An esophageal intubation possibly leading to gastric perforation: A case report

Unnoticed esophageal intubation is possible in a challenging difficult intubation and may rarely lead to gastric perforation. We report the case of a 66-year-old female who recently underwent craniotomy for brain tumour excision. Since many extubation trials failed, a decision was made to perform a percutaneous tracheostomy. Faulty esophageal intubation with aggressive bag-mask ventilation took place during the procedure due to laryngeal edema and hypoxia. Post-operative chest x-ray revealed significant pneumoperitoneum. Therefore, the patient underwent an emergency diagnostic laparoscopy. A gastric tear was identified and closed promptly with two layers of repair and reinforcement by door fundoplication. A high index of suspicion should be raised to avoid fatal complications, especially in patients with difficult intubation.