Rare Bilateral Massive Pneumothorax, Pneumomediastinum, Pneumoperitoneum, and Diffuse Subcutaneous Emphysema During Colonoscopy: Multidisciplinary Collaboration: Case Report

THORACOABDOMINAL PNEUMATOSIS COMPLICATING A COLONOSCOPY

ASGE review of adverse events in colonoscopy

Objective To investigate the value of endoscopic submucosal tunnel resection of large area esophageal mucosal lesions. Methods Between January 2015 and June 2017, 18 patients with large area esophageal high grade epithelial neoplasia confirmed by pathology were collected.All the patients were divided into two groups using random number table method.The patients in control group were treated with traditional endoscopic submucosal dissection(ESD), and the patients in test group were treated with submucosal tunnel resection.The therapeutic effect of the two groups were observed and compared. Results The total removal rate of the tunnel group was 100%.In the classic ESD group, 1 case was fractionally excised by a snare, and the total removal rate was 88.9%.The postoperative pathological results showed that the lateral cutting edge and basal cutting edge of the excised specimen were complete in the two groups of lesions.The maximum diameters in tunnel group and classic ESD group were(7.5±3.2)cm and(8.3±1.4)cm respectively, and the difference of the lesion resection area was not statistically significant between the two groups(P>0.05). The operation times in tunnel group and classic ESD group were(50.4±28.0)min and(82.5±29.7)min.There was significant difference between the two groups in lump-sum slice and average operation time(P<0.05). There was no subcutaneous emphysema in tunnel group, and the stripping process has no ring muscle injury.In classic ESD group, there were 2 cases of mediastinal and subcutaneous emphysema, of which 1 case of small perforation was applied with titanium clip, and the emphysema disappeared by itself 3 days after operation.There was a fever of 1 in 24 h after operation, accompanied by elevated white blood cell, and the symptom was completely relieved in the second day after treatment.The incidence of complications between the two groups has significant statistical significance(P<0.05). Conclusion Using submucosal tunnel technology for the treatment of large area esophageal mucosal lesion is a safe and effective method.It can effectively reduce the difficulty of endoscopic lesion resection, shorten the operation time, and reduce the complications. Key words: Esophagus; High grade epithelial neoplasia; Endoscopic submucosal tunnel technique; Endoscopic mucosal dissection

Tracheobronchial injury (TBI) associated with penetrating injuries has various clinical symptoms and often requires urgent surgical repair. A tracheal tube and/or placement of a drainage tube combined with multidetector computed tomography (CT) could be used to manage TBI without surgical repair in eligible patients. In this case report, we describe an 86-year-old woman with subcutaneous emphysema and suspected TBI caused by three knife wounds in her neck. After tracheal intubation at a local hospital, she was transferred to our hospital. On admission, she was diagnosed with subcutaneous and mediastinal emphysema due to TBI, as well as bilateral pneumothorax. We adjusted the position of the tracheal tube to a distal location from the TBI, and placed bilateral thoracic drainage tubes by referring to the CT images taken on admission and during the follow-up. The follow-up CT images revealed healing of the TBI. She did not show any worsening of her symptoms and she was successfully extubated on day 10 of her hospital stay. On day 18, she was considered self-reliant and was transferred to her previous hospital. Based on our experience in this case, we believe that ventilation with appropriate sedation, placement of a tracheal tube, and drainage are important conservative therapies for TBI caused by penetrating injuries. CT is also useful for evaluating the status of TBI.

Background Acute gastric dilatation is a rare but serious condition that can lead to ischemia, necrosis, and perforation of the stomach. This case report describes a 21-year-old female patient with an eating disorder who developed acute gastric necrosis and perforation following a binge-eating episode. Case Presentation A 21-year-old female with a history of eating disorder not otherwise specified (EDNOS) presented to the referring hospital with severe abdominal pain and on physical examination the suspicion of subcutaneous emphysema. Chest radiography showed the subcutaneous emphysema and also revealed a pneumothorax and a possible pneumomediastinum. Her condition deteriorated, prompting a CT scan that showed extensive pneumomediastinum, subcutaneous emphysema, a massively distended stomach, and portal venous air. The patient was transferred to our hospital, where further imaging confirmed these findings. After further deterioration and a suspected perforation, a second CT scan was performed, confirming a gastric perforation with extensive free fluid in the abdomen. An exploratory laparotomy revealed gastric perforation with necrosis and peritonitis, necessitating a sleeve gastrectomy. Outcome The patient underwent successful surgery with resection of necrotic gastric tissue and sleeve gastrectomy. Postoperative recovery was uncomplicated, and follow-up showed no further complications. Early surgical intervention was crucial in managing this life-threatening condition. Conclusion Acute gastric dilatation and subsequent necrosis are rare but potentially fatal complications in patients with eating disorders. Prompt recognition and surgical intervention are essential to reduce morbidity and mortality.

