Incidence Of Esophageal Perforation Research Articles

Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation.

Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.

THE BLEEDING MIGRATION: ESOPHAGEAL INJURY FROM CERVICAL HARDWARE

THE BLEEDING MIGRATION: ESOPHAGEAL INJURY FROM CERVICAL HARDWARE

COVID-19 and spontaneous esophageal perforation: a case report

: Pulmonary manifestations of the novel coronavirus, COVID-19, have been discussed heavily in the literature, however, there have been minimal reports regarding extra-pulmonary manifestations of the disease to date. In particular, there has been no literature to date discussing the pathophysiology or incidence of esophageal perforation in the COVID-19 patient. This case report describes a 65-year-old COVID-19 positive male presenting with a case of spontaneous esophageal perforation. The patient underwent esophagogastroduodenoscopy (EGD) with stent placement followed by thoracoscopic evacuation of gastric contents from the pleural spaces and mediastinal drainage. His clinical course was unique in that his esophageal perforation management was complicated by logistical and technical challenges due to COVID-19 infection. Several precautions were required before, during and after each test or intervention performed on the patient. This created a challenging set of circumstances which had not been dealt with in the past. Nevertheless, after a two-week hospital stay, the patient was discharged in stable condition with plans for outpatient follow-up and removal of stent. This case report provides an unusual presentation of esophageal perforation in a patient with concurrent COVID-19 infection while highlighting the special techniques required to diagnose and treat the patient.

Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery

Coronary artery bypass graft (CABG) surgery is the most widely performed cardiac surgery in the United States. Transesophageal echocardiography (TEE) is frequently used in a variety of cardiac surgical procedures, but its clinical benefit in isolated CABG surgery is unclear, and guidelines remain indeterminate. The aim of this study was to compare clinical outcomes among patients undergoing isolated CABG surgery with versus without TEE in order to test the hypothesis that TEE would be associated with improved clinical outcomes after CABG surgery. A matched retrospective cohort study was conducted among Medicare beneficiaries undergoing isolated CABG surgery with versus without intraoperative monitoring using TEE in the United States. The primary analysis was a near/far instrumental variable match that paired hospitals with similar characteristics and patient populations but with opposing probabilities for using TEE in CABG surgery. Outcomes included 30-day mortality, a composite outcome of stroke or 30-day mortality, length of hospitalization, and incidence of esophageal perforation. Of 114,871 patients undergoing isolated CABG surgery, 65,471 (57%) underwent TEE and 49,400 (43%) did not. Hospital-level instrumental variable matched analysis demonstrated that among the subset of 968 matched hospitals, TEE receipt was associated with lower 30-day mortality (3.7% vs 4.9%, P<.001), a lower incidence of the composite outcome of stroke or 30-day mortality (4.5% vs 5.6%, P<.001), no difference in length of hospitalization (10.32 vs 10.52days, P=.26), and no difference in the incidence of esophageal perforation (0.01% vs 0.01%, P=.63). These results were replicated in surgeon-level and patient-level matched-pair instrumental variable analyses, and all analyses were robust to sensitivity analyses that tested for biases introduced by unmeasured confounding. The findings from this study suggest that TEE may offer a clinical benefit to cardiac surgical patients undergoing isolated CABG surgery.

Impact of Extracapsular Lymph Node Involving the Esophagus in Esophageal Perforation During and After Radiotherapy: A Propensity Score-Matched Analysis.

BackgroundThis study aimed to analyze the risk factors for esophageal squamous cell carcinoma (ESCC), especially extracapsular lymph node involving the esophagus (ECLNIE), occurring during or after radiotherapy (RT) in patients with esophageal perforation (EP).MethodsIn total, 306 patients with ESCC who received RT and/or chemotherapy between January 2016 and December 2017 in our hospital and who met the inclusion criteria of the study were recruited. The continuous variables were converted into classification variables using the receiver operating characteristic curve or common clinical parameters. Risk factors for EP were examined by univariable analysis using the chi-square test or Fisher’s exact and by multivariable analysis using logistic regression model. Propensity score matching (PSM) was used to compensate for the differences in baseline characteristics, and the incidence of EP was compared after matching.ResultsEP was observed in 26 patients (incidence rate, 8.5%). Univariable analysis revealed that age, BMI, T4 stage, tumor length, esophageal wall thickness, ECLNIE, necrotic areas, niche sign by esophagogram before RT, neutrophil-to-lymphocyte ratio, and prognostic nutritional index were significantly associated with EP among patients with ESCC who received radiotherapy. Multivariable analysis demonstrated that age, ECLNIE, esophageal wall thickness, and niche sign by esophagogram before RT were independent risk factors for EP. After PSM, compared with patients without ECLNIE, patients with ESCC and ECLNIE had a significantly higher risk of EP.ConclusionThe presence of ECLNIE could be a strong risk factor of EP during and after RT.

