Esophageal Defects Research Articles

Atrioesophageal Fistula: imaging for a definitive diagnosis

Aim: Atrial fibrillation is a common arrhythmia, with a prevalence of 37.574 million cases worldwide. Atrioesophageal fistula is a rare but potentially fatal complication of ablation of atrial fibrillation developing up to 60-days post-ablation with a prevalence of 0.07% to 0.25%, and a 63% mortality. While chest CTs are abnormal in most of these patients (76%-93%), definitive atrioesophageal fistula is noted in only 23-35% of cases, complicating pre-intervention diagnosis. Surgical repair of the left atrial and primary esophageal defect is essential for these patients, resulting in reduced mortality compared to nonsurgical management (33.71% vs. 94.19%). Methods: Our case series and comprehensive review of the literature highlights the diagnostic and treatment challenges of atrioesophageal fistula. Results/Conclusions: For symptomatic patients within 60-days post-ablation, IV contrast-enhanced helical chest CT with thin section collimation as initial imaging and axial reconstruction utilizing a 1mm-mm detector with sagittal and coronal reformats should be completed to allow for optimal identification of abnormalities consistent with atrioesophageal fistula. Patients with neurologic symptoms with the presence of pneumocephalus, infarcts involving one or more vascular territories, or diffuse air emboli that are highly suggestive of atrioesophageal fistula, warrant a chest CT with IV contrast to evaluate the presence of AEF. An initial unremarkable chest CT does not rule out atrioesophageal fistula and repeat chest CT with IV contrast within 1-3 days increases the likelihood of a definitive AEF diagnosis. Surgery is the only recommended management in patients with atrioesophageal fistula who are clinically stable enough to endure the procedures.

Oral higher dose prednisolone to prevent stenosis after endoscopic submucosal dissection for early esophageal cancer.

Esophageal stenosis is one of the main complications of endoscopic submucosal dissection (ESD) for the treatment of large-area superficial esophageal squamous cell carcinoma and precancerous lesions (≥ 3/4 of the lumen). Oral prednisone is useful to prevent esophageal stenosis, but the curative effect remains controversial. To share our experience of the precautions against esophageal stenosis after ESD to remove large superficial esophageal lesions. Between June 2019 and March 2022, we enrolled patients with large superficial esophageal squamous cell carcinoma and high-grade intraepithelial neoplasia experienced who underwent ESD. Prednisone (50 mg/d) was administered orally on the second morning after ESD for 1 mo, and tapered gradually (5 mg/wk) for 13 wk. In total, 14 patients met the inclusion criteria. All patients received ESD without operation-related bleeding or perforation. There were 11 patients with ≥ 3/4 and < 7/8 of lumen mucosal defects and 1 patient with ≥ 7/8 of lumen mucosal defect and 2 patients with the entire circumferential mucosal defects due to ESD. The longitudinal extension of the esophageal mucosal defect was < 50 mm in 3 patients and ≥ 50 mm in 11 patients. The esophageal stenosis rate after ESD was 0% (0/14). One patient developed esophageal candida infection on the 30th d after ESD, and completely recovered after 7 d of administration of oral fluconazole 100 mg/d. No other adverse events of oral steroids were found. Oral prednisone (50 mg/d) and prolonged prednisone usage time may effectively prevent esophageal stricture after ESD without increasing the incidence of glucocorticoid-related adverse events. However, further investigation of larger samples is required to warrant feasibility and safety.

OGBN P12 Minimising the systemic effects of an oesophageal leak following high risk myotomy repair using Prophylactic Endoluminal Vacuum Therapy (EVT) - time for a change?