要旨 自然気胸の多くは片側であり重症例は少ない。しかし緊張性気胸および両側気胸は診断および介入が遅れると致死的となりうる。我々は，発症から1時間も経たないうちに心肺停止となり救急搬送された両側緊張性気胸の14歳男児の症例を経験した。本例では心肺蘇生により自己心拍は再開したが，頻脈・低血圧が遷延し，胸部X線写真で両側緊張性気胸と診断し胸腔ドレナージを行った。しかし，直後に撮影した頭部CTで低酸素脳症を呈し，その後意識障害が遷延し自発呼吸はなく，第12病日に平坦脳波を確認し，最終的にPCPC（pediatric cerebral performance category）6となった。両側気胸は気管支喘息発作と混同されやすく，アナフィラキシーも合わせて鑑別する必要がある。緊張性気胸には片側だけでなく，稀に両側があり，その診断は身体所見のみでは困難なため，近年有用性が報告されている超音波検査を併用し，可及的速やかに胸部X線写真を撮るべきである。

Endoscopic submucosal dissection (ESD) is efficient for en bloc resection of large colorectal tumors. However, it has several technical difficulties, because the wall of the colon is thin and due to the winding nature of the colon. The main complications of ESD comprise postoperative perforation and hemorrhage, similar to endoscopic mucosal resection (EMR). In particular, the rate of perforation in ESD is higher than that in EMR. Perforation of the colon can cause fatal peritonitis. Endoscopic clipping is reported to be an efficient therapy for perforation. Most cases with perforation are treated conservatively without urgent surgical intervention. However, the rate of postoperative hemorrhage in ESD is similar to that in EMR. Endoscopic therapy including endoscopic clipping is performed and most of the cases are treated conservatively without blood transfusion. In blood examination, some degree of inflammation is detected after ESD. For the standardization of ESD, it is most important to decrease the rate of perforation. Adopting a safe strategy for ESD and a suitable choice of knife are both important ways of preventing perforation. Moreover, appropriate training and increasing experience can improve the endoscopic technique and can decrease the rate of perforation. In this review, we describe safe procedures in ESD to prevent complications, the complications of ESD and their management.

Injection of mesna into submucosal layers was recently reported to chemically soften connective tissue and facilitate the gastric endoscopic submucosal dissection (ESD) procedure. This study aimed to evaluate the safety and feasibility of similarly using mesna for esophageal ESD (mesna ESD). We performed mesna ESD in 20 consecutive patients with superficial esophageal squamous cell carcinomas (SESCCs). To do this, a submucosal fluid cushion was initially formed using sodium hyaluronate, and the esophageal lesion was circumferentially isolated with a short blade needle-knife. Mesna solution was then injected into the submucosal layer, which was dissected mechanically by cleavage using the tip of a cap-fitted endoscope. The number of electrosurgical incisions was recorded by computer software in real time. The data from 20 conventional ESD procedures without mesna (consecutive 10 SESCCs pre and post the 20 consecutive mesna ESD) were used for comparison to evaluate the mesna ESD. The mesna ESDs achieved en bloc and R0 resection success rates of 100 and 95%, respectively. There was no perforation or uncontrollable hemorrhage during and after mesna ESD, and the median procedural time of submucosal dissection was significantly less with mesna ESD than with conventional ESD (median; 8 vs. 15min, P<0.05). There were also significantly fewer electrosurgical incisions made during the mesna ESD than with conventional ESDs (median; 65 vs. 183 times, P<0.01). Mesna ESD for SESCCs is a safe procedure with the potential to facilitate esophageal ESD.

