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Tipton KN, Schroder D. A Critical Combination of Esophageal Rupture and Upside-down Stomach: A Case Report. Clin Pract Cases Emerg Med 2024; 8:95-98. [PMID: 38869327 PMCID: PMC11166077 DOI: 10.5811/cpcem.20907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 06/14/2024] Open
Abstract
Introduction Spontaneous esophageal rupture, or Boerhaave syndrome, and upside-down stomach are rare pathologies associated with grave sequelae. Boerhaave syndrome can have a mortality rate as high as 44%. Upside-down stomach accounts for less than 5% of hiatal hernias and can lead to incarceration and volvulus. Case Report An 80-year-old woman presented to the emergency department with sudden onset, severe epigastric pain. Physical examination revealed normal vital signs with mild epigastric tenderness. Imaging obtained revealed a large hiatal hernia and findings concerning for esophageal perforation. The patient was started on 3.375 grams of intravenous piperacillin/tazobactam, and transfer to a tertiary care facility was initiated. After transfer, esophagography confirmed a perforation near the gastroesophageal junction and findings consistent with an upside-down stomach. The patient underwent successful repair of the esophageal perforation and gastropexy followed by intensive care unit admission and ultimately discharge. Conclusion Boerhaave syndrome and upside-down stomach are two conditions with high associated morbidity and mortality requiring prompt intervention. Information obtained in the history and physical examination including acute onset of chest pain after vomiting, tachypnea, subcutaneous emphysema, and hypoxia can assist in the diagnosis of the described pathologies. These signs and symptoms can be subtle on examination but are important in raising clinical suspicion for an otherwise rare etiology for acute onset chest pain.
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Affiliation(s)
- Kay Nicole Tipton
- UNC Health Southeastern, Department of Emergency Medicine, Lumberton, North Carolina
- Campbell University, School of Medicine, Emergency Medicine Residency, Lumberton, North Carolina
| | - Daniel Schroder
- UNC Health Southeastern, Department of Emergency Medicine, Lumberton, North Carolina
- Campbell University, School of Medicine, Emergency Medicine Residency, Lumberton, North Carolina
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2
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Lemmet T, Mazzucotelli JP, Collange O, Fath L, Mutter D, Brigand C, Falcoz PE, Danion F, Lefebvre N, Bourne-Watrin M, Gerber V, Hoellinger B, Fabacher T, Hansmann Y, Ruch Y. Infectious Mediastinitis: A Retrospective Cohort Study. Open Forum Infect Dis 2024; 11:ofae225. [PMID: 38751899 PMCID: PMC11095524 DOI: 10.1093/ofid/ofae225] [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: 01/16/2024] [Accepted: 05/02/2024] [Indexed: 05/18/2024] Open
Abstract
Background This study aimed to characterize the demographics, microbiology, management and treatment outcomes of mediastinitis according to the origin of the infection. Methods This retrospective observational study enrolled patients who had mediastinitis diagnosed according to the criteria defined by the Centers for Disease Control and Prevention and were treated in Strasbourg University Hospital, France, between 1 January 2010 and 31 December 2020. Results We investigated 151 cases, including 63 cases of poststernotomy mediastinitis (PSM), 60 cases of mediastinitis due to esophageal perforation (MEP) and 17 cases of descending necrotizing mediastinitis (DNM). The mean patient age (standard deviation) was 63 (14.5) years, and 109 of 151 patients were male. Microbiological documentation varied according to the origin of the infection. When documented, PSM cases were mostly monomicrobial (36 of 53 cases [67.9%]) and involved staphylococci (36 of 53 [67.9%]), whereas MEP and DNM cases were mostly plurimicrobial (38 of 48 [79.2%] and 8 of 12 [66.7%], respectively) and involved digestive or oral flora microorganisms, respectively. The median duration of anti-infective treatment was 41 days (interquartile range, 21-56 days), and 122 of 151 patients (80.8%) benefited from early surgical management. The overall 1-year survival rate was estimated to be 64.8% (95% confidence interval, 56.6%-74.3%), but varied from 80.1% for DNM to 61.5% for MEP. Conclusions Mediastinitis represents a rare yet deadly infection. The present cohort study exhibited the different patterns observed according to the origin of the infection. Greater insight and knowledge on these differences may help guide the management of these complex infections, especially with respect to empirical anti-infective treatments.
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Affiliation(s)
- Thomas Lemmet
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | | | - Olivier Collange
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Léa Fath
- Department of E.N.T. and Head and Neck Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Didier Mutter
- Department of Visceral and Digestive Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Cécile Brigand
- Department of General and Digestive Surgery, Strasbourg University Hospital, Strasbourg, France
| | | | - François Danion
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Nicolas Lefebvre
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Morgane Bourne-Watrin
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Victor Gerber
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Baptiste Hoellinger
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Thibaut Fabacher
- Department of biostatistics, Strasbourg University Hospital, Strasbourg, France
| | - Yves Hansmann
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
| | - Yvon Ruch
- Department of Infectious and Tropical Diseases, Strasbourg University Hospital, Strasbourg, France
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3
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Forsah SF, Ugwendum D, Fuoching N, Arrey Agbor DB, Villanueva K, Ndemazie NB, Kankeu Tonpouwo G, Ndema N, Diaz K, Saverimuttu J, Nfonoyim J. Bilateral Empyema With Beta Hemolytic Group C Streptococcus and Streptococcus constellatus Co-infection Resulting From an Esophageal Perforation and Associated With Septic Shock, Diffuse ST Elevation, and New-Onset Atrial Fibrillation. Cureus 2024; 16:e57251. [PMID: 38686265 PMCID: PMC11057215 DOI: 10.7759/cureus.57251] [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] [Accepted: 03/29/2024] [Indexed: 05/02/2024] Open
Abstract
Empyema is the collection of pus in the pleural cavity and most times, it occurs unilaterally. It is often associated with underlying pneumonia, but other causes have been identified as well. When it occurs after an esophageal perforation, which in itself is also rare, morbidity and mortality are even higher. Esophageal perforation can cause life-threatening complications due to its close proximity to the vital organs of the mediastinum, necessitating its timely diagnosis and aggressive management. Bacteria forming part of the normal esophageal and oral flora are the most common causative pathogens for empyema from an esophageal perforation. Streptococcus constellatus and group C Streptococci, though both rare and often not taken seriously, have been identified as individual causes of empyema. We present a case of a 58-year-old male who presented with a worsening cough, chest pain, and shortness of breath after choking on a fish bone. He was diagnosed with bilateral loculated empyema resulting from esophageal perforation with the pleural fluid culture isolating both group C streptococcus and Streptococcus constellatus. He also developed respiratory failure, mediastinitis, and septic shock. This case will enable physicians to take empyema caused by these bacteria seriously and also to include esophageal perforation as a differential diagnosis when a patient presents with bilateral empyema associated with chest pain and electrocardiographic changes.
