Abstract
BACKGROUND: Air embolism (AE) is a rare but potentially fatal complication of intestinal endoscopy (IE). CASE SUMMARY: Herein, we report the case of an 18-year-old woman who underwent a successful Kasai portoenterostomy (KPE) for biliary atresia but died of AE during intraoperative IE for stone removal at the portoenterostomy site. Our review of the English literature identified only four similar cases of fatal AE during IE in patients undergoing KPE. The common clinical setting in the five patients, including our case, was high-pressure air insufflation into the blind closed afferent loop of the KPE to secure visibility. We hypothesize that the highly pressurized air injected into the closed loop entered the bile canaliculi-previously opened by KPE for bile drainage-passed through the tiny, microscopic pores of the fenestrated liver sinusoid endothelial cells, and finally entered the bloodstream with ease, resulting in fatal AE. CONCLUSION: Meticulous performance of IE, especially on the KPE blind loop, is warranted owing to the risk of AE.