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Huang S, Huang S, Fang T. Endoscopic full-thickness resection of a large gastric schwannoma and iatrogenic cervical esophageal perforations: A case report. Medicine (Baltimore) 2024; 103:e38808. [PMID: 38996173 PMCID: PMC11245251 DOI: 10.1097/md.0000000000038808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
INTRODUCTION Gastrointestinal schwannomas are most commonly found in the stomach. Owing to their nonspecific clinical and endoscopic presentations, distinguishing gastric schwannomas (GS) from other gastric submucosal tumors based on typical symptoms and endoscopic features is challenging. Endoscopic full-thickness resection (EFTR) is safe and effective for GS management; however, no standard method exists for the extraction of large gastric specimens after endoscopic treatment. CASE PRESENTATION We report the case of a 72-year-old Chinese woman who presented with abdominal distension. DIAGNOSIS, INTERVENTIONS, AND OUTCOMES Gastroscopy revealed a submucosal bulge on the anterior wall of the lower stomach near the greater curvature. Endoscopic ultrasonography and computed tomography suggested a stromal tumor. The patient underwent EFTR of the stomach, and the tumor was successfully removed. The surgical specimen, with a long-axis diameter of approximately 5.5 cm in vitro, was extracted using a snare. Subsequent endoscopic examination revealed longitudinal, full-thickness perforations > 2 cm at the esophageal entrance. Over 10 metal clips were used to seal the mucosa, and a gastrointestinal decompression tube was placed. Follow-up radiography performed at 1 week postoperatively revealed an esophageal mediastinal fistula, which required subsequent endoscopic intervention to close the fistula using metal clips. The patient showed improvement and was discharged at 3 weeks postoperatively. Follow-up esophageal radiography revealed no abnormalities. Postoperative immunohistochemical analysis indicated CD34 (-), CD117 (-), DOG-1 (-), Ki67 (1%), S-100 (+), SDHB (+), SOX-10 (+), and Desmin (-), confirming the diagnosis of GS. Three months postoperatively, gastroscopy showed that the esophageal perforation healed well, a white ulcer scar had formed locally, metal clips were found in the stomach body, and no recurrence was found. CONCLUSION EFTR is effective for removing giant schwannomas, although the extraction of large specimens may result in iatrogenic cervical esophageal perforations. Perforations > 2 cm can be managed using endoscopic metal clip closure.
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Affiliation(s)
- Siying Huang
- Department of Gastroenterology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, P.R. China
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2
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Evans BA, Craig WY, Cinelli CM, Siegel SG. CT esophagogram in the emergency setting: typical findings and suggested workflow. Emerg Radiol 2024; 31:33-44. [PMID: 38093143 DOI: 10.1007/s10140-023-02193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/27/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide. METHODS Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance. RESULTS EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP. CONCLUSION CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.
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Affiliation(s)
- Brad A Evans
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA.
- University of Wisconsin, 750 Highland Ave., Madison, WI, 53705, USA.
| | - Wendy Y Craig
- MaineHealth Institute for Research, 81 Research Drive, Scarborough, ME, 04074, USA
| | - Christina M Cinelli
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
| | - Sharon G Siegel
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
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3
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Donado Jimenez MJ, Jimenez MC, Cubas R. Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation. BMJ Case Rep 2024; 17:e258060. [PMID: 38216165 PMCID: PMC10806898 DOI: 10.1136/bcr-2023-258060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Abstract
Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.
