Esophageal Defects Research Articles

The predictive value of fruit juice in the esophagus-pleural fistula

Esophageal-pleural fistula is a rare and challenging condition to diagnose and requires strong clinical suspicion in order to be recognized promptly. Chest computed tomography (CT) with contrast medium for oral contrast medium (OS) is the gold standard for diagnosis. The definitive therapy is purely surgical, except for a few selected cases that benefit from endoscopic therapy. Our case involves a 45-year-old woman who came to the Emergency Department with dyspnea and thoracalgia. Chest X-ray and high-resolution CT showed empyema and pleural effusion to the left hemithorax. The lack of improvement despite the therapy and a subsequent clinical finding gave rise to the suspicion of esophageal-pleural fistula, confirmed with CT with contrast medium for OS. In this case, we opted for endoscopy correction of the esophageal defects. The diagnostic delay and the pre-existing comorbidities (previous kidney transplant for chronic kidney disease from lupus nephritis, high blood pressure, familiarity with Ischemic cardiomyopathy) could justify the inauspicious course of our case.

New onset diabetes presenting with DKA, spontaneous pneumomediastinum and subcutaneous emphysema: a case series

AbstractHamman's syndrome, first described by Dr Louis Hamman in 1939, is a syndrome of spontaneous pneumomediastinum and subcutaneous emphysema. It is a rare complication of diabetic ketoacidosis (DKA), and self‐resolves within days with conservative management. Limited awareness about this condition may lead to an initial misdiagnosis of secondary pneumomediastinum due to spontaneous oesophageal perforation (Boerhaave's syndrome), which is associated with high mortality and often requires invasive management. It is important to distinguish between the two conditions to avoid unnecessary investigations, procedures and delays to hospital discharge.We hereby present our experience, between the years 2017–2019, of managing three cases of Hamman's syndrome, in young men aged 18–22 years, with no previous history of diabetes, presenting with severe vomiting, osmotic symptoms and a diagnosis of DKA. In all three cases the admission chest radiograph showed pneumomediastinum and in two of the cases surgical emphysema was also noted. The presentation with vomiting in association with the chest X‐ray findings raised a high index of suspicion for spontaneous oesophageal perforation. Consequently, they were kept nil‐by‐mouth for several days and cared for in high dependency settings. Total parenteral nutrition was initiated in two cases. Each individual underwent computer tomography of the chest, and sequential water‐soluble oral contrast swallow tests with no evidence of an oesophageal defect. The individuals were conservatively managed and discharged following a length of stay ranging from five to 14 days. Copyright © 2020 John Wiley & Sons.

Synchronous reconstruction of esophageal defect and voice with J-flap after laryngopharyngectomy: Indications and outcomes.

The primary reconstruction goal for patients with laryngopharyngectomy is the restoration of esophagus, whereas voice reconstruction is less readily reconstructed. J-flap is a novel surgical technique designed to reconstruct voice and esophagus synchronously, permitting functional rehabilitation of aerodigestive tract after laryngopharyngectomy. This study aims to present indications, surgical steps, and outcomes of an innovative technique for synchronous reconstruction of the esophagus and voice tube with a free thigh flap (J-flaps). Single-center study from 2011 to 2017 recruiting patients with hypopharyngeal cancer needing laryngopharyngectomy and J-flaps reconstruction. Patient details were analyzed, and surgical outcomes were examined. 20 patients were recruited with an average age of 61. Tumor staging was IIB or above. The average follow-up period was 15months. 65% of these patients resumed a full diet. The row phonation rate was 75%. The average maximum phonation time was 8.9s, and the average number of counting in a breath was 14. Most patients achieved a conversational level of speech capacity with a humanoid voice. J-flap can be utilized safely, supporting the social re-integration of these patients with their new voice.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes.