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Affiliation(s)
- Sabastain F Forsah
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Derek Ugwendum
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Nkeng Fuoching
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | | | - Kevin Villanueva
- Radiology, Richmond University Medical Center, Staten Island, USA
| | | | | | - Nancelle Ndema
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Keith Diaz
- Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, USA
| | - Jessie Saverimuttu
- Infectious Disease, Richmond University Medical Center, Staten Island, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, USA
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4
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Mohamed Ramlee FA, Ibrahim N, Hashim MH. Ingested Australasian Snapper (Chrysophrys auratus) Bone Migration to C5 Vertebral Body. Cureus 2024; 16:e56301. [PMID: 38629010 PMCID: PMC11019188 DOI: 10.7759/cureus.56301] [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] [Accepted: 03/13/2024] [Indexed: 04/19/2024] Open
Abstract
Fishbone ingestion has been reported multiple times previously as a cause of oesophageal perforation. This is a surgical emergency that needs to be identified early to ensure immediate medical attention. This report presents the case of a 70-year-old patient with laryngeal perforation and the migration of a Chrysophrys auratus (Australasian snapper) fishbone to the C5 vertebral body. It is hypothesized that the fishbone migrated from the larynx to the visceral fascia and prevertebral fascia before lodging in between the intramuscular substance of the longus coli muscle. Multiple imaging modalities were used to identify and locate the foreign body, including flexible nasopharyngoscopy, esophagogastroduodenoscopy, and a computed tomography (CT) scan of the neck. The exploration of the neck was done by the ENT team and the orthopaedic spine team via the left anterior cervical approach at the level of the C5 and C6 vertebral bodies. The foreign body was identified (15 mm fishbone) at the left lateral of the C5 body, lodged between the intramuscular substance of the longus coli muscle, and was successfully removed.
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Affiliation(s)
| | | | - Muhammad H Hashim
- Orthopaedics and Traumatology, Sultan Idris Shah Hospital, Serdang, MYS
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5
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Dagestani H, Alomar S, Alfraidy D, Twier KI, Alramahi G. Isolated Blowout Distal Esophageal Injury From Blunt Thoraco-Abdominal Trauma Following Airbag Deployment in an Unrestrained Driver: A Case Report. Cureus 2024; 16:e53718. [PMID: 38455768 PMCID: PMC10919379 DOI: 10.7759/cureus.53718] [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] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Esophageal perforation from blunt trauma is rare. It is more frequently encountered in a penetrative mechanism where the cervical esophagus is most commonly injured. Blunt esophageal injury is challenging to diagnose with nonspecific findings clinically and radiologically within trauma settings. The main factors contributing to difficulty in early recognition are its scarce occurrence combined with nonspecific manifestations clinically on patient examination and radiologically on usual trauma computed tomography with intravenous contrast. We report a case of a 15-year-old young man who sustained an isolated distal blowout esophageal perforation as a result of blunt thoraco-abdominal trauma. Despite early primary surgical repair, a leak developed later on, which was managed with stent placement. The leak and associated sepsis were resolved, with an overall status improvement and no subsequent complications. We report an unusual presentation of esophageal perforation from blunt trauma, which was promptly diagnosed and managed with multiple modalities. This case highlights the importance of early recognition and management of esophageal injury and, furthermore, the role of multiple diagnostic and therapeutic modalities that lead to a successful outcome.
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Affiliation(s)
- Hatoon Dagestani
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
| | - Sahar Alomar
- Department of Trauma Surgery, King Saud University Medical City, Riyadh, SAU
| | - Doaa Alfraidy
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
| | - Khaled I Twier
- Department of Trauma Surgery, King Saud University Medical City, Riyadh, SAU
| | - Ghassan Alramahi
- Department of Trauma Surgery, King Saud University Medical City, Riyadh, SAU
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6
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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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Ermerak NO, Uprak KT, Emran M, Lacin T, Yildizeli B, Yegen C. Esophageal Perforation During Intragastric Balloon Therapy: Management of a Patient with Late Referral. Obes Surg 2024; 34:272-273. [PMID: 37952060 DOI: 10.1007/s11695-023-06929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 06/30/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Nezih Onur Ermerak
- Department of Thoracic Surgery, Marmara University School of Medicine, Fevzi Çakmak Mah. Mimar Sinan Cad. No: 41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey.
| | - Kivilcim Tevfik Uprak
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Miray Emran
- Department of Thoracic Surgery, Marmara University School of Medicine, Fevzi Çakmak Mah. Mimar Sinan Cad. No: 41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey
| | - Tunc Lacin
- Department of Thoracic Surgery, Marmara University School of Medicine, Fevzi Çakmak Mah. Mimar Sinan Cad. No: 41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey
| | - Bedrettin Yildizeli
- Department of Thoracic Surgery, Marmara University School of Medicine, Fevzi Çakmak Mah. Mimar Sinan Cad. No: 41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey
| | - Cumhur Yegen
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
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8
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Gasanov MA, Danielyan SN, Chernousov FA, Gasanov AM, Rabadanov KM, Tatarinova EV, Barmina TG, Titova GP, Nevdah SK. [Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]. Khirurgiia (Mosk) 2024:21-28. [PMID: 38258684 DOI: 10.17116/hirurgia202401121] [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: 01/24/2024]
Abstract
OBJECTIVE To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations. MATERIAL AND METHODS The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions. RESULTS Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery. CONCLUSION EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.