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Affiliation(s)
| | - Maria Carolina Jimenez
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert Cubas
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Du J, Gao X, Hao D, Quan Z, Yan L, He B. Retrospective analysis of 10 cases with esophageal fistula after anterior surgery for cervical spine fracture. Heliyon 2023; 9:e21244. [PMID: 37908714 PMCID: PMC10613885 DOI: 10.1016/j.heliyon.2023.e21244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
Objective This study aims to discuss the appropriate treatment of esophageal fistula following anterior surgery for cervical spine fracture. Methods Clinical data of patients with cervical spine fracture treated at our research center from January 2000 to December 2019 were screened. Data of patients with esophageal fistula were included, and the causes of injury, diagnosis, and treatment were retrospectively analyzed. Results A total of 3578 patients with cervical spine fracture were screened, among whom there were 10 cases (0.28 %) of esophageal fistula. 60 % of the cases were early-onset and all were caused by intraoperative electric knife injury. The positive rate of early endoscopy was only 25 %, while routine radiography showed a positive rate of 33.3 % after three attempts. Among the six patients with early-onset esophageal fistula, three underwent sternocleidomastoid flap transfer and two underwent primary suture, all achieving successful healing. In the four cases of late-onset esophageal fistula, two patients received implant removal, debridement, incision lavage, and sternocleidomastoid muscle flap transfer three weeks later. One patient received implant removal, debridement, vacuum sealing drainage, followed by sternocleidomastoid muscle pedicle transfer muscle flap plus lavage two weeks later and achieved complete recovery. All patients gargled alternately with metronidazole and chlorhexidine gargle after surgery. Conclusion The occurrence of esophageal fistula is associated with surgical procedures, esophageal injury, and implant compression. Esophagography and endoscopy are the primary diagnostic methods, while incision exploration after ingestion of food mixed with methylene serves as a supplementary approach. Recommended treatments include alternating metronidazole and chlorhexidine gargles, esophageal rest, repair of the fistula, muscle flap packing, lavage and drainage, nutritional support, and removal of internal fixation if necessary. Post-surgery administration of antibiotics should continue until three consecutive lavage cultures yield negative results.
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Affiliation(s)
- Jinpeng Du
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Friendship East Road, Xi'an City, Shaanxi Province, China
| | - Xiangcheng Gao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Friendship East Road, Xi'an City, Shaanxi Province, China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Friendship East Road, Xi'an City, Shaanxi Province, China
| | - Zhengxue Quan
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liang Yan
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Friendship East Road, Xi'an City, Shaanxi Province, China
| | - Baorong He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Friendship East Road, Xi'an City, Shaanxi Province, China
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Kanlerd A, Mahawongkajit P, Achavanuntakul C, Boonyasatid P, Auksornchart K. Successful management of 72-h delay-detected blunt esophageal injury with trans-gastric primary repair; a case report and literature review. Trauma Case Rep 2023; 43:100755. [PMID: 36654763 PMCID: PMC9841267 DOI: 10.1016/j.tcr.2023.100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/08/2023] Open
Abstract
Diagnosis of blunt esophageal injury is currently a challenging issue. Early surgical interventions still play as the mainstay of treatment. There was no consensus about appropriate treatment options. However, it was potential morbidity if delayed management. We report a 33-year-old man with a history of a motorcycle accident who presented with hematemesis and epigastrium pain. He was initially diagnosed with left pneumohemothorax and low-grade gastric injury. The patient developed a high-grade fever with complex left pneumohemothorax 72-h after admission. The diagnostic studies revealed a lower esophageal rupture. He was treated with trans-gastric primary repair and recovered well with no complications. We propose the trans-gastric intraluminal repair is one of the surgical options in a blunt lower esophageal rupture.
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Affiliation(s)
- Amonpon Kanlerd
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand,Corresponding author at: Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, 95 M.8 Paholyotin Rd., Klongluang, Pathumthani 12120, Thailand.
| | - Prasit Mahawongkajit
- Gastrointestinal Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chompoonut Achavanuntakul
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Piyapong Boonyasatid
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Karikarn Auksornchart
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Yang Q, Liu H, Shu X, Liu X. Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience. BMC Gastroenterol 2022; 22:537. [PMID: 36550403 PMCID: PMC9784251 DOI: 10.1186/s12876-022-02624-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Esophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP. METHODS We retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients. RESULTS There were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776-6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418-23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674-17.233, P = 0.018) were independent risk factors for poor prognosis. CONCLUSION Foreign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.
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Affiliation(s)
- Qinyu Yang
- grid.412604.50000 0004 1758 4073Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haipeng Liu
- grid.412604.50000 0004 1758 4073Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Xu Shu
- grid.412604.50000 0004 1758 4073Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoming Liu
- grid.412604.50000 0004 1758 4073Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
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7
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High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med 2021; 53:29-36. [PMID: 34971919 DOI: 10.1016/j.ajem.2021.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality. OBJECTIVE This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence. DISCUSSION Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting. CONCLUSIONS An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.
