Case Report: Beyond the stomach: the role of preoperative imaging in assessing regurgitation risk in patients with esophageal dilatation: a report of two cases.

BACKGROUND: Perioperative regurgitation of gastric or esophageal contents remains a severe complication during anesthesia. While standard fasting protocols and rapid sequence induction (RSI) are routinely employed, esophageal dilatation creates a hidden reservoir for retained food and secretions that conventional methods often fail to mitigate. Furthermore, standard gastric ultrasound lacks the field of view to detect mid-to-proximal esophageal pooling.

CASE PRESENTATION: We present two parallel cases emphasizing this critical challenge. Case 1 involves a 68-year-old male with esophageal carcinoma who experienced massive regurgitation of white foam during RSI, despite five days of preoperative fasting. Airway security was ultimately achieved after intensified suctioning. Case 2 describes a 42-year-old female with achalasia and marked esophageal dilatation. Informed by preoperative computed tomography (CT) and barium swallow imaging, she was safely managed using targeted pre-anesthetic conscious endoscopic suctioning, leading to an uneventful induction and peroral endoscopic myotomy (POEM).

CONCLUSION: These cases highlight the limitations of conventional fasting in managing proximal pooling. They underscore the diagnostic value of preoperative cross-sectional imaging, such as CT, when clinically indicated. Active pre-induction decompression, specifically through tailored endoscopic evacuation, is a valuable adjunctive strategy for preventing perioperative regurgitation in selected patients with megaesophagus.