These images belong to a 30-yr-old man who underwent an arthroscopic knee meniscal repair. He had a body mass index of 29 kg/m2 and endorsed occasional mild gastroesophageal reflux after spicy food. Induction of anesthesia was unremarkable. A laryngeal mask airway (LMA) was inserted with a 14-French gastric tube inserted through the gastric port. The suction of the gastric tube yielded only trace amounts of gastric fluid. After a lung recruitment maneuver at pressure 35 cm H2O, particulate gastric material was noted in both the gastric and airway ports of the LMA. The patient was managed as per intraoperative aspiration protocol. Postoperatively, a chest roentgenogram revealed a central longitudinal opacity, which represents the outline of the dilated esophagus (fig. 1). Chest tomography showed that the patient’s esophagus was markedly dilated across its entire length, consistent with a diagnosis of achalasia (fig. 2). Upon further probing, the patient reported a decade-long history of intermittent dysphagia.
Achalasia is a rare primary motility disorder. It is characterized by insufficient relaxation of the lower esophageal sphincter causing incomplete esophageal emptying. Intraoperative aspiration as the first presentation of achalasia is an extremely rare event. This case demonstrates that patients with achalasia may present with minimal symptoms. It also shows that gastric tubes may not necessarily function as expected. In this case, a gastric tube was inserted, but it did not mitigate the risk of aspiration. Furthermore, uncertainty exists regarding whether inserting a gastric tube through an LMA reduces the incidence of aspiration. Finally, lung recruitment via an LMA in a patient, particularly one at risk, may potentially trigger regurgitation and aspiration.