title: Retropharyngeal Perforation With an Esophageal Dilator: A Case Report.
abstract: Esophageal "bougie" dilators are frequently used during esophageal surgeries to facilitate reconstruction and manipulation of the esophagus. Insertion of such dilators is usually a blind technique and not without risk. We present a case of retropharyngeal wall perforation resulting from esophageal dilator misplacement in a patient undergoing laparoscopic Heller myotomy and reconstruction. This case report demonstrates the importance of communication between surgery and anesthesiology teams during placement of devices into the oropharynx.
authors.affiliation: From the Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Blair
authors.forename: Robert
authors.initials: R
authors.lastname: Hsiung
mesh_terms: D004106:Dilatation / Q000295:instrumentation*; D004931:Esophageal Achalasia / Q000601:surgery; D004947:Esophagus / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D019300:Medical Errors; D008875:Middle Aged; D009960:Oropharynx / Q000293:injuries*; D011183:Postoperative Complications / Q000175:diagnosis*