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks

Introduction Oesophageal perforations and post-oesophagectomy anastomotic leaks are associated with high morbidity and mortality. Endoscopic vacuum therapy (EVT) is a novel treatment strategy with the potential to promote healing and ameliorate sepsis. Only two cases of its use have been reported in the UK in the management of oesophageal wall defects, representing a limited aetiological and demographic spectrum. Material and methods From May to December 2019, 7 patients aged 27–85 years underwent EVT for disparate oesophageal wall defects. Data regarding technical success and feasibility were analysed. Results Complete defect resolution was achieved in six cases (86%), requiring median of 13 days of treatment (range 6–23), and necessitating three replacement procedures (range 1–4). Significant improvement in C-reactive protein was achieved in all patients undergoing treatment (p = .015). No severe complications occurred that resulted directly from sponge placement, however two individuals (33%) developed oesophageal stricture necessitating endoscopic balloon dilatation, and one died whilst undergoing treatment. Conclusion In selected patients EVT is a safe, valuable tool for the management of a spectrum of oesophageal wall defects, with the potential to reduce associated morbidity and mortality. While this work significantly expands upon the UK reported experience of EVT, we outline the requirement for a national, prospective registry of EVT use in oesophageal leaks and perforations. Abbreviations AL: anastomotic leak; CRP: C-reactive protein; CT: computed tomography; EVT: endoscopic vacuum therapy; HES: hospital episode statistics; OGD: oesophago-gastro-duodenoscopy; SEMS: oesophageal stenting with self-expanding stents; UK: United Kingdom

Esophageal localized muscular defect detected immediately after endoscopic submucosal dissection.

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Effectiveness of fibrin sealant as a hemostatic technique in accelerating endoscopic submucosal dissection-induced ulcer healing and preventing stricture in the esophagus: A retrospective study.

The aim of the present retrospective study was to evaluate the effectiveness of conservative electrocoagulation followed by porcine fibrin sealant (FS) as a protective hemostatic technique for wounded microvessels in promoting the healing of endoscopic submucosal dissection (ESD)-induced ulcer, and preventing esophageal strictures that follow ESD. A total of 203 patients with early esophageal cancer or precancerous lesions were retrospectively analyzed. The 1-month ulcer healing and stricture rates were compared between the two groups (combined hemostats and electrocautery groups). The 1-month complete healing rate was 77.0% in the combined hemostats group and 52.6% in the electrocautery group (P=0.003). The use of FS and a smaller resected range (<3/4 circumference) was associated with a better 1-month healing rate. For patients with a ≥3/4 circumference mucosal defect, the esophageal stricture rate was 31.6% (6/19) in the combined hemostats group and 25.0% (2/8) in the electrocautery group. There was no difference in the stricture rate (P=0.737) and dilation time (P=0.733) between the two groups. In conclusion, the application of conservative electrocoagulation followed by porcine FS as a wound-protection technique promoted ESD-induced ulcer healing in the esophagus. However, this combined hemostatic technique was not superior to the conventional hemostatic method in preventing post-ESD stricture in patients with large esophageal mucosal defects.

Evaluation of Bilayer Silk Fibroin Grafts for Tubular Esophagoplasty in a Porcine Defect Model.

Surgical reconstruction of tubular esophageal defects with autologous gastrointestinal segments is the gold standard treatment to replace damaged or diseased esophageal tissues. Unfortunately, this approach is associated with adverse complications, including dysphagia, donor-site morbidity, and in some cases patient death. Bilayer silk fibroin (BLSF) scaffolds were investigated as alternative, acellular grafts for tubular esophagoplasty in a porcine defect model for 3 months of implantation. Adult Yucatan mini-swine (n = 5) were subjected to esophageal reconstruction with tubular BLSF grafts (2 cm in length) in combination with transient esophageal stenting for 2 months followed by a 1-month period, where the graft site was unstented. All animals receiving BLSF grafts survived and were capable of solid food consumption, however strictures were noted at graft regions in 60% of the experimental cohort between 2 and 3 months postop and required balloon dilation. In addition, fluoroscopic analysis showed peristaltic function in only 1/5 neotissues. Following swine harvest at 3 months, ex vivo tissue bath evaluations revealed that neoconduits exhibited contractile responses to carbachol, electric field stimulation, and KCl, whereas sodium nitroprusside and isoproterenol induced relaxation effects. Histological (Masson's Trichrome) and immunohistochemical analyses of regenerated tissue conduits showed a stratified, squamous epithelium expressing pan-cytokeratins buttressed by a vascularized lamina propria containing a smooth muscle-rich muscularis mucosa surrounded by a muscularis externa. Neuronal density, characterized by the presence of synaptophysin-positive boutons, was significantly lower in neotissues in comparison to nonsurgical controls. BLSF scaffolds represent a promising platform for the repair of tubular esophageal defects, however improvements in scaffold design are needed to reduce the rate of complications and improve the extent of constructive tissue remodeling. Impact statement The search for a superior "off-the-shelf" scaffold capable of repairing tubularesophageal defects as well as overcoming limitations associated with conventional autologous gastrointestinal segments remains elusive. The purpose of this study was to investigate the performance of an acellular, bilayer silk fibroin graft (BLSF) for tubular esophagoplasty in a porcine model. Our results demonstrated that BLSF scaffolds supported the formation of tubular neotissues with innervated, vascularized epithelial and muscular components capable of contractile and relaxation responses. BLSF scaffolds represent a promising platform for esophageal tissue engineering.