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Affiliation(s)
- M A Gasanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - Sh N Danielyan
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- National Institute of Health, Yerevan, Armenia
| | - F A Chernousov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A M Gasanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - K M Rabadanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - E V Tatarinova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - T G Barmina
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - G P Titova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - S K Nevdah
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
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9
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Bui J, Hendrickson M, Agala CB, Strassle PD, Haithcock B, Long J. Trends in the management and outcomes of esophageal perforations among racial-ethnic groups. J Thorac Dis 2023; 15:6579-6588. [PMID: 38249932 PMCID: PMC10797358 DOI: 10.21037/jtd-23-1004] [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: 06/28/2023] [Accepted: 11/03/2023] [Indexed: 01/23/2024]
Abstract
Background Esophageal perforation (EP) is a life-threatening emergency requiring emergent surgical intervention. Little is known about potential racial-ethnic disparities among patients with EP. Methods Hospitalizations of adult (≥18 years old) patients admitted with a diagnosis of EP were identified in the 2000-2017 National Inpatient Sample (NIS). Multivariable Cox proportional hazards regression was used to estimate the association between race-ethnicity and inpatient mortality. Inpatient complications were assessed using multivariable logistic regression. Results There were an estimated 36,531 EP hospitalizations from 2000-2017. One quarter of hospitalizations were racial or ethnic minorities. Non-Hispanic (NH) White patients were, on average, older (median age 58 vs. 41 and 47 years, respectively, P<0.0001). The rate of EP admissions, per 1,000,000 the United States (US) adults, significantly increased among all groups over time. In-hospital mortality decreased for both NH White and NH Black patients (10.2% to 4.6% and 8.3% to 4.9%, respectively, P<0.0001) but increased for Hispanic patients and patients of other races (2.9% to 4.7% and 3.4% to 6.9%, P<0.0001). NH Black patients were more likely to have sepsis during their hospital course [odds ratio (OR) =1.34; 95% confidence interval (CI): 1.08 to 1.66], and patients of other races (OR =1.44; 95% CI: 1.01 to 2.07) were more likely to have pneumonia. Similar rates of surgical intervention were seen among all racial-ethic groups. After adjustment, inpatient mortality did not differ among racial-ethnic groups. Conclusions Rates of EP admissions have increased for all racial-ethnic groups since 2000. Despite similar incidences of inpatient mortality across groups, NH Black and other race patients were more likely to experience postoperative complications, suggesting potential racial-ethnic disparities in quality or access to care.
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Affiliation(s)
- Jenny Bui
- Department of Surgery, Henry Ford Health, Detroit, MI, USA
| | - Michael Hendrickson
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Chris B. Agala
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Paula D. Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Benjamin Haithcock
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Jason Long
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Gidda H, Mansour M, Singh I, Nashed B, Ventimiglia W. The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum. Cureus 2023; 15:e38699. [PMID: 37292540 PMCID: PMC10246430 DOI: 10.7759/cureus.38699] [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] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.
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Affiliation(s)
- Harish Gidda
- Internal Medicine, Ascension St. John Hospital, Detroit, USA
| | - Mohamed Mansour
- Pulmonary and Critical Care Medicine, Ascension St. John Hospital, Detroit, USA
| | - Inderpal Singh
- Internal Medicine, Ascension St. John Hospital, Detroit, USA
| | - Bola Nashed
- Internal Medicine, Ascension St. John Hospital, Detroit, USA
| | - William Ventimiglia
- Pulmonary and Critical Care Medicine, Ascension St. John Hospital, Detroit, USA
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Angelette AL, Rando LL, Wadhwa RD, Barras AA, Delacroix BM, Talbot NC, Ahmadzadeh S, Shekoohi S, Cornett EM, Kaye AM, Kaye AD. Tetracycline-, Doxycycline-, Minocycline-Induced Pseudotumor Cerebri and Esophageal Perforation. Adv Ther 2023; 40:1366-1378. [PMID: 36763302 DOI: 10.1007/s12325-023-02435-y] [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] [Received: 08/26/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023]
Abstract
Tetracyclines are a class of broad-spectrum bacteriostatic antibiotics used to treat many infections, including methicillin-resistant Staphylococcus aureus (MRSA), acne, pelvic inflammatory disease, chlamydial infections, and a host of zoonotic infections. These drugs work by inhibiting protein synthesis in bacterial ribosomes, specifically by disallowing aminoacyl-tRNA molecules from binding to the ribosomal acceptor sites. While rare, tetracycline antibiotics, particularly minocycline and doxycycline, are associated with an increased risk of developing esophageal perforation and pseudotumor cerebri (PTC, or idiopathic intracranial hypertension). Since tetracyclines are a commonly prescribed class of medications, especially in adolescents for acne treatment, it is important for clinicians to appreciate significant side effects that can result in morbidity and mortality. This paper aims to consolidate and to emphasize current research on the association between tetracycline antibiotics and the development of esophageal perforation, and PTC. PTC is a neurological syndrome consisting of increased intracranial pressure, headache, and vision changes without evidence of the contributing source, such as mass lesion, infection, stroke, or malignancy. Esophageal perforation, while rare, can be the result of pill esophagitis. Pill-induced injuries occur when caustic medicinal pills dissolve in the esophagus rather than in the stomach. Most patients experience only self-limited pain (retrosternal burning discomfort, heartburn, dysphagia, or odynophagia), but hemorrhage, stricture, and perforation may occur. Tetracycline use can lead to pill esophagitis. In summary, clinicians should appreciate the potential risks of tetracycline compounds in clinical practice.
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Affiliation(s)
- Alexis L Angelette
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Lauren L Rando
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Reena D Wadhwa
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Ashley A Barras
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Blake M Delacroix
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Norris C Talbot
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, 95211, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
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12
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Lin EK, Lee F, Cao J, Saliba C, Lu V, Okeke RI, Sobrino J, Blewett C. Vacuum-Assisted Closure Treats Refractory Esophageal Leak in a Pediatric Patient. Cureus 2023; 15:e35257. [PMID: 36968879 PMCID: PMC10035385 DOI: 10.7759/cureus.35257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/23/2023] Open
Abstract
Esophageal perforations can have iatrogenic and non-iatrogenic causes. Early identification is a predictor of good outcomes. When identified, perforations can be managed conservatively with wide drainage or repaired surgically. Endoscopic esophageal vacuum-assisted closure may be used as a definitive treatment, particularly in scenarios where conservative management and primary surgical repair fail to achieve complete healing. We present such a scenario advocating for the consideration of endoscopic esophageal vacuum-assisted closure in patients with refractory esophageal leaks.