Evaluation of oesophagoscopy for staging and restaging of head and neck squamous cell carcinoma

Oesophagoscopy is important in diagnostic and follow up investigation in patients with head and neck squamous cell carcinoma (HNSCC). Second primary malignancies of the oesophagus have major impact on therapy of the primary tumour. Considering the low incidence of oesophageal second primaries and the serious complication of oesophageal perforation routine oesophagoscopy is being discussed. Incidence of oesophageal second primaries and complication rates in oesophagoscopy were identified in a systematic review. A retrospective analysis was performed in our own patient collective. To evaluate the current practice at German ENT Clinics a survey was conducted. 1053 oesophagoscopies in 800 patients were analysed. In 800 patients seven (0.9 %) synchronous secondary malignancies of the oesophagus occurred. In 253 follow up oesophagoscopies five (2 %) metachronous secondary malignancies were discovered. 14 (1.3 %) complications were detected; oesophageal perforation was only detected in one case (0.1 %). There was no association of certain risk factors with the incidence of secondary malignancies. The review of literature showed an incidence of secondary malignancies for Europe/USA of 1.8 % and for Asia of 4.1 %. Incidence of oesophageal perforation was 0-0.2 %. Survey results showed routine oesophagoscopy in staging (100 %) and regularly in follow up (65.3 %). Oesophagoscopy is a convenient method to detect secondary malignancies of the oesophagus. To allow a selection of patients developing secondary malignancies according to risk profiles further prospective multicentre studies are required.

ATRIO-ESOPHAGEAL FISTULA: A RARE AND GRAVE COMPLICATION OF ATRIAL FIBRILLATION ABLATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Atrio-esophageal fistula (AEF) is an extremely rare, life-threatening complication of catheter radiofrequency ablation (RFA) which has an increasing incidence of > 50,000/year in the US. AEF commonly causes death via cerebral air embolism, massive gastrointestinal bleeding (GIB) and septic shock in 2 months post RFA. The associated mortality of AEF is > 80% and requires prompt diagnosis and intervention.(1) CASE PRESENTATION: An 80 year old female with heart failure with reduced ejection fraction and cardiomyopathy due to persistent atrial fibrillation (AF) despite prior interventions presented 18 days post convergent VATS, left atrial (LA) clip/LA appendage ligation with epicardial ablation of LA posterior wall, while on Eliquis to the ER after 1 episode of hematemesis. There was no history of PUD, melena, NSAID use or heavy alcohol use. She had tachycardia but other vitals were normal. Exam revealed dried blood in the mouth, generalized abdominal tenderness but was otherwise normal. Pantoprazole infusion was commenced. Esophagogastroduodenoscopy (EGD) revealed a large deep mid-esophageal ulcer with clot. Post EGD, she became lethargic with acute hypoxic respiratory failure and was intubated. Chest x-ray showed new lung infiltrate and she was started on Zosyn and vancomycin. CTA of the chest revealed a 2.5 cm thrombus in the posterior left atrium and air within the right atrium. Fluconazole was added and she was taken to the OR for LA repair. The next day she underwent esophagectomy and gastric tube placement, during which she developed hemorrhagic shock requiring multiple transfusions and vasopressor support. Blood cultures grew Rothia mucinolaginosus, B6-deficient streptococcus and lactobacillus and CT head showed an acute stroke. Unfortunately, she died after palliative extubation 10 days post admission. DISCUSSION: AEF following RFA has an incidence of < 0.03% and is thought to be multifactorial. Thermal injury during the ablation, results in fistulization of the esophagus into the atrium i.e. AEF, a 1-way valve, causing strokes more often than upper GIB. CTA chest is the modality of choice, as EGD increases the risk of air embolization resulting in stroke or death. Currently early surgical repair appears to have the best survival.(2) Preventative measures such as an esophageal temperature probe for real-time temperature monitoring was used in this case. However, there is a 0.016% incidence of esophageal perforation despite monitoring in 90% of patients.(3) Other strategies to prevent AEF include: reduced power titration while ablating the posterior LA wall, decrease delivery time and active esophageal cooling with saline. CONCLUSIONS: The incidence of RFA for AF is rapidly increasing for which AEF is a rare yet grave complication that uncommonly presents as hematemesis. Awareness is imperative for prompt diagnosis as without urgent surgical intervention mortality approaches 100%. Reference #1: Patricia C, Franz HM, Abel CD, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart. 2015; 2(1), e000257. https://doi.org/10.1136/openhrt-2015- 000257. Reference #2: Singh SM, d’Avila A, Singh SK, et al. Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm. 2013; 10(11):1591–1597. Reference #3: Chirag RB, Saurabh K, Yu G, et al. Global Survey of Esophageal in Atrial Fibrillation: Characteristics and Outcomes of Esophageal Perforation and Fistula. JACC: Clinical Electrophysiology. 2016; 2(2):143-150. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Nisha Gandhi, source=Web Response No relevant relationships by Alexandra Gottdiener, source=Web Response No relevant relationships by Gene Otuonye, source=Web Response No relevant relationships by Dan Ran-Castillo, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response