VACTERL Association in a Newborn – A Rare Case Report

Syndrome or association VACTERL is a group of several birth defects of congenital anomalies in an individual. There must be at least 3 anomalies simultaneously for this syndrome to be referred, including spinal anomalies, anorectal anomalies, cardiac disorders, esophageal atresia with tracheoesophageal fistula, renal anomaly and limb anomalies. The organs involvement in VACTERL may present different severity and quality, from asymptomatic to life-threatening cases. Various studies have reported the other congenital associations such as cerebrovascular and pulmonary anomalies in addition to the above-mentioned called as the non-VACTERL association. The patient in this study had all 6 VCTERL syndrome criteria. The feature of this patient was the involvement of his limb and kidney anomaly, which were different on both sides. However, in previously reported cases, these two anomalies were both in one direction and on the same side. Finally, the VACTERL syndrome and Non-VACTERL Association in this patient represented in the form of esophageal atresia with trachea esophageal fistula and atrial septal defect, and the presence of a kidney with severe hydronephrosis and sacral agenesis and imperforated anus, recto vesical fistula and limb anomalies in the form of one-phalanx fingers on the left.

Multi-layered Free-form 3D Cell-printed Tubular Construct with Decellularized Inner and Outer Esophageal Tissue-derived Bioinks

The incidences of various esophageal diseases (e.g., congenital esophageal stenosis, tracheoesophageal fistula, esophageal atresia, esophageal cancer) are increasing, but esophageal tissue is difficult to be recovered because of its weak regenerative capability. There are no commercialized off-the-shelf alternatives to current esophageal reconstruction and regeneration methods. Surgeons usually use ectopic conduit tissues including stomach and intestine, presumably inducing donor site morbidity and severe complications. To date, polymer-based esophageal substitutes have been studied as an alternative. However, the fabrication techniques are nearly limited to creating only cylindrical outer shapes with the help of additional apparatus (e.g., mandrels for electrospinning) and are unable to recapitulate multi-layered characteristic or complex-shaped inner architectures. 3D bioprinting is known as a suitable method to fabricate complex free-form tubular structures with desired pore characteristic. In this study, we developed a extrusion-based 3D printing technique to control the size and the shape of the pore in a single extrusion process, so that the fabricated structure has a higher flexibility than that fabricated in the conventional process. Based on this suggested technique, we developed a bioprinted 3D esophageal structure with multi-layered features and converged with biochemical microenvironmental cues of esophageal tissue by using decellularizedbioinks from mucosal and muscular layers of native esophageal tissues. The two types of esophageal tissue derived-decellularized extracellular matrix bioinks can mimic the inherent components and composition of original tissues with layer specificity. This structure can be applied to full-thickness circumferential esophageal defects and esophageal regeneration.

Cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy: a case report and review of the literature

BackgroundObesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy.Case presentationThe complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m2) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful.ConclusionsWe made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

A Case of VACTERL Association Complicated with Multiple Rib Abnormalities

VACTERL association is an acronym that includes vertebral anomalies (V), anal atresia (A), cardiac defects (C), tracheoesophageal fistula (TEF) or esophageal atresia (EA), renal anomalies (R), and limb defects (L). Rib abnormalities have rarely been reported with the VACTERL association. The second case of VACTERL association complicated with multiple rib abnormalities will be reported in this case report. A 4-year-old girl who had been diagnosed with congenital cardiovascular disease and received surgical corrections soon after birth consulted our institution by complaining congenital scoliosis. The little girl was diagnosed with VACTERL association (congenital cardiovascular disease, scoliosis with hemivertebra and butterfly vertebra, and nephrolithiasis) and congenital multiple rib abnormalities. The Cobb angle of the main curve was 29.3° before surgery, 19.9° after surgery, and 23° at last follow-up. Multiple rib abnormalities may be seen in the VACTERL association. Clinicians should have a high index of suspicion when evaluating patients with rib abnormalities associated with VACTERL. It is extremely necessary for careful physical examination and detailed auxiliary examination to each system (including echocardiography, computed tomography, magnetic resonance imaging, and so on) when diagnosing VACTERL association. Also, recognizing and understanding the congenital multiple system malformation is important, which aids in the diagnosis of disease and accordingly plan the therapeutic interventions. Early diagnosis of congenital scoliosis with appropriate surgical intervention decreases long-term morbidity.