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13
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Delayed Esophageal Perforation Diagnosed 12 Years After Anterior Cervical Diskectomy and Fusion: A Case Report and Review of Current Literature. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202210000-00003. [PMID: 36227832 PMCID: PMC9575766 DOI: 10.5435/jaaosglobal-d-22-00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/25/2022] [Indexed: 11/05/2022]
Abstract
Esophageal perforation associated with anterior cervical diskectomy and fusion (ACDF) is a rare but serious complication. ACDF-related esophageal perforations can be acute or delayed. Delayed perforations more than 10 years after ACDF are exceedingly rare. Here, a delayed esophageal perforation discovered 12 years after a three-level ACDF is presented. This case highlights two main points. First, all diverticula after an ACDF warrant close clinical monitoring. Second, routine follow-up should be performed for patients with screw pullout to assist in early diagnosis of delayed esophageal perforation.
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14
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Maher TR, Rech JVT, Pereira Ternes CM, dal Forno A, D’Avila A. Esophageal Perforation Following Radiofrequency Catheter Ablation for Atrial Fibrillation: A Conservative Approach. J Innov Card Rhythm Manag 2022; 13:5154-5158. [PMID: 36196233 PMCID: PMC9521727 DOI: 10.19102/icrm.2022.130904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/23/2022] [Indexed: 11/06/2022] Open
Abstract
Esophageal perforation following radiofrequency catheter ablation of atrial fibrillation (AF) is a rare and potentially deadly complication. Here, we report a case with successful conservative management of esophageal perforation following AF ablation demonstrating how surgery is not always required in properly selected patients.
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Affiliation(s)
- Timothy Richard Maher
- Harvard-Thorndike Arrhythmia Institute and Division of Cardiovascular Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA,Address correspondence to: Timothy Richard Maher, MD, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA.
| | | | | | - Alexander dal Forno
- Cardiac Arrhythmia Service—Hospital SOS Cardio, Florianópolis, Santa Catarina, Brazil
| | - André D’Avila
- Harvard-Thorndike Arrhythmia Institute and Division of Cardiovascular Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA,Cardiac Arrhythmia Service—Hospital SOS Cardio, Florianópolis, Santa Catarina, Brazil
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15
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Chu QD, Candal R, White RK. A Novel and Simple Method of Managing Thoracic Esophageal Perforation: The "ASSIST" Approach. Am Surg 2021:31348211063564. [PMID: 34911375 DOI: 10.1177/00031348211063564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes). METHODS Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake. RESULTS Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet. CONCLUSIONS The "ASSIST" method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities.
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Affiliation(s)
- Quyen D Chu
- Departments of Surgery, 23346LSU Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Raquel Candal
- Departments of Surgery, 23346LSU Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Robert K White
- Departments of Surgery, 23346LSU Health Sciences Center-Shreveport, Shreveport, LA, USA
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16
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Enokida T, Tahara M. Management of VEGFR-Targeted TKI for Thyroid Cancer. Cancers (Basel) 2021; 13:5536. [PMID: 34771698 PMCID: PMC8583039 DOI: 10.3390/cancers13215536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022] Open
Abstract
Recent advances in the development of multitarget tyrosine kinase inhibitors (MTKIs), which mainly target the vascular endothelial growth factor receptor (VEGFR), have improved prognoses and dramatically changed the treatment strategy for advanced thyroid cancer. However, adverse events related to this inhibition can interrupt treatment and sometimes lead to discontinuation. In addition, they can be annoying and potentially jeopardize the subjects' quality of life, even allowing that the clinical outcome of patients with advanced thyroid cancer remains limited. In this review, we summarize the potential mechanisms underlying these adverse events (hypertension, proteinuria and renal impairment, hemorrhage, fistula formation/gastrointestinal perforation, wound healing, cardiovascular toxicities, hematological toxicity, diarrhea, fatigue, and acute cholecystitis), their characteristics, and actual management. Furthermore, we also discuss the importance of related factors, including alternative treatments that target other pathways, the necessity of subject selection for safer administration, and patient education.
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Affiliation(s)
| | - Makoto Tahara
- Department of Head and Neck Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan;
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17
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Kim JD. Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study. J Cardiothorac Surg 2021; 16:291. [PMID: 34627308 PMCID: PMC8502388 DOI: 10.1186/s13019-021-01680-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/29/2021] [Indexed: 12/05/2022] Open
Abstract
Background Esophageal perforation and rupture (EPR) is a serious, potentially life-threatening condition. However, no treatment methods have been established, and data concerning factors affecting mortality are limited. This report presents the prognostic factors of mortality in EPR based on experience in the management of such patients. Methods For this retrospective analysis, 79 patients diagnosed as having EPR between 2006 and 2016 and managed at Gyeongsang National University Hospital were examined. The management method was determined in accordance with the location and size of the EPR, laboratory findings, and radiological findings. Thirty-nine patients were treated with surgery; and 40, with nonsurgical management. Results The most common cause of EPR was foreign body (fish bone or meat bone), followed by vomiting, iatrogenic causes, and trauma. Thirty-nine patients underwent primary repair of EPR, of whom 4 patients died. Forty patients underwent nonsurgical management, of whom 3 patients died. The remaining patients were discharged. Mortality correlated with the size of the EPR (> 25 mm) and the segmented neutrophil count percentage (> 86.5%) in the white blood cell test and differential. Conclusions The mortality risk was increased when the EPR size and the segmented neutrophil count percentage in the white blood cell test and differential was high. Delayed diagnosis, which was considered an important predictive factor in previous investigations, was not statistically significant in this study. Trial registration: Not applicable.
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Affiliation(s)
- Jong Duk Kim
- Department of Cardiothoracic Surgery, School of Medicine, Gyeonsang National University, Gyeongsang National University Hospital, Jin-Ju, 79 Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.
