Surgical management of primary aortic thrombus in thoracic aorta

Background

Primary aortic thrombus (PAT) in the absence of underlying aortic pathology such as atherosclerosis or aneurysm is quite rare and presents with various symptoms related to distal embolization. Treatment options include anticoagulation alone, open surgical thrombectomy, endovascular repair, and a combination of these approaches. The optimal management strategy remains controversial.

Methods

Between 2016 and 2020, 10 patients (6 females; mean age, 49.1 years) presented to our institution with PAT in the thoracic aorta. All 10 patients were active tobacco users, and 6 patients were found to have an underlying hypercoagulable state. Locations of the PAT included the ascending aorta in 4 patients, the descending thoracic aorta in 3 patients, and the aortic root, aortic arch, and thoracoabdominal aorta in 1 patient each. At presentation, 2 patients had developed myocardial infarction, and 2 others had cerebral infarction. All patients but 1, who was managed medically for PAT, underwent open surgical thrombectomy via either sternotomy or left thoracotomy. Concomitant procedures included coronary artery bypass grafting in 2 patients and pulmonary thromboembolectomy in 1 patient. There were no operative deaths. During a median follow-up of 18 months, 2 patients developed recurrent PAT, owing primarily to poor compliance with anticoagulation. One patient required redo open thrombectomy. Two patients had mesenteric ischemia necessitating small bowel resection.

Conclusions

Open surgical thrombectomy of the thoracic aorta can be performed with low mortality and morbidity; however, PAT can recur, especially in patients who have difficulty managing anticoagulation.

A rare case of combined black esophagus and stomach: a case report

Background

Black esophagus is a relatively rare phenomenon that seems to occur in a morbid patient population, however, this entity may be more common than we currently know. Additionally, black esophagus may even be reversible in some cases. There are far fewer cases of black stomach described. The exact etiology and cause are less well known but may have similar risk factors as black esophagus. These disease pathologies are devastating to the patients they affect and can pose clinical challenges for the providers that encounter them.

Case Description

This case report details our experience with a moribund patient who was found to have extensive pneumomediastinum and gastric perforation secondary to black esophagus and black stomach. This was diagnosed on endoscopy following imaging that showed extensive pneumomediastinum. Initially the intent was to temporize the disease process in an attempt to stabilize the patient however at the time of diagnosis, the degree of ischemia had led to perforation and the disease process was not reversible or recoverable. He ultimately expired after comfort directed care measures were put in place.

Conclusions

To the best of our knowledge, this case will be the first reported in current literature and will hopefully shed some light on this unusual and devastating pathology.

Endoscopic tissue approximation in clinical practice and the OverStitch device: a narrative review

Objective

The current article describes modern endoscopic technologies that allow for advanced endoscopic tissue approximation and suturing. These technologies include such devices as through the scope and over the scope clips, endoscopic suturing OverStitch device and through the scope suturing X-Tack device.

Background

Since the original introduction of the diagnostic endoscopy, progress in the field has been astonishing. Over the past several decades endoscopy has made numerous advancements allowing for a minimally invasive mechanism to treat life threatening conditions such as gastrointestinal (GI) bleeding, full thickness injuries, as well as chronic medical conditions such as morbid obesity and achalasia.

Methods

A narrative review of all relevant and available literature on endoscopic tissue approximation devices over the last 15 years ago was conducted.

Conclusions

Multiple new devices, including endoscopic clips and endoscopic suturing devices, have been developed for endoscopic tissue approximation that allow advanced endoscopic management of a wide variety of GI tract conditions. It is critical for practicing surgeons to actively participate in the development and use of these new technologies and devices in order to maintain leadership in the field, hone expertise, and to drive innovation. Further research in minimally invasive applications for these devices is needed as they continue to be refined. This article provides a general overview of the devices available and their clinical applications.

Endoscopic interventions in the management of the gastroesophageal reflux: a narrative review

Objective

The goal of this review is to describe and compare current and historic endoscopic interventions for gastroesophageal reflux disease (GERD).

Background

The prevalence of GERD affects a large portion of the population. Nearly half of those treated with conservative medical therapy have refractory symptoms of reflux. Surgery is a durable solution for reflux, however, it is an invasive procedure and classical fundoplication comes with its own share of side effects and complications. In this review, we will discuss the advantages and pitfalls of available endoscopic procedures, and describe medium-term (up to several years) outcomes.

Methods

Literature search of the PubMed database, including the years 1999 to 2021 was performed with search terms to reflect the described devices in the review. Individual review of retrieved references was performed for additional sources. Thorough review of societal guidelines was also conducted in preparation of this manuscript.

Conclusions

Gastroesophageal reflux is a common problem in the United States and worldwide, and its prevalence continues to increase. Within the last two decades, there have been several new endoscopic modalities introduced for the management of this disease. Here, we present a focused review of endoscopic gastroesophageal reflux interventions, its advantages and pitfalls. Surgeons focusing on the foregut conditions should be aware of these procedures as they may provide a minimally invasive option for the selected group of patients.