P91 PHARYNGO-OESOPHAGEAL PERFORATION FOLLOWING CERVICAL SPINE SURGERY: A SINGLE CENTRE EXPERIENCE

Abstract Aim Pharyngo-oesophageal perforation is a rare, life-threatening complication of cervical spine surgery. Only isolated cases are reported in the English literature and correct management of these patients remains poorly defined. The aim of this study is to review our experience to better clarify the appropriate treatment of this dreadful complication. Background and Methods Data regarding demographics, clinical course, diagnosis, management and outcomes of 13 patients (8 M, 5F, mean age 49 years) with oesophageal perforation after cervical spine surgery were collected during the period from 2002 to 2019. Results Pharyngo-oesophageal perforation occurred at a median of 8 days (range 0-4745 days) after cervical spine surgery. Clinical manifestations included neck abscess in 7 cases, fever in 3 cases, dysphagia and regurgitation in 3 cases. In 2 patients conservative management with fasting and antibiotics was attempted but, in both cases, a subsequent surgical intervention was required. All patients underwent surgical treatment. A step-up approach with initial surgical drainage of a purulent cervical collection was performed in 7 patients, delaying definitive surgery after resolution of cervical infection. Definitive surgical treatment with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty (either with sternocleidomastoid or pectoralis major muscle flap) was performed in 10 patients. Perforation recurred in two cases, requiring further surgical management. At a median follow-up of 23 months (range 5-149 months) all patients exhibited permanent resolution of the perforation. Conclusions Pharyngo-oesophageal perforation following cervical spine surgery is a rare but dreadful complication: prompt recognition and treatment of these injuries is critical to minimize morbidity and mortality. Partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients.

P201 LAPAROSCOPIC TRANSHIATAL OMENTAL REPAIR OF IATROGENIC ESOPHAGEAL PERFORATION IN ACHALASIA

Abstract Aim Laparoscopic transhiatal omental patch repair(OPR) of esophageal perforation after pneumatic balloon dilatation(PBD) for achalasia. Background&amp;Methods In August 2018 a 72yrs woman with a history of dysphagia for solids and liquids, nocturnal regurgitation and chest pain had a diagnosis of achalasia. After inhalation during a barium swallow the patient developed fever, respiratory insufficiency and worsening of vital signs leading to ICU and intubation. She developed a right-pleural empyema, massive pneumothorax and right-upper lobe abscess, requiring thoracotomy and right-superior lobectomy. She had been scheduled for a Per Oral Endoscopic Myotomy in November. After the submucosal tunnel, the procedure had been suspended due to presence of fibrosis. In December the patient underwent a first PBD up to 30mm with symptoms resolution and 2kg weight regain. In February, few hours after a second PBD up to 35mm, she complained mild pain at the left hemithorax and fever. 24hrs later a CTscan with water-soluble-contrast revealed a 3cm long esophageal perforation 5cm above the diaphragm and left paraesophageal mediastinal abscess without pleural involvement. Endoscopic treatment was excluded for significant dilatation of the esophagus and the fragile esophageal wall. Because of the frailty status of the patient, the delayed diagnosis, the high risk of a direct suture of the esophageal wall through a left thoracotomy, the even higher risk of an emergency esophagectomy, we performed a laparoscopic approach. Limited dissection of the esophagogastric-junction and of the left diaphragmatic crura allowed access to the abscess cavity, no attempt to direct suture was done, a drain was placed, a pedicled omental flap was realized filling the cavity and repairing the esophageal defect. A jejunostomy was placed. Results The post-op period was uneventful; a CTscan with per-os contrast on POD3 and POD9 didn’t show any collection. The patient started an oral semisolid-diet on POD11. An EGDS on POD19 confirmed the presence of the OPR in the esophageal lumen and after 2-months showed a completely re-epithelialized esophagus. Conclusions Laparoscopic trans hiatal OPR of esophageal perforation in achalasia proved to be a minimally invasive and effective procedure in this patient due to its immunogenic and angiogenetic properties.