Abstract Background Endoluminal Vacuum Therapy (EVT) continues to gain momentum as a first line treatment for oesophageal perforations. Outside the emergency setting there is growing interest in using EVT prophylactically to protect high-risk elective oesophageal repairs. We present a case which demonstrates the benefit of prophylactic EVT in preventing extraluminal contamination, mediastinitis and sepsis following elective oesophageal surgery. Methods An 80-year-old female underwent laparoscopic Hellers Myotomy and Dor Fundoplication for Type 2 Achalasia following worsening symptoms including weight loss despite nutritional optimisation. She had multiple prior balloon dilatations without long term symptom control and remained frail, with a performance status of 0 and an ASA 2. During surgery the oesophageal myotomy was challenging due to extensive scarring. Endoscopy was performed on completion of the myotomy to confirm adequacy and a 1cm oesophageal perforation at 38cm was noted. Primary repair was performed with 5 interrupted 3/0 maxon sutures. An ad-hoc EVT device was constructed using V.A.C granufoam (KCI) sutured to the end of an 18Fr nasogastric tube, and placed intraluminally in the oesophagus across the repair. Continuous negative pressure of 75mmHg was applied. Post operatively the patient was kept nil by mouth and received parenteral nutrition. Her clinical and biochemical parameters were monitored, and the progress of her oesophageal repair was assessed endoscopically. Results The first post-operative endoscopy was performed at day 4. On visual inspection a full thickness oesophageal defect was seen at the proximal aspect of the oesophageal repair. There was no associated leak cavity or other endoscopic evidence of extraluminal contamination. A further ad-hoc EVT device was constructed and placed intraluminally in the oesophagus across the suture repair and oesophageal wall defect. A second endoscopy was performed on day 10 post-operative and the oesophageal defect had completely healed. Despite having a documented full thickness oesophageal wall defect the patient remained clinically well throughout her post-operative recovery with no clinical signs of sepsis. The highest recorded CRP was 131 and WCC was 12.7 on day 1 and day 8 respectively. At no point was a higher level of care or input required than the general surgical ward. Her total LOS was 14 days. Conclusions A leak following elective oesophageal surgery is a serious complication which may result in mediastinitis, sepsis and death. This case demonstrates the utility of prophylactic EVT in reducing the impact of an oesophageal leak in patients where breakdown of the oesophageal repair occurs. Without prophylactic EVT in this case, we are certain the breakdown of the oesophageal repair would have resulted in a significant oesophageal leak with mediastinitis and sepsis which an 80-year-old patient with limited physiological reserve may not have survived. While prophylactic EVT is not a substitute for sound surgical technique, it should be considered in high-risk patients undergoing elective oesophageal surgery to reduce or prevent the septic hit consequent to an oesophageal leak if breakdown of an oesophageal repair occurs.

OGC P37 Towards an era of eliminating leak related morbidity from major oesophago-gastric surgery

Abstract Background A leak following oesophago-gastric surgery remains a life-threatening complication associated with a long intensive care stay and high mortality and morbidity. We hypothesised that Endoluminal Vacuum Therapy (EVT) could be used prophylactically to provide source control, prevent mediastinitis and minimise sepsis related morbidity if breakdown of an oesophageal or gastric anastomosis or repair occurred. In the first instance, this could be a particularly attractive adjunct in cases where technical and/or patient factors deem an anastomosis or repair as high risk. Methods We collected data prospectively from all patients where a prophylactic EVT device was placed during elective oesophago-gastric surgery. Primary outcome measures included length of stay (LOS) and post-operative leak rate. Prophylactic EVT was provided using an ad-hoc EVT device constructed by suturing a piece of V.A.C granufoam (KCI) to the end of an 18Fr NG tube and positioning this intraluminally across the anastomosis or area of repair at the time of surgery using endoscopic guidance. Continuous negative pressure of between 75 and 125mmHg was applied. Following removal of the EVT device, assessment of the integrity of the anastomosis or repair was made using one, or a combination of endoscopic assessment, CT with oral contrast, and clinical assessment. Results Prophylactic EVT was utilised in 9 patients; M:F ratio=7:2, median age 72 years (range 50–80). 8 patients had ASA 3, and 1 had ASA 2. The index surgery was resection of an epithelial cancer in 7 patients (3 partial/total gastrectomies, 4 oesophagectomies), resection of a gastric GIST in 1 patient, and a Hellers myotomy in 1 patient. All anastomosis/repairs were deemed high risk due to technical(n=3), patient(n=4) or combined (n=2) factors. Prophylactic EVT was placed for a median of 6 days (range 4–10). The integrity of the anastomosis/repair was assessed using both CT and gastroscopy (n=3), CT alone (n=3), gastroscopy alone (n=2), and clinical grounds (n=1). One patient was found to have a full thickness oesophageal defect at their first endoscopic assessment. This was managed with a further period of intraluminal EVT until the oesophageal defect healed. The patient remained clinically well throughout and was managed entirely with ward-based care. The median LOS was 11 days (range 7–96). The two longest stays were secondary to a prolonged chyle leak and longer term sequelae of a life threatening on-table bleed. In all cases the site of repair remained healthy with no evidence of early stricturing. Conclusions Prophylactic EVT therapy was safe and did not result in any short-term adverse events in this small cohort of patients. Although it may not prevent breakdown at the site of oesophageal anastomosis/repair and is not an alternative to sound surgical technique, the use of prophylactic EVT in high risk anastomosis could be beneficial in preventing life threatening sepsis and associated systemic effects resulting from inadequate source control. Current studies are under way to look at longer term outcomes in the form of prospective cohort studies and randomised controlled trials. This provides the oesophago-gastric community the unique opportunity to collectively eliminate life threatening leak related morbidity and mortality for once and for all.

