Pneumoabdomen with abdominal compartment and aortic collapse due to gastric bursting acute release by trocar insertion.

A 63-year-old man was admitted to our emergency department because of abdominal pain with distension and ischemia of both lower limbs for the past 2 hours. Previously, he had vomited extremely following alcoholic excess and an opulent meal. In his previous history, distal esophageal stenosis was obvious after surgical therapy of Boerhaave syndrome 3.5 years earlier with primary suturing of the distal esophageal perforation and anterior semifundoplication. At clinical examination, the patient presented with stable cardiopulmonary function. The abdomen was massively distended and tender, and both legs were blue, revealing signs of prolonged ischemia with absent palpable pulses of the femoral artery in both groins. Palsy of the legs was not yet apparent. Computed tomography of the chest and abdomen showed huge amounts of free intra-abdominal air and fluid, suggesting perforation (Figure 1A). Consecutively, there was an external abdominal aortic compression with lumen collapse (Figure 1B), and the iliac arteries, as well, were compressed down to the superficial femoral artery as a consequence of severe abdominal compartment syndrome. Because the patient got progressively unstable during computed tomography examination and shocky, we inserted a trocar (intravenous needle) into the abdominal wall. The abdominal free air could be evacuated immediately (Figure 2A). Computed tomography documented reversal of the aortic compression (Figure 2B), and the lower extremities were reperfused. Clinically, the groin pulses were palpable. At laparotomy, perforation (8 cm in diameter) of the lesser gastric curvature was found, combined with fibrinous peritonitis of all 4 abdominal quadrants. Moreover, the stomach was rather burst and revealed an abnormal dilatation. This