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

BackgroundPerioperative 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 presentationWe 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).ConclusionThese 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.