Abstract 15622: Hydro-Pneumopericardium Due to Esophageal-Pericardial Fistula: A Rare Complication of Esophageal Stent Migration

Introduction: Esophageal-pericardial fistulas are rare complications of a variety of conditions ranging from benign esophageal disorders to iatrogenic etiologies such as radiofrequency catheter ablation. Here, we present a unique case of esophageal-pericardial fistula formation following esophageal stent migration in the setting of ulcerative esophagitis and benign esophageal stricture. Case Presentation: A 53-year-old woman with a history of ulcerative esophagitis and associated esophageal stricture was managed with esophageal stenting. Following stenting, her course was complicated by esophageal stent migration, resulting in severe dysphagia and multiple gastrointestinal bleeds requiring percutaneous endoscopic gastrostomy (PEG) tube placement. She presented with fatigue, melena, and dark output from her PEG tube and was hypotensive, tachycardic, and tachypneic. An echocardiogram (Figure 1A) showed hydro-pneumopericardium with cardiac tamponade physiology requiring emergent pericardiocentesis and aspirated fluid shown in Figure 1B. A subsequent computed tomography (CT) scan of the chest demonstrated a large complex pericardial effusion with air in the anterior pericardium, a large esophageal-pericardial fistula, and a moderate left hydropneumothorax (Figure 1C). Given the extent of her esophageal defect, the patient was taken for an esophagectomy with esophagostomy formation. Discussion: On review, we found only a few cases of hydro-pneumopericardium in the context of spontaneous pericardial herniation due to subcutaneous emphysema, radiofrequency ablation for atrial arrhythmias and esophagectomy for esophageal adenocarcinoma. However, there has been no report of esophageal-pericardial fistula due to esophageal stent migration. Conclusion: In an appropriate setting, clinicians should maintain a high index of suspicion for esophageal-pericardial fistulas, as delay in the management of these conditions could be fatal.

S2384 The First Case of Water Immersion Endoscopy in the Definitive Diagnosis of Atrio: Esophageal Fistula

Introduction: Atrial fibrillation (AF) is the most common heart rhythm disorder with estimated global prevalence of 33.5 million. Catheter ablation is the treatment modality of choice for refractory AF. Atrio-esophageal fistula (AEF) is a serious complication of catheter ablation. Diagnosis is critical to the management of AEF, and includes computed tomography of the chest, esophagram and esophagogastroduodenoscopy (EGD). Prompt diagnosis of AEF is essential for survival. Case Description/Methods: A 56-year-old male with AF presented with fever, fatigue and bilateral leg weakness. Twenty days prior to presentation he underwent pulmonary vein isolation radiofrequency ablation and discharged the following day. Upon re-presentation his vitals were notable for fever and tachycardia. Labs revealed a normal white count and hemoglobin, and elevated lactate and troponin. One hour after arrival he developed complex focal seizure and AF with rapid ventricular rate followed by respiratory decompensation requiring intubation. His blood cultures revealed Streptococcus mitis and Gemella haemolysans. His MRI disclosed numerous bilateral emboli concerning for endocarditis, however TEE did not reveal any valvular vegetation, thus proposing AEF as a possible complication accounting for the emboli. CT chest angiogram revealed subtle irregularity along the posterior wall of the left atrium (figure A), but did not provide conclusive evidence to warrant high-risk cardiothoracic surgery. Water immersion EGD was performed to diagnose and localize the fistula, revealing esophageal defect in the proximal esophagus with movement of non-bloody debris through the tract (figure B). One hemostatic clip was placed near the tract to assist with localization for surgical closure. The following day the patient underwent right thoracotomy with placement of intercostal muscle flap to fistula (Figure C). Discussion: AEF is a rare complication of radiofrequency ablation therapy for AF. High mortality rate is primarily attributed to major cerebrovascular morbidity from septic thrombi. Currently there is no effective modality to visualize AEF safely and reliably. Water immersion colonoscopy allows for completion of difficult colonoscopies, decreased insertion pain, and increased adenoma-detection rates. This technique was applied to identify the AEF. Water immersion EGD is an important modality that can confidently be considered within the diagnostic armamentarium of gastroenterologists to ensure safe and rapid diagnosis and treatment of AEF.Figure 1.: 1: (A) Illustrates a subtle contour abnormality involving the posterior wall of the left atrium (arrow) concerning for AEF (B) Water immersion endoscopy illustrating 3mm defect (arrow) in the wall of the esophagus (C) Underwent right thoracotomy to access AEF. This image highlights 3mm fistula site (arrow) that is approximated to be at the midpoint of the atrium.