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18
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Aho JM, La Francesca S, Olson SD, Triolo F, Bouchard J, Mondano L, Sundaram S, Roffidal C, Cox CS, Wong Kee Song LM, Said SM, Fodor W, Wigle DA. First-in-Human Segmental Esophageal Reconstruction Using a Bioengineered Mesenchymal Stromal Cell-Seeded Implant. JTO Clin Res Rep 2021; 2:100216. [PMID: 34590055 PMCID: PMC8474397 DOI: 10.1016/j.jtocrr.2021.100216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Resection and reconstruction of the esophagus remains fraught with morbidity and mortality. Recently, data from a porcine reconstruction model revealed that segmental esophageal reconstruction using an autologous mesenchymal stromal cell-seeded polyurethane graft (Cellspan esophageal implant [CEI]) can facilitate esophageal regrowth and regeneration. To this end, a patient requiring a full circumferential esophageal segmental reconstruction after a complex multiorgan tumor resection was approved for an investigational treatment under the Food and Drug Administration Expanded Access Use (Investigational New Drug 17402). Methods Autologous adipose-derived mesenchymal stromal cells (Ad-MSCs) were isolated from the Emergency Investigational New Drug patient approximately 4 weeks before surgery from an adipose tissue biopsy specimen. The Ad-MSCs were grown and expanded under current Good Manufacturing Practice manufacturing conditions. The cells were then seeded onto a polyurethane fiber mesh scaffold (Cellspan scaffold) and cultured in a custom bioreactor to manufacture the final CEI graft. The cell-seeded scaffold was then shipped to the surgical site for surgical implantation. After removal of a tumor mass and a full circumferential 4 cm segment of the esophagus that was invaded by the tumor, the CEI was implanted by suturing the tubular CEI graft to both ends of the remaining native esophagus using end-to-end anastomosis. Results In this case report, we found that a clinical-grade, tissue-engineered esophageal graft can be used for segmental esophageal reconstruction in a human patient. This report reveals that the graft supports regeneration of the esophageal conduit. Histologic analysis of the tissue postmortem, 7.5 months after the implantation procedure, revealed complete luminal epithelialization and partial esophageal tissue regeneration. Conclusions Autologous Ad-MSC seeded onto a tubular CEI tissue-engineered graft stimulates tissue regeneration following implantation after a full circumferential esophageal resection.
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Affiliation(s)
- Johnathon M Aho
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | | | - Scott D Olson
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | - Fabio Triolo
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | | | | | | | | | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | | | - Sameh M Said
- Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Dennis A Wigle
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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19
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Amirian A, Shahriarirad R, Mardani P, Salimi M. Non-operative management of bilateral contained thoracic esophageal perforation: a case report. BMC Surg 2021; 21:129. [PMID: 33711959 PMCID: PMC7953744 DOI: 10.1186/s12893-021-01121-6] [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: 11/11/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite profound advances in conservative management of esophageal perforation, patients' selection for this type of treatment requires expert clinical judgment. Surgical intervention has been historically introduced as the optimal management in multifocal ruptures. CASE PRESENTATION Here, we presented a 30-year-old man whose barium esophagogram confirmed bilateral perforations in the lower third of the esophagus contained in the mediastinum, and contrast drained back into the esophageal lumen. Concerning available contrast imaging studies and thoracic surgeons, conservative non-operative management was considered despite pneumomediastinum, a mild right-sided pleural effusion, and minimal leukocytosis. The patient was followed up for two months without any complications. CONCLUSIONS Bilateral and multifocal esophageal perforations can be managed conservatively provided that the leaks are confined to the mediastinum and drain back to the esophageal lumen, and other criteria for conservative management are met.
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Affiliation(s)
- Armin Amirian
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mardani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
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20
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Ritz LA, Hajji MS, Schwerd T, Koletzko S, von Schweinitz D, Lurz E, Hubertus J. Esophageal Perforation and EVAC in Pediatric Patients: A Case Series of Four Children. Front Pediatr 2021; 9:727472. [PMID: 34458215 PMCID: PMC8386293 DOI: 10.3389/fped.2021.727472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/12/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: In pediatric patients, esophageal perforation (EP) is rare but associated with significant morbidity and mortality rates of up to 20-30%. In addition to standard treatment options, endoscopic esophageal vacuum-assisted closure (EVAC) therapy has shown promising results, especially in adult patients. Thus far, the only data on technical success and effectiveness of EVAC in pediatric patients were published in 2018 by Manfredi et al. at Boston Children's Hospital. The sparse data on EVAC in children indicates that this promising technique has been barely utilized in pediatric patients. More data are needed to evaluate efficacy and outcomes of this technique in pediatric patients. Method: We reviewed five cases of therapy using EVAC, ArgyleTM Replogle Suction Catheter (RSC), or both on pediatric patients with EP in our institution between October 2018 and April 2020. Results: Five patients with EP (median 3.4 years; 2 males) were treated with EVAC, RSC, or a combination. Complete closure of EP was not achieved after EVAC alone, though patients' health stabilized and inflammation and size of EP decreased after EVAC. Four patients then were treated with RSC until the EP healed. One patient needed surgery as the recurrent fistula did not heal sufficiently after 3 weeks of EVAC therapy. Two patients developed stenosis and were successfully treated with dilatations. One patient treated with RSC alone showed persistent EP after 5 weeks. Conclusion: EVAC in pediatric patients is technically feasible and a promising method to treat EP, regardless of the underlying cause. EVAC therapy can be terminated as soon as local inflammation and C-reactive protein levels decrease, even if the mucosa is not healed completely at that time. A promising subsequent treatment is RSC. An earlier switch to RSC can substantially reduce the need of anesthesia during subsequent treatments. Our findings indicate that EVAC is more effective than RSC alone. In some cases, EVAC can be used to improve the tissues condition in preparation for a re-do surgery. At 1 year after therapy, all but one patient demonstrated sufficient weight gain. Further prospective studies with a larger cohort are required to confirm our observations from this small case series.
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Affiliation(s)
- Laura Antonia Ritz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Mohammad Samer Hajji
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Tobias Schwerd
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Sibylle Koletzko
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Eberhard Lurz
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Jochen Hubertus
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilian-University of Munich, Munich, Germany
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21
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Geraedts ACM, Broos PPHL, Gronenschild MHM, Custers FLJ, Hulsewe KWE, Vissers YLJ, Loos ERD. Minimally Invasive Approach to Esophageal Perforation after Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Report of 2 Cases. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:313-316. [PMID: 32919448 PMCID: PMC7553825 DOI: 10.5090/kjtcs.19.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/16/2020] [Accepted: 02/22/2020] [Indexed: 11/16/2022]
Abstract
Esophageal perforation after endoscopic ultrasound-guided fine-needle aspiration for mediastinal staging is a rare but severe complication. We report 2 cases of patients with esophageal perforation who were treated using video-assisted thoracoscopic surgery in combination with esophageal stenting. Through these cases, the feasibility of minimally invasive thoracic surgery was evaluated.