Repair of Adult Benign Tracheoesophageal Fistulae With Absorbable Patches: Single-Center Experience

This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique. Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed. An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n= 6), mediastinal radiotherapy (n= 1), and a complication of lung resection (n= 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower. Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

902 Dual Modality Therapy for Endoscopic Management of Esophageal Defects

INTRODUCTION: Previously, surgical management represented the mainstay of therapy for esophageal defects such as tracheoesophageal fistulas, perforations, and post-operative leaks. As technical improvements in devices and endoscopic techniques improved, non-surgical management options increased to include clips, fibrin glue, and endoscopic suturing. Hybrid therapy involving both primary closure of the defect with endoscopic suturing and esophageal stent placement to protect the site was investigated. METHODS: We report a single center experience on dual modal therapy with endoscopic suturing and esophageal stenting for management of esophageal defects including tracheoesophageal fistulas, perforations, and post-operative leaks from 2013 to 2019. Factors such as etiology of defect (spontaneous perforation, iatrogenic perforation, tracheoesophageal fistula), size of defect, prior esophageal surgeries, and other factors were evaluated. Resolution was confirmed using esophagram to rule out leaks. RESULTS: 18 patients underwent dual modality therapy with primary closure using endoscopic suturing with concurrent esophageal stenting. Mean length of defects was 14.5 mm. 2 patients were lost to followup, and 1 patient was excluded because they underwent thoracostomy for concomitant therapy. Of the 15 patients left for analysis, successful closure was achieved in 14 patients.There were no significant complications related to the procedures. CONCLUSION: Early data from dual modality therapy from our single center report appear positive, however, there have not been enough cases to provide sufficient statistical analysis. Still, our combined approach show promising rates of success with minimal adverse effects. Further investigation comparing dual modality therapy with standard therapy are planned to be performed.

2128 Successful Treatment of Large Cavity Esophageal Disruptions With Transluminal Washout and Endoscopic Vacuum Therapy

INTRODUCTION: Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy (EVT) has proven to be a feasible, safe therapy for management of esophageal wall defects, but there is limited data on the effiacy of EVT for large and severe collections. We demonstrate that large and even multiple collections could be managed by EVT with serial endoscopic debridement and washout. CASE DESCRIPTION/METHODS: We describe a retrospective single-center analysis of two patients who underwent EVT for significant esophageal disruptions. Patient 1 developed esophageal perforation from Boerhaave Syndrome with a 2 cm disruption and 10.7 cm cavity, and Patient 2 developed postoperative anastomotic leak after Ivor-Lewis Esophagectomy with two separate disruptions: a 2 cm proximal disruption with a 4 cm mediastinal cavity and 14 cm gastric pull up disruption with a cavity encompassing the entire central and lower right thorax. EVT was accomplished with the use of a standard upper video endoscope, nasogastric (NG) tube and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal/ thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. DISCUSSION: Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross sectional diameter was 10.7 cm. The average number of EVT procedures performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. In conclusion, endoscopic washout and debridement followed by EVT can be effective for large, even multiple, thoracic and/or mediastinal contaminations following esophageal perforation and gastroesopagheal anastamotic dehiscence and leaks in appropriately-selected patients. Our technique involving EVT coupled with serial washout and debridement has the potential to change the current approach to the management of severe mediastinal or thoracic contamination from anastomotic dehiscence and other types of esophageal disruptions.