571. ESOPHAGEAL PERFORATION AFTER LOBECTOMY: PADLOCK CLIP TO THE RESCUE

Abstract Esophageal perforation or fistula is a devastating condition with diagnostic and therapeutic challenges. It is associated with high morbidity and mortality due to its rapid progression to mediastinitis or peritonitis, septic shock and multiorgan failure. Iatrogenic perforation is the commonest in this era. We hereby report a case of esophagopulmonary fistula following a right lower lobectomy which was successfully treated with endoscopic clipping. A 52-year-old man presented with productive cough and weigh loss for 2 weeks. Initial workup in another center revealed right lung lower lobe lesion and a right lower lobectomy was done. Saliva and food particle were noted in chest drain on post-operative day 2 due to esophageal perforation. Re-thoracotomy, washout and esophageal repair was done. An open window thoracostomy was created for further drainage and parenteral nutrition was initiated. Histology of the lobectomy specimen revealed actinomycosis of right lung. However, there was persistent leak from the esophagus with suspicion of esophagopulmonary fistula. He was then transferred to our center for further treatment. OGDS revealed a 5mm defect at right lateral wall mid thoracic esophagus, about 28cm from incisor, with healthy and supple surrounding mucosa. Contrast study revealed esophagopulmonary fistula. Esophageal defect was successfully closed with over-the-scope padlock clip (Steris). Repeat contrast study 1 week later revealed resolution of fistula. Sepsis and source control, nutritional support with restoration of gastrointestinal tract intergrity are key steps in the management of esophageal perforation. Endoscopic treatment is efficacious, less invasive, and with the advantage of organ preservation. Endoscopic clipping is safe and effective in selected group of patients with esophageal perforation or fistula.

613. DOUBLE LUMEN JEJUNAL FREE FLAP RECONSTRUCTION AFTER PROXIMAL ESOPHAGEAL RESECTION FOR MALIGNANCY

Abstract Malignancies located at the level of the upper esophageal sphincter pose a challenge due to the proximity to pharyngeal, laryngeal, and upper esophageal anatomic structures. Poorly differentiated tumors in this area can pose both diagnostic and therapeutic dilemmas, and patients with prior neck radiation may require surgery. In cases that are treated with laryngectomy, pharyngectomy, and proximal esophagectomy, jejunal free flap reconstruction can restore gastrointestinal continuity and function. A single institution early experience with multidisciplinary complex head and neck reconstruction requiring pharyngectomy and proximal esophagectomy was reviewed. Charts were reviewed for demographic details, operative details, and 30 day perioperative occurrences. Radiographic, clinical, and endoscopic records were reviewed. Method and approach for jejunal harvest and abdominal complications were obtained. Location of microvascular anastomoses were recorded for implantation of the jejunum. Length of small bowel utilized was recorded along with details of operative technique and methods for both proximal and distal anastomoses. Pre-operative and post-operative pathology reports were reviewed and compared. The initial 4 cases of pharyngeal and esophageal resection requiring jejunal free flap reconstruction were reviewed. Mean age was 65.3 (50-74), mean BMI was 31.7 (21.7-49.8), and 75% of patients were female. Median length of stay was 13.5 days (8-14) after the index operation. Flap survival rate was 100%, and there was 0% leak rate. Three patients had previous neck surgery, 75% survived to 30 days with 1 patient opting for palliative care. All flaps were harvested using a laparoscopic approach. There were no abdominal donor site related complications. Pathology 50% SCC, mucoid epidermoid carcinoma, and anaplastic thyroid carcinoma. Reconstruction of complex pharyngeal and proximal esophageal defects after oncologic resection for malignancy involving the proximal esophagus abutting the upper esophageal sphincter poses a complex challenge. These proximal esophageal defects are managed effectively with jejunal free flap reconstruction utilizing microvascular anastomoses. A double lumen jejunal free flap should be considered to restore pharygo-esophageal continuity, provides good pharyngeal size match, and can also be safely performed in patients with a re-operative field or prior neck radiation.

535. ENDOSCOPIC AND THORACOSCOPIC MANAGEMENT OF OESOPHAGEAL PERFORATION

Abstract This is a rare case of boerhaave’s syndrome associated with ischaemic small bowel in a young patient. A 45-year-old man, background of schizophrenia, alcohol excess and previous TIAs, presented to resus room in a peri-arrest condition secondary to sepsis. A CT scan confirmed gross mediastinitis with extensive right pleural contamination and an ischaemic segment of small bowel. An intercostal chest drain in resus was placed and drained enteric content from the oesophagus confirming the diagnosis. The patient was immediately taken to operating theatre and a large distal oesophageal perforation was localized on OGD under GA. Using a novel technique, a guide wire was placed into the mediastinal cavity via the perforation. Over the guide wire, an exudrain was placed to act as an endovac (200mmHg wall suction) and a large bore NG tube placed into the stomach. A right sided VATs decortication and wash out and insertion of further chest drains was carried out, followed by laparotomy and resection of a 10cm segment of ischaemic small bowel. Following a short critical care unit stay, the patient made a steady recovery free of any complications. In total, 3 endoscopies were performed post operatively to assess mediastinal healing. Psychotropic medications were delivered through an NJ tube. At 3 weeks, the patient showed complete healing of the oesophageal defect and had a stricture which needed dilatation. Endoscopic negative pressure treatment can be combined with a minimally invasive thoracoscopic approach to the mediastinum to achieve success even in an unstable patient. Vigilance needs to be applied for concomitant pathology such as small bowel ischaemia, although rare, contributes to the risk associated with this serious condition.