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Affiliation(s)
- Anna C M Geraedts
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.,Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter P H L Broos
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | | | - Frank L J Custers
- Department of Respiratory Medicine, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewe
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
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22
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Mediastinal fluid as a predictor for esophageal perforation as the cause of pneumomediastinum. Emerg Radiol 2020; 28:233-238. [PMID: 32813157 DOI: 10.1007/s10140-020-01841-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/12/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Pneumomediastinum is not an uncommon finding on emergency CTs and is seen in a variety of settings, including acute trauma, recent repeated emesis and recent thoracic surgery, and after EGD (Kouritas et al. J Thorac Dis 7(Suppl 1):S44-S49, 2015). The purpose of this study was to examine cases of CT pneumomediastinum for distinguishing features which could support or exclude esophageal injury as a cause, which in turn could help guide evaluation of these patients. METHODS CT chest scans showing pneumomediastinum performed in the emergency department between January 2013 and December 2018 were included. The presence or absence of fluid within the mediastinal compartments was correlated with esophageal perforation and subdivided into the clinical scenarios of trauma, suspected Boerhaave's syndrome, recent surgery or EGD, and other. Accuracy of this finding was compared with fluoroscopic esophagography. RESULTS Twenty-two cases of esophageal perforation were identified out of a total of 324 included cases. The cases were subdivided into four categories: trauma, suspected Boerhaave syndrome, suspected iatrogenic perforation from recent procedure or surgery, and other. Two hundred fourteen cases of pneumomediastinum occurred in the setting of trauma, and 2 had esophageal perforation. Both showed mediastinal fluid. Twenty-two cases had mediastinal fluid without perforation. Seventeen cases of pneumomediastinum occurred in the setting of suspected Boerhaaves, and 3 had esophageal perforation. Every case with esophageal perforation had mediastinal fluid, and every case without perforation had no mediastinal fluid. Nine cases of pneumomediastinum occurred in the setting of suspected iatrogenic perforation after recent surgery or procedure. Six cases had esophageal perforation, and 5 of these had mediastinal fluid. All three cases without perforation also had mediastinal fluid. Eighty-six cases were classified as other and included a variety of clinical histories. This category contained 8 esophageal perforations, 7 of which had mediastinal fluid. One case of mediastinal fluid was not associated with esophageal perforation in this category. CONCLUSION The presence of mediastinal fluid, specifically within the visceral compartment, strongly suggests esophageal injury, and its absence strongly argues against it. An important caveat is in the setting of recent surgery, in which mediastinal fluid can be seen normally. An esophagography study can supplement the evaluation if there is a discrepancy between the clinical suspicion and the original CT findings.
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23
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Lambert RG, Angmorterh SK, Benjamin MB, Gonzalez MR, Aboagye S, Ofori EK. Esophageal perforation by tilapia fish bone ingestion - A case report. Int J Surg Case Rep 2020; 71:23-26. [PMID: 32446226 PMCID: PMC7242979 DOI: 10.1016/j.ijscr.2020.04.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/10/2020] [Accepted: 04/19/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Esophageal perforation (EP) is a rare, severe and challenging surgical emergency which can be caused by several factors. This report presents the case of a patient with EP caused by ingestion of a Tilapia fish bone. PRESENTATION OF CASE A 41-year-old male patient presented with a six-day history of painful right-sided neck swelling, associated with a progressive dysphagia, regurgitation, fever and chills. Physical examination revealed an axillary temperature of 39 °C and a subcutaneous emphysema in the neck. Cervical spine x-ray and ultrasound scan revealed a neck foreign body with abscess. The case was managed by a right cervicotomy. DISCUSSION Despite over 20-years of clinical experience in Ghana, this was the first case of EP caused by a 2 cm long Tilapia fish bone, to be treated by the authors. This is significant because tilapia consumption is very popular in Ghana and it would be predicted that such cases would be more common. It is suggested that such cases do occur more frequently but are not reported to hospitals due to cultural-spiritual beliefs. CONCLUSION Ingestion of Tilapia fish bones can cause significant damage to the esophagus and Tilapia should be consumed with care. Ultrasound is a very useful tool with high diagnostic accuracy for EP. Further studies are needed to establish the prevalence of EP from fish bone ingestion in Ghana and the factors accounting for the mismatch between the high consumption of Tilapia across the population and the low occurrence of patients presenting with EP from fish bone ingestion.
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Affiliation(s)
- Radisnay Guzman Lambert
- Department of Surgery, School of Medicine, University of Health and Allied Sciences (UHAS), Ho, Ghana
| | - Seth Kwadjo Angmorterh
- Department of Medical Imaging, School of Allied Health Sciences, University of Health and Allied Sciences (UHAS), Ho, Ghana.
| | | | | | - Sonia Aboagye
- Department of Speech, Language & Hearing Sciences, School of Allied Health Sciences, University of Health and Allied Sciences (UHAS), Ho, Ghana
| | - Eric Kwasi Ofori
- Department of Medical Imaging, School of Allied Health Sciences, University of Health and Allied Sciences (UHAS), Ho, Ghana
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24
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Abila AW, Nditika ME, Kipkemoi RD, Ondigo S, Khwa-Otsyula BO. Primary repair of esophageal perforation: Case report. Int J Surg Case Rep 2020; 71:159-162. [PMID: 32454452 PMCID: PMC7248577 DOI: 10.1016/j.ijscr.2020.04.026] [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: 02/18/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mortality after esophageal perforation is high irrespective of the treatment modality. The rarity of traumatic esophageal perforations has made it difficult to conduct comprehensive studies that can answer pertinent questions with regard to management. PRESENTATION OF CASE We report a case of through and through thoracic esophageal injury caused by an assailant's arrow in a young physically active male adult. Diagnosis was made on-table. He successfully underwent primary repair of the esophageal injury 16 h post injury via a left thoracotomy. Recurrent lung collapse and pleural effusion was managed with tube thoracostomy and chest physiotherapy. DISCUSSION Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion. CONCLUSION Primary repair of traumatic injury to a healthy esophagus is feasible for cases diagnosed early and without significant mediastinal contamination as in our case. Associated injuries are more likely in such cases to lead to increased morbidity and prolonged hospital stay and must be handled carefully.
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Affiliation(s)
- Akello W Abila
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Faculty of Health Sciences, Egerton University, Nakuru, Kenya.
| | - Mburu E Nditika
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya
| | - Rono D Kipkemoi
- Faculty of Health Sciences, Egerton University, Nakuru, Kenya
| | - Stephen Ondigo
- Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barasa O Khwa-Otsyula
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
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25
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Lampridis S, Mitsos S, Hayward M, Lawrence D, Panagiotopoulos N. The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions. J Thorac Dis 2020; 12:2724-2734. [PMID: 32642181 PMCID: PMC7330325 DOI: 10.21037/jtd-19-4096] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.