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Tang A, Ahmad U, Raja S, Siddiqui HU, Sinopoli JN, O'Dell A, Pande A, Blackstone EH, Murthy SC. Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus. Ann Surg 2021; 274:e417-e424. [PMID: 33630450 DOI: 10.1097/sla.0000000000003648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to determine differences in esophageal perforation populations undergoing different advanced interventions for perforated esophagus and identify predictors of treatment outcomes. SUMMARY BACKGROUND DATA Contained esophageal perforation can often be managed expectantly, but uncontained perforation is uniformly fatal without invasive intervention. Treatment options for the latter range from simple endoscopic control through advanced intervention. Clinical presentation varies greatly and directs which intervention is most appropriate. METHODS From 1996 to 2017, 335 patients were treated for esophageal perforation, and 166 for advanced interventions: 74 primary repair with tissue flap (repair), 26 esophagectomy and gastric pull-up (resection), and 66 esophagectomy and immediate diversion with planned delayed reconstruction (resection-diversion). Patient characteristics, clinical presentation, operative outcomes, and survival were abstracted. Pittsburgh Severity Scores (PSS) were retrospectively calculated. Random survival forest analysis was performed for 90-day mortality and competing risks for reconstruction after resection-diversion. RESULTS Repair and resection patients had lower PSS than resection-diversion patients (3 vs 3 vs 6, respectively). Ninety-day mortality for repair, resection, and resection-diversion was 11% vs 7.7% vs 23%, and 5-year survival was 71% vs 63% vs 47%. Risk of death after resection-diversion was highest within 1 year, but 52% of patients had reconstruction of the upper alimentary tract within 2 years. CONCLUSIONS Several advanced interventions exist for critically ill patients with uncontained esophageal perforation. Repair and organ preservation are always preferred; however, patients at extremes of illness might best be treated with resection-diversion, with the understanding that the competing risk of death may preclude eventual reconstruction.
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Affiliation(s)
- Andrew Tang
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Usman Ahmad
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Siva Raja
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Hafiz U Siddiqui
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Jillian N Sinopoli
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Alexander O'Dell
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Amol Pande
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
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9
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Shennib H, Baribault M, Heuser R. Bovine xenograft pericardial patch use for definitive single stage repair of a large esophageal defect: a case report. J Cardiothorac Surg 2021; 16:300. [PMID: 34645503 PMCID: PMC8515757 DOI: 10.1186/s13019-021-01670-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Large esophageal perforations are challenging and often treated with exclusion or resection. This case demonstrates the feasibility of definitive surgical repair of a large esophageal perforation using large bovine pericardial patch. Case A patient with missed Boerhaave Syndrome underwent transesophageal echocardiography causing worsening perforation and sepsis. At thoracotomy and faced with a large esophageal defect, a large Bovine pericardial patch was used for repair with omentopexy. The patient recovered promptly and at 8 months was asymptomatic with satisfactory studies. Conclusion Xenograft pericardium is available and widely used for vascular reconstructions. It’s use for primary repair of large esophageal perforations should be considered.
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Affiliation(s)
- Hani Shennib
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA.
| | - Michelle Baribault
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA
| | - Richard Heuser
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA
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MacKay EJ, Zhang B, Heng S, Ye T, Neuman MD, Augoustides JG, Feinman JW, Desai ND, Groeneveld PW. Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery. J Am Soc Echocardiogr 2021; 34:571-581. [DOI: 10.1016/j.echo.2021.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 12/18/2022]
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Saffo S, Farrell J, Nagar A. Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock. Acute Crit Care 2021; 36:264-268. [PMID: 33691378 PMCID: PMC8435440 DOI: 10.4266/acc.2020.01067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.