409. RECONSTRUCTION OF A SEGMENTAL OESOPHAGEAL DEFECT WITH A TUBED RADIAL ARTERY FOREARM FREE FLAP GUIDED BY 3-DIMENSIONAL MODELLING

Abstract Segmental defects of the oesophagus are rare but complex. If the patient survives the initial insult, reconstructive techniques most commonly involve gastric pull-up or colonic interposition (1) however alternative techniques such as free flap reconstruction can be utilised if the former are unsuitable (2). The surgical field often is quite hostile in these cases, making pre-operative visualisation and planning critical in achieving a successful outcome. We describe our approach after a surgical complication in a 49-year-old man. cT3N2M0 GOJ adenocarcinoma, pre-operative FLOT4, three-stage oesophagectomy complicated by anastomotic leak and tracheo-gastric fistula. Cervical oesophagostomy and venting gastrostomy (via laparotomy) was performed (severe illness precluded one-lung ventilation). He improved and was discharged, but a persistent fistula from the gastric conduit to his trachea remained. Reconstruction was planned by a multidisciplinary team using detailed 3D modelling. Via right thoracotomy, the gastric conduit was reduced into the abdomen and the tracheal defect was repaired with an intercostal muscle flap. A retrosternal colonic interposition restored gastrointestinal continuity. The superior 2 cm infarcted and was replaced by a dual-paddled tubular radial forearm free flap. This complex surgical situation demonstrates how 3D visualisation of a segmental oesophageal defect can be extremely helpful in pre-operative planning. In particular, the precise anatomical location of the gastro-tracheal fistula and its relationship to the bony landmarks and surrounding vascular anatomy were critical in considering surgical access and reconstruction options. Whilst the literature describes applications of 3D visualisation for surgical planning in alternative contexts, there is minimal information of its use in upper gastrointestinal reconstruction. The use of 3D modelling and printing within the surgical context has frequently been associated with reduced operating times and improved medical outcomes (3). This case adds to the previously documented advantages of 3D modelling in surgical planning but applies them to an area not well covered in the literature. Additionally, it demonstrates the utility of an infrequently used technique (RAFF) for reconstructing a segmental oesophageal defect. Further research into quantifying the outcomes following the implementation of 3D modelling in visualisation and surgical planning would be useful in encouraging its integration into mainstream surgical practice.

Efficacy of free anterolateral thigh flap and free jejunum in reconstruction for hypopharyngeal and cervical esophagus.

Because of its peculiar anatomical location, most patients with hypopharyngeal and cervical esophageal cancer are at advanced stage when they visit the hospital. At present, the treatment for hypopharyngeal and cervical esophageal cancer is primarily surgical resection and radiotherapy. However, due to the wide range of surgical resection, it can often lead to a large range of annular defects. Therefore, the upper digestive tract reconstruction after tumor resection is very important. We use the free anterolateral thigh flap (ALT) and free jejunum (FJ) transfer to reconstruct the hypopharyngeal and cervical esophagus, and to investigate the effect of both reconstruction methods on upper gastrointestinal tract defects. A retrospective analysis was conducted to investigate the clinical data of 42 patients with hypopharyngeal and cervical esophageal cancer (Clinical Stage IV) from Jan. 2004 to Jan. 2016 in the Second Xiangya Hospital of Central South University. All patients underwent total laryngopharyngectomy and cervical esophageal resection. The hypopharyngeal circumferential and cervical esophageal defects were reconstructed with free ALT (n=22) or FJ (n=20). Four patients who underwent radiotherapy and chemotherapy before surgery did not receive radiotherapy or chemotherapy after surgery. The remaining 38 patients underwent postoperative radiotherapy and chemotherapy. All patients were followed up by telephone or outpatient review, with a follow-up deadline in Jan. 2021. We compared the differences between the 2 groups in postoperative complications, radiotherapy complications, and survival rate. The differences in individual characteristics between 2 groups were analyzed using Fisher test. The differences in postoperative and radiotherapy complications between two groups were analyzed using χ² test. The 3- and 5-year overall survival rates were calculated using Kaplan-Meier survival curve method. In the ALT group, the postoperative complications mainly included anastomotic fistula, chylous fistula and subcutaneous hematoma of the donor site. The radiotherapy complication was anastomotic stenosis. However, in the FJ group, the postoperative complications mainly included chylous fistula, intestinal obstruction, and intestinal fistula. The radiotherapy complications mainly contained anastomotic fistula and tissue flap necrosis. The cases of postoperative complications in the ALT group and the FJ group were 7 and 5, respectively (P=0.625), and the cases of radiotherapy complications were 3 and 4, respectively (P=0.563). The 3-year overall survival rates in the ALT group and the FJ group were 52.9% and 46.7%, respectively, and the 5-year total survival rates were 35.1% and 31.9%, respectively (P=0.53). The cases of anastomotic stenosis after radiotherapy in the ALT group were more than those in the FJ group (P=0.097). However, the cases of jejunal necrosis and anastomotic fistula after radiotherapy in the FJ group were more than those in the ALT group (P=0.066). There are no significant differences in postoperative and radiotherapy complications and 3-and 5-year survival rates between the ALT group and the FJ group. The reconstruction with ALT is prone to develop anastomotic stricture. The reconstruction with FJ cannot withstand high-dose radiotherapy. The ALT and FJ are effective methods in the reconstruction of hypopharynx and cervical esophagus. The treatment protocol should be carefully chosen based on its advantages and disadvantages of these 2 methods.

