[Subcutaneous emphysema during endoscopic resection of the gastric mucosa]

A 69-year-old male underwent endoscopic mucosal resection for an early gastric cancer under general anesthesia with sevoflurane and nitrous oxide. Because of gastro-intestinal gas insufflation for endoscopic visualization, abdominal distension was found remarkable and the peak inspiratory pressure increased from 20 cmH2O to 30 cmH2O. About 2.5 hours after initiation of the procedure, iatrogenic perforation was identified endoscopically and emphysema became apparent not only in the scrotum, but also in the subcutaneous tissues of the chest and neck. In order to ameliorate this complication, an emergent distal gastrectomy was performed involving laparotomy. Nitrous oxide should be avoided in endoscopic mucosal resection under general anesthesia to prevent intestinal distension and attention should be paid to subcutaneous emphysema as a sign of perforation of the gastro-intestinal tract.