Fatal air embolism during intestinal endoscopy in Kasai portoenterostomy for biliary atresia: A case report

Table 1 Timeline of patient’s course

Timeline	Patient’s course
HOD 1	Admission for jaundice and stone at KPE site
HOD 6	MRCP
HOD 11	Attempted PTBD, but the procedure failed due to the patient's uncooperativeness
HOD 16, 08:40 AM	Operation starts
12:00 PM	Intraoperative endoscopy insertion
12:03 PM	Arrhythmia, hypotension, bradycardia
12:10 PM	Asystole, CPR start
13:07 PM	ECMO insertion, compression stop
15:15 PM	Operation end, the patient was sent to ICU
17:10 PM	The patient expired.

KPE: Kasai portoenterostomy; HOD: Hospital day; MRCP: Magnetic resonance cholangiopancreatography; PTBD: Percutaneous transhepatic biliary drainage; CPR: Cardiopulmonary resuscitation; ECMO: Extracorporeal membrane oxygenation; ICU: Intensive care unit.

Table 2 Summary of common clinical settings in the cases of fatal air embolism in patients with Kasai portoenterostomy for biliary atresia

Ref.	Age	Indication	Endoscopic entry	Air insufflation to closed loop	Time to arrest (minutes)	Paradoxical embolism	Result
Lowdon and Tidmore[1], 1988	4 months	Cholangitis	Enterotomy of A-loop	Yes	5	Yes	Died (autopsy)
Desmond and MacMahon[2], 1990[2]	10 years	Stone of KPE site	Enterotomy of A-loop	Yes	10	Yes	Died (autopsy)
Park et al[3], 2010	17 years	Intestinal bleeding	Enterotomy of A-loop	Yes	Immediately	Yes	Survived
Pujari et al[4], 2012	5 years	Intestinal bleeding	Enterotomy of A-loop	Yes	1	Yes	Died (no autopsy)
2023 (present case)	18 years	Stone at KPE site	Enterotomy of A-loop	Yes	3	Yes	Died (no autopsy)

Age: Patient’s age when endoscopy was performed; A-loop: Afferent loop; KPE: Kasai portoenterostomy.