Decellularization of porcine esophageal tissue at three diameters and the bioscaffold modification with EETs‐ECM gel

Damaged complex modular organs repair is a current clinical challenge in which one of the primary goals is to keep their biological response. An interesting case of study it is the porcine esophagus since it is a tubular muscular tissue selected as raw material for tissue engineering. The design of esophageal constructs can draw on properties of the processed homologous extracellular matrix (ECM). In this work, we report the decellularization of multilayered esophagus tissue from 1-, 21- and 45-days old piglets through the combination of reversible alkaline swelling and detergent perfusion. The bioscaffolds were characterized in terms of their residual composition and tensile mechanical properties. The biological response to esophageal submucosal derived bioscaffolds modified with ECM gel containing epoxyeicosatrienoic acids (EETs) was then evaluated. Results suggest that the composition (laminin, fibronectin, and sulphated glycosaminoglycans/sGAG) depends on the donor age: a better efficiency of the decellularization process combined with a higher retention of sGAG and fibronectin is observed in piglet esophageal scaffolds. The heterogeneity of this esophageal ECM is maintained, which implied the preservation of anisotropic tensile properties. Coating of bioscaffolds with ECM gel is suitable for carrying esophageal epithelial cells and EETs. Bioactivity of EETs-ECM gel modified esophageal submucosal bioscaffolds is observed to promote neovascularization and antiinflammatory after rabbit full-thickness esophageal defect replacement.

A Good Result of Cardiopulmonary Resuscitation Following Colonic Segment Interposition with Vascular Supercharge

A 70-year-old man who underwent surgical excision of an esophageal leiomyoma developed esophageal leak and underwent esophagectomy. Colonic segment interposition was performed to address the esophageal defect. Cardiopulmonary resuscitation (CPR) was subsequently performed for desaturation due to pulmonary atelectasis; spontaneous circulation resumed without indication of contrast leakage or necrosis. Redundancy of the esophagus in the neck occurred due to migration of the colon segment during CPR. We shortened the colonic segment, which improved swallowing function. Here we report the first case of a positive outcome of cervical herniation of a colon graft due to CPR after a colonic interposition procedure.

Endoscopic vacuum therapy for the treatment of suture failure after resection of the esophageal wall for removal of an enterogenic cyst in a 9-year-old child

INTRODUCTION. Intrathoracic esophageal postoperative suture’s failure occurs in 8–26 % after distal esophagectomy and 3–12 % after total gastrectomy, also this leads to the development of life-threatening complications and a rather high mortality rate. Endoscopic vacuum therapy is an actively developing and modern method of treating defects in the wall of hollow organs.CINICAL EXAMPLE. 9-year-old patient had resection of the esophageal wall for an enterogenic cyst. The failure of the postoperative suture was clinically diagnosed after the 1st day of operation, confirmed by endoscopic and X-ray findings. We decided to use endoscopic vacuum therapy with Suprasorb sponge. The sponge was replaced at intervals of 3–5 days. On the 9th twenty-four hours after the operation, a delimited cavity into the mediastinal pleural space with a length of 8 cm and a width 1.5 cm with fibrin deposits on the walls was diagnosed. The size and shape of the sponge depended on the size of the defect of the esophageal wall and the volume of the delimited cavity. Conservative and rehabilitation therapy was also carried out. On the 40th day after the operation, complete epithelialization of the esophageal wall defect was noted. The patient was discharged in a satisfactory condition. Due to the results of our clinical observation, we reached a conclusion that endoscopic vacuum therapy is applicable in clinical practice, because it is an effective method of treatment for the of intra-thoracic esophageal suture’s failure. The technique is relatively safe, contributes to the complete elimination of the full-wall defect, reducing the period of social recovery and maintaining a high quality of life after treatment.