Objective To investigate the effect and safety of endoscopic submucosal dissection (ESD) for treating rectal laterally spreading tumor (LST) extending to the dentate line. Methods Data of 45 cases of rectal LSTs extending to the dentate line were collected, which were treated by ESD in endoscopy center in Hubei Tumor Hospital from Oct 2012 to Oct 2014. The lesion types of LST, size, procedure time, the en-bloc complete resection rate, complications, pathological diagnosis and fellow-up were retrospective analyzed. Results Among 45 LSTs in the rectum, average size of the lesion was 28 mm. en bloc R0 curative resection rate was 100%. The procedure time of ESD was 45 min~240 min, The average procedure time was (100±25) min. Delayed bleeding occurred in six patients (13.3%), all of which underwent successful endoscopic hemostasi. Perforation developed in 2 cases (4.4%), the perforation was cured by hemostat and conservative medical management. Thirty-seven cases were diagnosed post-surgically as low grade intraepithelial neoplasia and eight cases as high grade intraepithelial neoplasia, all of the lesion invasion was confined to mucosal layer. The average time of the follow-up was 30.2 months (10~46 months).None of the cases had recurrent or residual, and the anal defecation function was normal. Conclusions ESD was an effective and safe treatment for rectal LSTs for its high resection rate and low recurrence rate. ESD had no influence on the anal defecation function. Key words: Rectal neoplasms; Endoscopes; Laterally spreading tumors; Endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that allows curative treatment of early gastric cancer (EGC) in selected patients. To report our initial experience with ESD. Analysis of prospective data from 16 patients aged 61 to 84 years, who underwent ESD between December 2011 and June 2014. Tumor type, operative time, hospitalization length, oncologic outcomes, complications and short-term follow up were registered. En-block resection was achieved in all cases. The median operative time was 135 min (range: 50-320 min). Specimens' median size was 3.5 cm (range: 3-10). All the resections were R0. In 14 patients ESD was considered curative. In two patients, ESD was considered potentially non-curative due to the presence pathological risk factors for lymph-node metastases in the biopsy specimen. Both patients underwent laparoscopic gastrectomy with lymph-node dissection. There was one case of gastric wall perforation that was repaired by laparoscopic suture. There was no mortality. The median follow-up time was 15 months (range: 2-30 months). ESD is a feasible and safe procedure in our institution with good results in this initial experience.

Objective To investigate the clinical efficacy of endoscopic resection, laparoscopic resection and open resection in the treatment of gastric stromal tumor (GIST). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 254 GIST patients who were admitted to the First Affiliated Hospital of Army Medical University between January 2007 and June 2017 were collected. The endoscopic submucosal dissection (ESD) and laparoscopic or open wedge resection of GIST were performed according to the patients′ conditions. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy and survival up to June 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery situations: of 254 patients, 112 underwent ESD, including 111 with successful operation and 1 with intraoperative conversion to open surgery due to excessive bleeding-induced blurred operating view, 93 underwent successful laparoscopic wedge resection of GIST and 49 underwent successful open wedge resection of GIST. The operation time, volume of intraoperative blood loss, time for initial fluid diet intake, duration of hospital stay and hospital expenses were respectively (75±21) minutes, (6.9±0.5)mL, (2.8±0.9)days, (5.5 ± 0.2)days, (22 167±1 364)yuan in patients with ESD and (137±65)minutes, (48.1±2.6)mL, (3.9±1.4)days, (8.3 ± 2.2)days, (32 937±1 823)yuan in patients with laparoscopic operation and (168±60)minutes, (157.2±10.3)mL, (5.8±1.7)days, (11.3±3.5)days, (38 462±1 961) yuan in patients with open operation. Two patients with ESD had subcutaneous emphysema and didn′t receive special treatment, and then emphysema disappeared after 2 days. No complication was detected in patients with laparoscopic or open operations. (2) Postoperative pathological examination: tumor diameter in patients with ESD, laparoscopic operation and open operation was respectively (2.6±1.6)cm, (6.1±2.2)cm and (6.4±2.3)cm. The cases with positive CD117, discovered on GIST-1 (DOG1), CD34 and smooth muscle actin (SMA) were 106, 105, 86, 17 with ESD and 89, 87, 59, 11 with laparoscopic operation and 46, 47, 30, 8 with open operation, respectively. The extremely low risk, low risk, medium risk and high risk were respectively detected in 67, 42, 3, 0 patients with ESD and 16, 36, 23, 18 patients with laparoscopic operation and 7, 20, 14, 8 in patients with open operation. (3) Follow-up and survival situations: 210 of 254 patients were followed up for 6.0-120.0 months, with an average time of 36.0 months, including 86 with ESD, 82 with laparoscopic operation and 42 with open operation. During the follow-up, of patients with ESD, 3 patients with medium risk respectively received imatinib therapy for 7.0 months, 1.5 years and 2.0 years, and postoperative gastroscopy reexaminations every 6 months, without tumor recurrence; 81 with extremely low risk and low risk received postoperative gastroscopy reexaminations every 6 months and didn′t receive targeted therapy, without tumor recurrence; 2 died of non-stromal tumor. The postoperative average survival time, 1-, 3- and 5-year survival rates were respectively 56.3 months, 98.8%(81/82), 91.5%(75/82), 74.4% (61/82) in patients with laparoscopic surgery and 52.4 months, 97.6%(41/42), 85.7% (36/42), 81.0%(34/42) in patients with open surgery. Conclusions According to patients′ conditions, endoscopic resection, laparoscopic resection and open resection are safe and feasible in the treatment of GIST. Endoscopic resection of GIST should be selectively applied to patients with smaller diameter, with advantages of lower hospitalization expenses and better long-term prognosis. Key words: Gastric neoplasms; Stromal neoplasms; Endoscopic submucosal dissection; Surgical procedures, operative; Open resection; Laparoscopy

