Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report

Esophageal perforation due to soft coagulation heat injury after right lower lobectomy: A case report

INTRODUCTION

Soft coagulation is a hemostatic system of electrosurgical units that automatically regulates its output to avoid carbonization or incision. This system is widely used in invasive procedures, including thoracic surgery. Few reports exist on the harmful effects of these devices. Herein, we encountered a case of an esophagopleural fistula caused by soft coagulation.

PRESENTATION OF CASE

A 74-year-old man with a history of bladder cancer was diagnosed with a tumor in the right lower lung lobe 2.5 cm in diameter. A thoracoscopic right lower lobectomy with lymph node dissection was performed. During surgery, hemostasis using soft coagulation was performed on the right wall of the lower esophagus. Eight days after surgery, thoracoscopic empyema curettage and drainage were performed. Three days after the second surgery, an esophageal fistula was identified. Suturing for the esophageal fistula and omentoplasty were performed. Suture failure occurred and an esophagobronchial fistula developed after the third surgery, which was reduced by drainage, antibiotics, and enteral nutrition. The fistula was finally addressed by fibrin glue filling in its cavity.

DISCUSSION

Soft coagulation helps manage hemostasis and contributes to safe surgery. However, it may cause severe complications owing to the unpredictable spread of heat denaturation. It is suspected that delayed esophageal perforation was caused by an unnoticed heat injury to the deeper layer of the esophageal wall.

CONCLUSION

There have been no reports of esophagus injury caused by soft coagulation exept for our experience. Although soft coagulation is a useful device owing to its excellent hemostatic capacity, the spread of heat denaturation may cause unpredictable tissue damage. Extra caution should be observed when using this device for hemostasis.

Current approach for Boerhaaves syndrome: A systematic review of case reports

BACKGROUND

There is no consensus on the appropriate therapeutic strategy for Boerhaave syndrome due to its rarity and changing therapeutic approaches. We conducted a systematic review of case reports documenting Boerhaave syndrome.

AIM

To assess the therapeutic methods and clinical outcomes and discuss the current trends in the management of Boerhaave syndrome.

METHODS

We searched PubMed, Google scholar, MEDLINE, and The Cochrane Library for studies concerning Boerhaave syndrome published between 2017 and 2022.

RESULTS

Of the included studies, 49 were case reports, including a total of 56 cases. The mean age was 55.8 ± 16 years old. Initial conservative treatment was performed in 25 cases, while operation was performed in 31 cases. The rate of conservative treatment was significantly higher than that of operation in cases of shock vital on admission (9.7% vs 44.0%; P = 0.005). Seventeen out of 25 conservative cases (68.0%) were initially treated endoscopic esophageal stenting; 2 of those 17 cases subsequently underwent operation due to poor infection control. Twelve cases developed postoperative leakage (38.7%), and 4 of those 12 cases underwent endoscopic esophageal stenting to stop the leakage. The length of the hospital stay was not significantly different between the conservative treatment and operation cases (operation vs conservation: 33.52 ± 22.69 vs 38.81 ± 35.28 days; P = 0.553).

CONCLUSION

In the treatment of Boerhaave syndrome, it is most important to diagnose the issue immediately. Primary repair with reinforcement is the gold-standard procedure. The indication of endoscopic esophageal stenting or endoluminal vacuum-assisted therapy should always be considered for patients in a poor general condition and who continue to have leakage after repair.

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

Background

The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.

Case presentation

A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88.

Conclusions

Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.

Percutaneous transesophageal gastro-tubing for the management of anastomotic leakage after upper GI surgery: a report of two clinical cases

Background

Anastomotic leakage is a serious, sometimes critical complication of upper gastrointestinal (GI) surgery. The cavity and target drainage tubes are difficult to reach; therefore, a nasogastric tube (NGT) and fasting are required for an extended period. We successfully treated and managed two patients with anastomotic leakage using percutaneous transesophageal gastro-tubing (PTEG).

Case presentation

In case 1, a 79-year-old man with gastric cancer underwent total gastrectomy; 1 week later, he underwent emergent open laparotomy due to panperitonitis attributed to anastomotic leakage-related jejunojejunostomy. We resected the portion between esophagojejunostomy and jejunojejunostomy and reconstructed it using the Roux-en-Y technique. On postoperative day (POD) 9, anastomotic leakage was diagnosed at the esophagojejunostomy site and jejunotomy staple line. After using a circular stapler for jejunojejunostomy, a stapled jejunal closure was added. We inserted an NGT and performed aspiration for bowel decompression. As he did not improve within 2 weeks, we decided to perform PTEG to free him of the NGT. We kept performing intermittent aspiration; leakage stopped shortly after, due to effective inner drainage. The PTEG catheter was removed after oral intake was restarted. In case 2, an 81-year-old man with esophagogastric junction cancer underwent resection of the distal esophagus and proximal stomach. After shaping the remnant stomach, esophagogastrostomy was performed under the right thoracotomy. On POD 11, anastomotic leakage was identified, along with a mediastinal abscess. We inserted an NGT into the abscess cavity through the anastomotic leakage site. On POD 25, we performed PTEG and inserted a drainage tube, instead of an NGT. Although the abscess cavity disappeared, anastomotic leakage persisted as a fistula. We exchanged the PTEG with a double elementary diet (W-ED) tube with jejunal extension, with the side hole located near the anastomosis. The anastomotic fistula disappeared after treatment. Dysphagia persisted due to disuse atrophy of swallowing musculature; PTEG was useful for enteral feeding, even after the leakage occurred.

Conclusion

Patients are sometimes forced to endure pain for a long time for transnasal inner drainage. Using PTEG, patients will be free of sinus pain and discomfort; PTEG should be helpful for patients withstanding NGT.