Congenital Tracheoesophageal Fistula Presenting in an Asymptomatic Adult- A Case Report

Introduction: Congenital tracheoseophageal fistula (TEF) involve an abnormal pathological connection between the oesophagus and trachea. Congenital TEF presenting in adults is extremely rare and literature is limited to case series of significantly symptomatic patients. Case presentation: An asymptomatic 41 year-old gentleman presented to clinic, having been diagnosed with a congenital tracheoesophageal fistula 10 years ago on a routine oesophagogastroduodenoscopy (OGD) in Brazil. He underwent a barium contrast swallow revealing contrast in the left main bronchi and significant pooling in the upper trachea. A computerised tomography (CT) scan of the neck and thorax with contrast revealed a small fistula measuring 6mm in diameter between the trachea and the oesophagus at the level of the second thoracic vertebral body. A microlaryngobronchoscopy and examination under anaesthesia visualised a fistula measuring 1.8cm to 2cm superior to inferiorly and similar in transverse dimension, 6-7cm below the level of the glottis. Management and outcome: He opted to have surgical treatment to prevent symptoms developing in the future. A trans-cervical approach was performed, and the oesophageal defect and tracheal defect underwent primary closure with sutures. The oesophageal defect repair was oversewn with the sternohyoid. He recovered well post-operatively but due to the considerable rotation and retraction of the trachea, he suffered a vocal cord palsy. This is improving at the latest follow-up. Discussion: Otolaryngologist (ENT) surgeons need to be aware of asymptomatic adult patients presenting with congenital tracheoesophageal fistulas and the investigation and management options available.

Why is endosonography insufficient for residual diagnosis after neoadjuvant therapy for esophageal cancer? Solutions using muscle layer evaluation.

BACKGROUNDThe diagnosis of residual tumors using endoscopic ultrasound (EUS) after neoadjuvant therapy for esophageal cancer is considered challenging. However, the reasons for this difficulty are not well understood.AIMTo investigate the ultrasound imaging features of residual tumors and identify the limitations and potential of EUS.METHODSThis exploratory prospective observational study enrolled 23 esophageal squamous cell carcinoma patients receiving esophagectomy after neoadjuvant therapy [15 patients after neoadjuvant chemotherapy (NAC) and 8 patients after chemoradiotherapy (CRT)] at the Department of Surgery, Chiba University Hospital, between May 2020 and October 2021. We diagnosed the T stage for specimens using ultrasound just after surgery and compared ultrasound images with the cut surface of the fixed specimens of the same level of residual tumor. The ratio of esophageal muscle layer defect measured by ultrasound was compared with clinicopathological factors. Furthermore, the rate of reduction for the muscle layer defect was evaluated using EUS images obtained before and after neoadjuvant therapy.RESULTSThe accuracy of T stage rate was 61% (n = 14/23), which worsened after CRT (38%, n = 3/8) than after NAC (73%, n = 11/15) because of overstaging. Moreover, pT0 could not be diagnosed in all cases. The detection rate of residual tumor for specimens using ultrasound retrospectively was 75% (n = 15/20). There was no correlation between after-NAC (79%, n = 11/14) and after-CRT (67%, n = 4/6) detection rate. The detection of superficial and submucosal types was poor. The pathologic tumor size and pathological response were correlated. Tumor borders were irregular and echogenicity was mixed type after CRT. There was a correlation between the pT stage (pT0/1 vs pT2/3) and the length of muscle layer circumference (P = 0.025), the length of muscle layer defect (P < 0.001), and the ratio of muscle layer defect (P < 0.001). There was also a correlation between the pT stage and the rate of muscle layer defect reduction measured by EUS (P = 0.001).CONCLUSIONCompared to pathological images, some tumors are undetectable by ultrasound. Focusing on the esophageal muscle layer might help diagnose the depth of the residual tumor.