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Affiliation(s)
- Savvas Lampridis
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Sofoklis Mitsos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Martin Hayward
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - David Lawrence
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Nikolaos Panagiotopoulos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
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Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold. Case Rep Emerg Med 2020; 2020:4963493. [PMID: 32099689 PMCID: PMC7040390 DOI: 10.1155/2020/4963493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022] Open
Abstract
Descending necrotizing mediastinitis and pharyngeal perforation are uncommon complications of pharyngitis that are associated with high morbidity and mortality. This case report describes a previously healthy 18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. The patient had a complicated hospital course including multiple operative interventions, abscess formation, and development of pericardial and pleural effusions. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. It is important to recognize descending necrotizing mediastinitis as a clinical entity that may result from oropharyngeal infections as early intervention significantly decreases subsequent complications and mortality. Furthermore, pharyngeal perforation is an extremely rare complication which requires either CT with oral contrast or esophagram for diagnosis.
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Bae SH. Transcatheter embolization of the esophagomediastinal fistula with N-butyl cyanoacrylate glue: A case report. Int J Surg Case Rep 2019; 65:73-77. [PMID: 31689633 PMCID: PMC6838795 DOI: 10.1016/j.ijscr.2019.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 01/11/2023] Open
Abstract
Acute mediastinitis with esophageal perforation is a fatal disease. Esophagomediastinal fistula due to esophageal perforation is difficult to curable treatment. Successful embolization of the esophagomediastinal fistula with N-butyl cyanoacrylate.
Introduction Acute mediastinitis with esophageal perforation is a very fatal condition and must be treated promptly. Esophagomediastinal fistula is a rare complication of acute mediastinitis with esophageal perforation. There are many treatment options such as surgery or endoscopic treatment, but it is most important to start treatment immediately. Presentation of case A 69-year-old female presented with chest pain and fever. Contrast enhanced chest computed tomography was compatible with acute mediastinitis and esophageal perforation. Esophagography revealed esophagomediastinal fistula in the upper esophagus. Endoscopic clipping with fibrin was failed and endoscopic vacuum therapy (EVT) was not effective for esophagomediastinal fistula. We performed the successful transcatheter embolization of the esophagomediastinal fistula with N-butyl cyanoacrylate (NBCA) glue. Discussion There are many considerations in the treatment of acute mediastinitis with esophageal perforation, but surgery is the mainstay of treatment. Recently non operative management is appropriate in certain well-defined situations. Like our case patients, non-operative management may be considered if the diagnosis is delayed and the surgical treatment period is missed. Currently, endoscopic treatment such as covered stenting, clipping and application of fibrin glue are useful and a less invasive rather than surgical treatment. However, if endoscopic or surgical procedure are not possible, we considered transcatheter NBCA glue embolization. Conclusion Transcatheter embolization with NBCA glue was proven to its effectiveness as an alternative therapeutic option in the treatment of esophagomediastinal fistula which endoscopic or surgical treatment are impossible or fails.
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Affiliation(s)
- Suk Hyun Bae
- Department of Radiology, Inje University College of Medicine, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang, 10380, Republic of Korea.
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Matsumoto R, Sasaki K, Omoto I, Noda M, Uchikado Y, Arigami T, Kita Y, Mori S, Maemura K, Natsugoe S. Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report. Surg Case Rep 2019; 5:152. [PMID: 31650260 PMCID: PMC6813377 DOI: 10.1186/s40792-019-0717-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/27/2019] [Indexed: 01/11/2023] Open
Abstract
Background Spontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients. Case presentation A 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH2O and at − 20 cmH2O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day. Conclusion Conservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.
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Affiliation(s)
- Ryu Matsumoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
| | - Itaru Omoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Masahiro Noda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
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Chinn M, Biedrzycki L. Prehospital Laryngeal Tube Airway Device Placement Resulting in Hypopharyngeal Perforation: A Case Report. PREHOSP EMERG CARE 2019; 24:590-594. [PMID: 31550188 DOI: 10.1080/10903127.2019.1671565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A 26-year-old female patient presented in cardiac arrest from presumed opioid overdose. An Ambu King LTS-D laryngeal device was placed by EMS providers for airway management during the resuscitation. There was no documented difficulty with placement and breath sounds and waveform capnography were consistent with appropriate placement. The resuscitation was terminated on scene after extensive resuscitative efforts by the EMS crew. Upon autopsy of the patient, it was discovered that the laryngeal tube device had caused a deep 5 cm perforation to the left piriform recess. The laryngeal tube had bent and was pushed into the perforation in the piriform recess; had the patient had regain of spontaneous circulation this could have caused significant morbidity. Laryngeal tube airway devices have shown increased usage in healthcare settings, in particular in the prehospital arena. Studies of these airway devices have shown they have quick insertion times, high success rates, and low complications. Tongue swelling and minor trauma are common complications of laryngeal tube airway devices. The case report describes a rare, yet potentially life-threatening, complication of laryngeal tube airway device placement- hypopharyngeal injury. If unrecognized, this injury could lead to serious complications. Providers should be aware of the common and uncommon injuries that are associated with prehospital laryngeal tube airway device placement.
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Lenvatinib Administered via Nasogastric Tube in Poorly Differentiated Thyroid Cancer. Case Rep Endocrinol 2019; 2019:6831237. [PMID: 31641541 PMCID: PMC6766666 DOI: 10.1155/2019/6831237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/02/2019] [Indexed: 11/18/2022] Open
Abstract
Background The tyrosine kinase inhibitors (TKIs) are indicated for the treatment of locally advanced or metastatic progressive thyroid carcinoma (CDT), refractory to radioactive iodine. The following report describes the efficacy of lenvatinib administered through a nose-gastric tube (SNG) in a patient affected with a poorly differentiated thyroid carcinoma (PDTC) which determined a stenosis of the esophagus. Material and Methods A patient was followed up for papillary thyroid carcinoma follicular variant (T3NxMx), subjected to total thyroidectomy and treated with iodine-131 radio metabolic therapy. Two years after surgery, following the onset of dysphonia and dysphagia, patient was submitted to a computed tomography (CT) scan of the neck that showed the presence of a lesion of 6 × 2.5 × 3.5 cm, which determined trachea deviation and cervical esophagus compression. The biopsy indicated the presence of PDTC, triggering tracheal lumen reduction and sub-stenosis of the cervical esophagus for an ab-extrinsic compression. A nose-gastric tube (SNG) was placed and lenvatinib was started at a dose of 20 mg/day, administered via this probe after opening the capsules and diluting the drug in 10 ml of saline solution. Results One month later, CT showed a significant cervical lesion reduction. Bronchoscopy confirmed tracheal infiltration, but the residual caliber was improved from 50% to 75%. At the esophagogastroduodenoscopy (EGDS), the sub stenosis of the cervical esophagus was no longer appreciated; however, a double perforation of the esophagus was found, without fistula. Conclusion Lenvatinib therapy is effective also when administered via SNG. Our result is of particular relevance in the management of thyroid cancer patients, especially in the presence of subjects unable to swallow. Further studies are needed to validate the administration of lenvatinib by SNG, in order to extend the indications to this alternative administration way, beside the oral one.