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Affiliation(s)
- Saad Saffo
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - James Farrell
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Anil Nagar
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.,West Haven Veteran Affairs Medical Center, West Haven, CT, USA
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Armocida D, Brunetto GMF, Proietti L, Palmieri M, Pesce A, Santoro A, Balsamo G, Di Nardo G, Frati A. Transoral Endoscopic Approach to Repair Early Pharyngeal Perforations After Anterior Cervical Spine Surgery without Failure of Instrumentation: Our Experience and Review of Literature. World Neurosurg 2020; 141:219-225. [PMID: 32562902 DOI: 10.1016/j.wneu.2020.06.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pharyngoesophageal injury during anterior cervical spine surgery is a rare and potentially life-threatening complication; generally it is the result of intraoperative manipulation or hardware erosion and sometimes may be due to weakness of the pharyngoesophageal wall from pre-existing pathologic conditions, such as diabetes, gastritis, or obesity. CASE DESCRIPTION We describe the management strategies in patients with an early postoperative hypopharyngeal perforation that occurred after anterior cervical spine surgery without failure of instrumentation, and we present a case treated endoscopically at our institution. CONCLUSIONS Appropriate treatment for pharyngoesophageal perforations is controversial and not investigated in detail. There is a lack of prospective studies comparing initial conservative versus surgical approaches to treatment. In addition, endoscopic management is growing as a therapeutic option, but no consensus concerning the indications for an endoscopic approach in the treatment of pharyngoesophageal injury in anterior cervical spine surgery is currently reached. A common theme proposed in the literature is that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. A customized interdisciplinary surgical approach is essential for successful treatment. Use of the transoral endoscopic approach is a useful noninvasive method to treat this rare but potentially devastating complication.
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Affiliation(s)
- Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, Sapienza University of Rome, Rome, Italy.
| | | | - Luca Proietti
- Institute of Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy; NESMOS Department, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Mauro Palmieri
- Neurosurgery Division, Human Neurosciences Department, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pesce
- Neurosurgery Division, Human Neurosciences Department, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy
| | - Antonio Santoro
- Neurosurgery Division, Human Neurosciences Department, Sapienza University of Rome, Rome, Italy
| | - Giorgio Balsamo
- Department of Otorhinolaryngology, Sant'Eugenio Hospital, Rome, Italy
| | - Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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13
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Chen S, Shapira-Galitz Y, Garber D, Amin MR. Management of Iatrogenic Cervical Esophageal Perforations. JAMA Otolaryngol Head Neck Surg 2020; 146:488-494. [DOI: 10.1001/jamaoto.2020.0088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Sophia Chen
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Yael Shapira-Galitz
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - David Garber
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Milan R. Amin
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
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14
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Durleshter VM, Markov PV, Pykhteev VS, Gabriel SA, Dynko VY. [Minimally invasive treatment of post-burn esophageal perforation]. Khirurgiia (Mosk) 2020:93-98. [PMID: 33301261 DOI: 10.17116/hirurgia202012193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.
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Affiliation(s)
- V M Durleshter
- Region Clinical Hospital No. 2, Krasnodar, Russia
- Kuban State Medical University, Krasnodar, Russia
| | - P V Markov
- Region Clinical Hospital No. 2, Krasnodar, Russia
- Kuban State Medical University, Krasnodar, Russia
| | - V S Pykhteev
- Region Clinical Hospital No. 2, Krasnodar, Russia
- Kuban State Medical University, Krasnodar, Russia
| | - S A Gabriel
- Region Clinical Hospital No. 2, Krasnodar, Russia
- Kuban State Medical University, Krasnodar, Russia
| | - V Yu Dynko
- Region Clinical Hospital No. 2, Krasnodar, Russia
- Kuban State Medical University, Krasnodar, Russia
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15