Esophageal tuberculosis induced dysphagia: a case report

BackgroundPatients can present for a wide variety of etiologies for dysphagia, and it is important to consider less common causes once common etiologies have been ruled out. Extrapulmonary Mycobacterium tuberculosis (TB) presentations are rare to see in the western populations due to relative lack of TB exposure and overall less immunocompromised populations, but should be considered for at-risk patients. Gastrointestinal (GI) TB is rare, and the GI tract is considered only the sixth most frequent site of extrapulmonary TB (EPTB).Case presentationThis is a case report of a 35-year-old Ethiopian male presenting with dysphagia and retrosternal odynophagia who was found to have infiltration of mediastinal lymphadenopathy into the esophageal wall secondary to TB. This patient underwent an upper endoscopy, which revealed a linear 2 cm full thickness mucosal defect in the middle esophagus concerning for an infiltrative process with full thickness tear. Computed tomography (CT) of the chest demonstrated a subcarinal soft tissue mass that was inseparable from the esophagus. He was referred to thoracic surgery and underwent an exploratory mediastinal dissection. A mediastinoscopy scope was inserted and the mediastinal dissection was made until the subcarinal nodes were identified and removed. Biopsy results showed necrotizing and non-necrotizing granulomas, and acid-fast bacilli (AFB) culture from the surgically removed lymph node showed Mycobacterium TB complex growth. He had no known TB exposures and did not have any TB risk factors. He then followed up in infectious disease clinic and was managed with anti-tuberculosis treatment (ATT) with complete resolution of symptoms.ConclusionsOur patient was ultimately found to have esophageal TB secondary to mediastinal invasion into the esophageal wall from lymphadenopathy associated with TB. This is an extremely rare presentation in western populations due to diminished exposure rates and overall less immunocompromised populations compared to impoverished countries with increased TB exposure and human immunodeficiency virus (HIV) infection rates. Although TB is not as commonly seen in western populations, it should be considered on the differential for any atypical presentations of GI diseases for patients with clinical or geographic risk factors.

Eso-Sponge® for anastomotic leakage after oesophageal resection or perforation: outcomes from a national, prospective multicentre registry

BackgroundAnastomotic leakage (AL) after oesophagectomy and oesophageal perforations are associated with significant morbidity and mortality. Minimally invasive endoscopy is often used as first-line treatment, particularly endoluminal vacuum therapy (EVT). The aim was to assess the performance of the first commercially available endoluminal vacuum device (Eso-Sponge®) in the management of AL and perforation of the upper gastrointestinal tract (GIT).MethodsThe Eso-Sponge® registry was designed in 2014 as a prospective, observational, national, multicentre registry. Patients were recruited with either AL or perforation within the upper GIT. Data were collected with a standardized form and transferred into a web-based platform. Twenty hospitals were enrolled at the beginning of the study (registration number NCT02662777; http://www.clinicaltrials.gov). The primary endpoint was successful closure of the oesophageal defect.ResultsEleven out of 20 centres recruited patients. A total of 102 patients were included in this interim analysis; 69 patients with AL and 33 with a perforation were treated by EVT. In the AL group, a closure of 91 per cent was observed and 76 per cent was observed in the perforation group. The occurrence of mediastinitis (P = 0.002) and the location of the defect (P = 0.008) were identified as significant predictors of defect closure.ConclusionsThe Eso-Sponge® registry offers the opportunity to collate data on EVT with a uniform, commercially available product to improve standardization. Our data show that EVT with the Eso-Sponge® is an option for the management of AL and perforation within the upper GIT.

Chitosan/collagen layer-by-layer deposition for improving the esophageal regeneration ability of nanofibrous mats

The morbidity of a diverse array of esophageal diseases has been increasing in recent years, and postoperative bacterial infection is a common potential risk. Current research on artificial esophageal stents is lacking and less than satisfactory. Artificial materials with excellent mechanical, antimicrobial, and cytocompatible properties at the same time still have great potential. In this study, chitosan (CS) and collagen (COL) were deposited on nylon 6 (N6)/silk fibroin (SF) composite nanofibers using layer-by-layer self-assembly (LBL). The obtained nanofibrous mats were characterized, and the results indicated that the surface morphology and hydrophilicity of the composite nanofibrous mats were obviously improved by the deposition of CS and COL. The mechanical properties of the composite nanofibrous mats were also improved after LBL modification. In addition, the LBL-structured nanofibrous mats possessed excellent antibacterial activity, reaching more than 90% inhibition of gram-positive and negative bacteria. The results of cell experiments indicated that the nanofibrous mats modified by CS and COL had excellent biocompatibility for promoting human esophageal epithelial cell adhesion and proliferation. In vivo animal experiments showed that the LBL-structured nanofibrous mats were beneficial to the healing of esophageal defects compared with the control group. In summary, LBL-structured nanofibrous mats are very promising materials for esophageal replacement to reduce the incidence of postoperative complications.

Development and Prospect of Esophageal Tissue Engineering.

Currently, patients with esophageal cancer, especially advanced patients, usually use autologous tissue for esophageal alternative therapy. However, an alternative therapy is often accompanied by serious complications such as ischemia and leakage, which seriously affect the prognosis of patients. Tissue engineering has been widely studied as one of the ideal methods for the treatment of esophageal cancer. In view of the complex multi-layer structure of the natural esophagus, how to use the tissue engineering method to design the scaffold with structure and function matching with the natural tissue is the principle that the tissue engineering method must follow. This article will analyze and summarize the construction methods, with or without cells, and repair effects of single-layer scaffold and multi-layer scaffold. Especially in the repair of full-thickness and circumferential esophageal defects, the flexible design method and the binding force between the layers of the scaffold are very important. In short, esophageal tissue engineering technology has broad prospects and plays a more and more important role in the treatment of esophageal diseases.