Complex colovesicular fistula: A severe complication caused by biliary stent migration

While colonoscopy is generally regarded as a safe procedure, colonic perforation can occur and the risk of this is higher when interventional procedures are undertaken. The presentation may be acute or delayed depending on the extent of the perforation. Extracolonic gas following colonic perforation can migrate to several body compartments that are embryologically related and it has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs. This review discusses in detail the anatomical pathways that led to a rare case of widespread subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and mediastinal shift from colonic perforation during a diagnostic colonoscopy. This is further supported by a description of the radiological images.

Cases of mediastinal emphysema (pneumomediastinum), as a complication of endoscopic colonoscopy perforation of the colon, according to the publications and given its own experience in the treatment of this rare complication were analyzed. There are few publications on the perforation of the colon during colonoscopy, with the development of pneumomediastinum, pnevmoretroperitoneuma, pneumothorax in a scientific literature. Air supply into the retroperitoneal space and the mediastinum from perforation of the intestine through the place connected with the lifting him through the natural anatomical connection. Some authors provide proven X-ray of the chest clinical cases pneumomediastinum and subcutaneous emphysema in a patient suspected of having ulcerative colitis after outpatient colonoscopy with biopsies, as well as pneumomediastinum with emphysema of soft tissues of the neck after endoscopic polypectomy. The diagnosis was established clinically (dyspnea, subcutaneous emphysema of the neck), but also the data of X-ray studies. The most life-threatening complication of colonoscopy a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum retropnevmoperitoneuma that requires immediate diagnosis and surgical intervention. In these cases, it may be a tension pneumothorax, in which is shown an emergency thoracostomy. During the stress pneumomediastinum an adequate drainage of the mediastinum and (if indicated) pleural cavities is performed. Clinical terms of self-resolution of mediastinal emphysema account for an average of 6.2 days in the majority of patients. During colonoscopy balloon dilation of strictures of the colon may also be complications: subcutaneous emphysema and bilateral pneumothorax. In our practice, there were two clinical cases of mediastinal emphysema at colonoscopy due to perforation of the sigmoid colon in one case, and perforation of the sigmoid colon diverticulum in another. The patients were operated on with a favorable outcome, laparotomy and bowel resection with anastomosis device SEEA-29 were performed. The perforation of the gut during endoscopy requires emergency surgery. Mediastinal emphysema may be as a complication of colonoscopy and is associated with the air intake from the intestine through the perforation into the retroperitoneal space, and then in the mediastinum. During unstressed pnemomediastinume resorption occurs independent of emphysema in the next day after a bowel injury.

Endoscopic submucosal dissection (ESD) is recommended for en bloc R0 resection of superficial esophageal neoplasms larger than 20 mm, but is high risk and time-consuming. In the tunnel technique, incisions at the lower and upper lesion edges are joined by a submucosal tunnel and then lateral incisions are made. The mucosa is thereby easily separated from the muscular layer. We report our experience of esophageal tunnel ESD. We retrospectively reviewed all consecutive esophageal tunnel ESDs performed at our unit between January 1 2010 and January 11 2013. Lesions were superficial esophageal neoplasms, UT1N0 at EUS. 11 patients underwent tunnel ESD (nine squamous cell carcinomas, two adenocarcinomas). Mean dissected surface area was 13.25 cm(2). Mean procedure duration was 76.7 minutes. All 11 resections were en bloc and 9/11 were R0. Complications were one subcutaneous emphysema with spontaneous resolution, and stenosis in 4/11 patients (36.4%) with resolution after 1-5 dilations. Tunnel ESD of superficial esophageal neoplasms is an interesting option, seeming to be faster and more effective than standard ESD, without higher morbidity.