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Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series. Ann Med Surg (Lond) 2019; 44:62-67. [PMID: 31316769 PMCID: PMC6611994 DOI: 10.1016/j.amsu.2019.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries. Materials and methods A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level. Results Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects. Conclusion Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome. Sixteen patients were treated for esophageal injuries at the PRTH. Two patients suffered blunt esophageal trauma and 14 patients had penetrating trauma to the esophagus. Most patients had a prompt diagnosis of traumatic esophageal perforation, while 3 patients had a delayed diagnosis. Regarding esophageal location, of the 16 patients, 9 presented cervical, 6 thoracic, and 1 abdominal esophageal injury. Only 2 deaths occurred among our 16 patients, including 1 in delayed diagnosed subjects.
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32
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Burr NE, Everett SM. Management of benign oesophageal strictures. Frontline Gastroenterol 2019; 10:177-181. [PMID: 31205660 PMCID: PMC6540277 DOI: 10.1136/flgastro-2018-101075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Benign oesophageal strictures are an important gastrointestinal condition that can cause substantial morbidity. There are many different aetiologies and each case needs careful evaluation and individualised treatment. Management usually involves targeting therapy to the underlying cause, but oesophageal dilatation is an important part of the algorithm. The recent British Society of Gastroenterology guidelines provide advice on the use of dilatation for benign strictures and cover patient preparation, the dilatation procedure and disease-specific considerations. This article provides a summary of the key messages from the guidelines and applies them to routine clinical practice. It also includes practical advice on the clinical assessment, investigation and management of benign oesophageal strictures and gives an approach to the management of refractory strictures. Areas where evidence is sparse and further research is needed are highlighted.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Simon M Everett
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
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33
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Pomeranz K, Mohr N. Esophageal Perforation After Failed Prehospital Intubation. Clin Pract Cases Emerg Med 2018; 2:255-257. [PMID: 30083646 PMCID: PMC6075498 DOI: 10.5811/cpcem.2018.6.38088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/18/2018] [Accepted: 06/14/2018] [Indexed: 11/11/2022] Open
Abstract
Esophageal perforation is a rare condition with high rates of mortality if not recognized quickly. This is a case of a 67-year-old male with a self-inflicted gunshot wound to the head. He had one failed intubation attempt prior to arrival. On postmortem autopsy it was discovered that in addition to significant head trauma he also had an esophageal and gastric rupture.
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Affiliation(s)
- Kaila Pomeranz
- University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa
| | - Nicholas Mohr
- University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa
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34
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Still S, Mencio M, Ontiveros E, Burdick J, Leeds SG. Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks. Ann Thorac Cardiovasc Surg 2018; 24:173-179. [PMID: 29877217 PMCID: PMC6102603 DOI: 10.5761/atcs.oa.17-00107] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. METHODS We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. RESULTS In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. CONCLUSION Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.
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Affiliation(s)
- Sasha Still
- Department of Surgery, Baylor University Medical Center at Dallas, Texas, USA
| | - Marissa Mencio
- Department of Surgery, Baylor University Medical Center at Dallas, Texas, USA
| | | | - James Burdick
- Department of Gastroenterology, Baylor University Medical Center at Dallas, Texas, USA
| | - Steven G Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center at Dallas, Texas, USA
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35
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Ebrahim A, Still S, Schwartz G. Thoracoscopic management of a mediastinal abscess caused by extra-esophageal migration of a metal brush bristle. Proc (Bayl Univ Med Cent) 2018; 31:192-193. [PMID: 29706816 DOI: 10.1080/08998280.2017.1416240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 01/02/2023] Open
Abstract
Foreign body perforations of the esophagus are infrequent events yet have the potential to cause significant morbidity and mortality. The clinical consequences of esophageal perforation by a foreign body are dependent upon the severity of infectious sequelae and damage to surrounding structures by the foreign object itself, as detailed in previous published reports. We describe the thoracoscopic management of a mediastinal abscess caused by a foreign body perforation in a patient with an intact esophagus.
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Affiliation(s)
- Ahmed Ebrahim
- Texas A&M Health Science Center, College of Medicine, Dallas, Texas
| | - Sasha Still
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas
| | - Gary Schwartz
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, Texas
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36
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Conservative Management of an Iatrogenic Esophageal Tear in Kenya. Case Rep Surg 2015; 2015:102540. [PMID: 26257974 PMCID: PMC4516850 DOI: 10.1155/2015/102540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/28/2015] [Accepted: 07/01/2015] [Indexed: 11/25/2022] Open
Abstract
Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis.
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Liyanage IK, Navinan MR, Pathirana ACA, Herath HRIS, Yudhishdran J, Fernandopulle N, Kulatunga A. A case of methyl ethyl ketone peroxide poisoning and a review of complications and their management. J Occup Med Toxicol 2015; 10:26. [PMID: 26236387 PMCID: PMC4521457 DOI: 10.1186/s12995-015-0071-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 07/28/2015] [Indexed: 01/21/2023] Open
Abstract
Methyl Ethyl Ketone Peroxide (MEKP) is a highly toxic clear liquid used as a solvent. It is a strong oxidizing agent and a corrosive. Acute and chronic toxicity can occur as an occupational hazard. Ingestion is associated with corrosive burns leading to stricture formation, inhalational pneumonitis, acidosis, liver failure and renal failure. In this paper we present a case of a young patient who intentionally ingested MEKP. The patient developed multiple complications including proximal intestinal obstruction, acidosis and acute kidney injury. He was managed conservatively and recovered after a prolonged hospital stay. He had multiple inflammatory strictures on esophageal endoscopy, which improved over 3–6 moths.
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Affiliation(s)
- Isurujith K Liyanage
- National Hospital of Sri Lanka, Colombo 10, Sri Lanka ; Department of Pharmacology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
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