and then she was noted to have slightly distended abdomen too. Oxygen saturation improved immediately after change of position and ventilation with 100% oxygen. A gastrointestinal surgery consultation was obtained and it was decided to undertake surgical exploration immediately. However, laparotomy did not reveal any definitive perforation even though there was minimal retro-duodenal staining with bile. Roux-en-Y hepaticojejunostomy and gastrojejunostomy was performed as a palliative measure. After surgery, the patient was shifted to intensive care unit (ICU) for elective ventilation where a chest X-ray revealed diffuse subcutaneous emphysema without any evidence of pneumothorax and pneumomediastinum []. She was weaned off the ventilator next morning, had a steady resolution of subcutaneous emphysema, and was discharged on day 12 without any jaundice and emphysema.