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Tzeng CH, Chen WK, Lu HC, Chen HH, Lee KI, Wu YS, Lee FY. Challenges in the diagnosis of Boerhaave syndrome: A case report. Medicine (Baltimore) 2020; 99:e18765. [PMID: 31914100 PMCID: PMC6959951 DOI: 10.1097/md.0000000000018765] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute chest pain remains one of the most challenging complaints of patients presenting to emergency departments (EDs). The diverse etiologies of chest pain frequently lead to diagnostic and therapeutic challenges. Esophageal perforation is a rare but potentially life-threatening disease. It results in delayed diagnosis and an estimated mortality risk of 20% to 40%. Prompt diagnosis and immediate therapeutic interventions are key factors for a good prognosis. PATIENT CONCERNS Case 1 involved a 66-year-old man who presented to the ED with acute chest pain radiating to the back and hematemesis. Emergent contrast thoracic computerized tomography (CT) indicated the presence of a massive pneumothorax with pleural effusion. The continuous drainage of a dark-red bloody fluid following emergent thoracic intubation led to the discovery that the patient had experienced severe vomiting after whiskey consumption before admission to the hospital. Re-evaluation of the CT indicated spontaneous pneumomediastinum, whereas barium esophagography confirmed the presence of an esophageal perforation. Case 2 involved an 18-year-old Vietnamese man admitted to our ED with acute chest pain and swelling of the neck after vomiting due to beer consumption. A chest x-ray indicated diffuse subcutaneous emphysema of the neck and upper thorax. Contrast CT indicated pneumomediastinum with extensive emphysema and air in the paraspinal region and spinal canal. DIAGNOSES Both of the 2 cases were diagnosed as spontaneous perforation of the esophagus (Boerhaave syndrome [BS]). INTERVENTIONS Case 1 received surgical interventions, whereas case 2 decided not to avail our medical services. OUTCOMES Case 1 was discharged after a good recovery. Case 2 lost to follow-up. LESSONS We recommend all physicians in the ED to raise their index of suspicion for BS when dealing with patients having acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion.
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Affiliation(s)
- Ching-Hsuane Tzeng
- Department of Emergency Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Wei-Kung Chen
- Department of Emergency Medicine, Trauma and Emergency Center, China Medical University Hospital, Taichung
| | - Huei-Chun Lu
- Department of Emergency Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Hsin-Hung Chen
- Department of Emergency Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Kuan-I Lee
- Department of Emergency Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Emergency Medicine, School of Medicine, Tzu Chi University
| | - Yung-Shun Wu
- Department of Emergency Medicine, Mennonite Christian Hospital, Hualien, Taiwan (R.O.C.)
| | - Feng-You Lee
- Department of Emergency Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Emergency Medicine, School of Medicine, Tzu Chi University
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16
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Mureșan M, Mureșan S, Balmoș I, Sala D, Suciu B, Torok A. Sepsis in Acute Mediastinitis - A Severe Complication after Oesophageal Perforations. A Review of the Literature. J Crit Care Med (Targu Mures) 2019; 5:49-55. [PMID: 31161141 PMCID: PMC6534941 DOI: 10.2478/jccm-2019-0008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite recent advancements in antibiotic therapy and the progress made in critical care and modern diagnostic methods, acute mediastinitis continues to be a severe condition. DIAGNOSIS AND TREATMENT Acute mediastinitis can occur in the context of cardio-thoracic surgery, oesophageal perforations and oropharyngeal infections condition. Forty-five percent of oesophageal perforations occurs during simple endoscopy. Spontaneous perforation (Boerhaave syndrome) accounts for 15% of perforations, and twelve percent are due to the ingestion of foreign bodies. Other causes include blind or penetrating trauma, and circa 9% to intraoperative lesions. CT scan is the standard investigation that reveals direct signs of mediastinitis.The oral administration of contrast substances can underscore the level of oesophageal perforation. Conservative treatment is the first-choice treatment and surgical treatment is reserved only for specific situations.The principles of surgical treatment consist of drainage, primary suture, oesophageal exclusion with or without the application of oesophagectomy, endoscopic vacuum wound assisted therapy of the perforation and associated paraoesophageal mediastinal drainage and endoscopic stenting associated with drainage. CONCLUSIONS The lowest mortality rate is recorded in patients with perforations diagnosed less than twenty-four hours after the onset of symptoms. Surgical treatment remains the gold standard especially in cases of thoracic and abdominal perforations while further investigations are mandatory before endoscopic stenting is carried out.
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Affiliation(s)
- Mircea Mureșan
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Simona Mureșan
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Physiology Department, Târgu Mureș, Romania
| | - Ioan Balmoș
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Daniela Sala
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Bogdan Suciu
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Thoracic Surgery Department, Târgu Mureș, Romania
| | - Arpad Torok
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
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