To the Editor:- Accidental mercury ingestion after rupture of the mercury-filled balloon in the Miller-Abbot tube has been reported. We would like to report another case of mercury ingestion that was caused by leakage from needle holes in the bougies used in this Nissen fundoplication.
A 47-yr-old man with a 5-year history of gastric reflux underwent a laparoscopic Nissen fundoplication during general anesthesia. The patient was generally healthy and active. He had no remarkable medical history other than gastric reflux. He took only antacids as an occasional medication. Induction and maintenance of general anesthesia were performed uneventfully using propofol, fentanyl, isoflurane and air/oxygen. Laparoscopic surgery was performed during carbon dioxide insufflation. During the procedure, an anesthesiologist inserted mercury-filled Mahoney esophageal bougies (Pilling Weck, Fort Washington, PA) ranging from 42 French to 50 French to facilitate the procedure.
Emergence from anesthesia was uneventful. As soon as the patient was extubated and regained consciousness, he complained of severe mid-chest pain with shortness of breath and diaphoresis. He described the pain as sharp and burning, with a 10/10 on an analog pain scale. The chest pain did not radiate to the shoulders or arms and was not relieved by administration of nitroglycerin or opioids. Twelve-lead electrography showed no signs of myocardial ischemia and no changes from the preoperative study. Chest radiography revealed vertically streaked 1 cm x 3 cm shadows in the mid-chest field (Figure 1). Because of the location of the shadow in the mediastinum, mercury deposition in the esophagus was suspected.
After careful inspection, needle punctures were found in one of the used bougies, and leak of mercury was easily identified by squeezing. Gastroenterologists performed endoscopy on the patient during intravenous sedation and found a collection of mercury in the mucosal pouch in the distal esophagus. A total of 3 cm3mercury was aspirated through the scope. Rupture of the esophagus was ruled out. After the removal of mercury, the patient's chest pain subsided during the next 24 hours. Subsequently, the patient was discharged without problems.
Ingestion of elemental metallic mercury is considered to be harmless because of the poor absorption in the gastrointestinal tract. However, metallic mercury may undergo oxidization to yield reactive divalent mercuric acid when water and chloride are available. Systemic mercury intoxication after rupture of a Miller-Abbott tube is reported. A high concentration of the soluble mercuric salts can act corrosively on mucosal membranes, causing painful necrotic lesions in the mouth, the esophagus, and the stomach. We believe that the chest pain probably was caused by the mercurial irritation of the esophageal mucosa, which was subjected to the surgical injury, and active removal of the trapped mercury was most indicated.
James Taylor, M.D.
Hiroshi Kamaya, M.D.
Department of Anesthesiology; University of Utah Medical Center; VA Medical Center; Salt Lake City, Utah
(Accepted for publication April 24, 1998.)