1934 Atrioesophegeal Fistula, a Rare but Devastating Cause of Upper Gastrointentinal Bleeding

INTRODUCTION: Atrial fibrillation is the most common cardiac arrhythmia globally, with an estimated prevalence of 33.5 million persons. Over the past 20 years, catheter ablation for atrial fibrillation has grown in acceptance and is now a first-line treatment option for patients with symptomatic paroxysmal atrial fibrillation. Atrioesophegeal fistula (AEF) is a rare but often fatal complication associated with atrial fibrillation ablation. CASE DESCRIPTION/METHODS: A 73-year-old woman who underwent radiofrequency ablation for atrial fibrillation 7 weeks prior to presentation to the hospital presented with right-hand weakness, numbness, and ataxia. Initial laboratory evaluation was remarkable for hemoglobin 9.2 g/dL(13.0–17.0 g/dL). Initially, a head computerized tomography (CT) was unremarkable but a subsequent magnetic resonance imaging study demonstrated a right cerebellar stroke. Tissue plasminogen was not prescribed. Transthoracic echocardiogram showed normal left ventricular systolic function, with dilated atria. Later on the day of admission, she developed hematemesis. On day 2 of her admission, she underwent esophagogastroduodenoscopy (EGD) and was found to have a large esophageal defect with thrombus and active bleeding (See Figures 1 and 2). Her clinical status declined quickly and she was taken emergently to the operating room. Unfortunately, despite maximal supportive care, she died prior to surgery. Autopsy revealed an atrioesophageal fistula involving the middle 1/3 of the esophagus and the posterior wall of the left atrium adjacent to the left pulmonary veins. The defects measured 1.5 × 1.0 cm on the esophageal portion and 1 cm × 1 cm on the atrial aspect (See Figure 3). The stomach contained 910 cc of both liquid and clotted blood. DISCUSSION: AEF typically occur 20 ± 12 days post-ablation, ranging from 2 to 60 days. AEF has been reported in surgical RFA, percutaneous RFA, and cryoballoon ablation for atrial fibrillation. CT of the chest with intravenous contrast can show pneumomediastinum, pericardial effusion, and communication between the atrium and esophagus. EGD and transesophageal echocardiogram are not recommended if AEF is suspected, as air insufflation during either procedure may lead to massive air embolization and worsening bleeding. Following the diagnosis of AEF, early surgical intervention is critical as the mortality rate without intervention is 100%. AEF is a rare but often fatal complication of catheter ablation for atrial fibrillation. Untreated, the mortality rate of AEF is 100%.

Comorbidity of esophageal achalasia, mixed anxiety and depressive reaction in a young female patient: problems of diagnosis and treatment

Achalasia cardia (“cardiospasm”, “phrenospasm”, “dolichoesophagus”, “megaesophagus”, “stenosis of cardia”) represents a primary impairment of esophageal motor function associated with impaired lower esophageal sphincter relaxation and peristalsis defects of the thoracic esophagus. It is diagnosed at the age of 25 to 60 years, making up to 20% of all diseases of the esophagus, and is characterized by a triad of symptoms: dysphagia, regurgitation and chest pain when swallowing. In most cases the first manifestations of achalasia are preceded by stress situations in the anamnesis that complicates the differential diagnosis of psychogenic esophageal spasm. The presented clinical case illustrates difficulties of early diagnosis of achalasia cardia in a young femalepatient with severe anxiety and depressive symptoms which develop under conditions of chronic stressful situations in the family or at work. The issues of interdisciplinary interaction of health professionals (physician, gastroenterologist, psychiatrist, psychotherapist, and surgeon) on the course of examination and management of patients with comorbid physical and mental pathology are discussed. The efficiency of the integrative approach to treatment and rehabilitation with the use of modern reconstructive surgical interventions as well as conservative methods of therapy, psychopharmacotherapy and personality-oriented psychotherapy proves the relevance of studying psychosomatic aspects of achalasia cardia.

DOZ047.101: Preclinical studies of tissue engineering for long-gap esophageal atresia in pigs. A systematic literature review

Abstract Introduction Current approaches for esophageal substitution in long-gap esophageal atresia (LGEA) are associated with complications that impact quality of life. Tissue-engineered (TE) esophagus appears as a promise to overcome these issues. The pig has been used as large-animal model to test TE esophagus before its clinical application. Different approaches have been reported. This study aims at conducting a systematic review of TE approaches for complete esophageal defects in pigs. Materials and Methods This work was registered in PROSPERO (ID 127838). A systematic literature review was performed following SYRCLE’s guidelines, using the CAMARADES-NC3Rs platform (SyRF). PubMed and OpenGrey databases were reviewed identifying articles on complete esophagus defects in pigs restored by TE. The analyses of bias and 3Rs were based on the ARRIVE guidelines. Results In the period 2009–2018, 14 articles were identified using pigs as a model for a TE approach in complete esophageal defects. Animal age/weight/sex, size/localization of the defect, TE strategy, follow-up, and outcomes greatly differ among different studies. Few studies report strategies to improve 3Rs and internal validation. Discussion Further studies in LGEA preclinical models should be performed in an attempt to create a defect in the intrathoracic esophagus. Methodological design may help to avoid bias and define strategies related to the 3Rs. TE approaches with best results include the use of different cell populations seeded in scaffolds that are maturated in bioreactors before their implantation. The next questions to be addressed are developing techniques to avoid stent migration and promoting regeneration of the enteric nervous system.