Stenting the Upper/Cervical Oesophagus with a Proximal Deployment Cervical Oesophageal Stent: Technique and Outcomes.

Proximal oesophageal stent deployment continues to provide challenges due to the proximity of the upper oesophageal sphincter and the associated subsequent complications such as globus sensation and stent migration. Patients with cervical oesophageal cancer have previously had limited stenting options available to them with a paucity of the literature describing the radiological technique for successfully placing these high-risk stents. In this paper, we present our experience using the Taewoong Niti-S CERVICAL Oesophageal Stent. We describe our method for stent deployment highlighting the importance of pre-procedural planning in ensuring an adequate proximal landing zone for the short proximal flare of the stent. Furthermore, we outline how we have adapted our placement technique to incorporate a routine pre-dilatation stage which has optimised retrieval of the proximal to distal deployment system. We have placed eight cervical oesophageal stents within our institution. Contrast swallows in all the patients following stent deployment have demonstrated free flow of contrast to the stomach with all patients reporting symptomatic relief and no foreign body/globus sensation. There has been one episode of stent migration but no incidence of oesophageal perforation or haemorrhage. Evolution of stenting technique and the properties of the stents themselves are improving accuracy of stent placement in relation to the important landmark of the upper oesophageal sphincter. Stenting of cervical oesophageal malignancy has proved successful in our institution and provided symptom relief for a subset of palliative patients who were previously unable to benefit from oesophageal stenting.

Esophageal Perforation Associated With Barotrauma

Esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique. The incidence of esophageal perforation has increased with the advancement of invasive diagnostic technology and the etiology has changed from spontaneous or traumatic to mostly iatrogenic. The incidence of esophageal perforation following external blast injuries is quite rare, 0.004-0.01%. We describe a case of barotrarumatic esophageal perforation. A 30-year-old male presented to hospital following a high pressure air hose injury of mid face and mouth. The patient complained of immediate shortness of breath, neck and facial pain was intubated on scene for stridor and shortness of breath. Examination was significant for facial swelling, subcutaneous emphysema to his neck and upper chest. Computed Tomography(CT) scan of chest was significant for bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema. B/L chest tube were placed followed by resolution of pneumothorax. He was admitted to intensive care unit with preliminary diagnosis of bilateral traumatic pneumothorax and lung contusion. Due to concern for digestive tract injury urgent esophagoscopy (EGD) was performed which didn't reveal any perforation or tears. Further course was complicated by development of empyema and mediastinitis. Repeat CT scan with oral and IV contrast demonstrated a large 4 cm tear in the mid esophagus. The medical therapy included parenteral nutritional support and broad spectrum antibiotics. The patient refused surgical treatment and an esophageal stent was placed under endoscopic and fluoroscopic guidance. Despite the stent placement he developed persistent leak. Perforation was successfully treated by surgical repair with muscle flap followed by interval removal of the stent post surgery. Common clinical manifestations of esophageal perforation include chest pain, dysphagia, dyspnea, subcutaneous emphysema, epigastric pain, fever, tachycardia, and tachypnea. Any combination of these signs and symptoms following instrumentation of the esophagus or respiratory tract implies perforation until proven otherwise. In spontaneous perforations like blast injuries the left border of lower third of thoracic esophagus is involved in 80% of the cases, 3-6cm on average. GI Contrast enhanced CT is the initial choice of diagnosis as its sensitivity ( 92-100% ) is better than esogastroduodenal follow through.

Pediatric esophageal perforation due to firearm injuries during the Syrian war and a new suture technique

Abstract The incidence of esophageal perforation (EP) due to firearm injury (FAI) is markedly low compared with that occurring in other organs. The most frequently reported cause of EP is iatrogenic injuries. The incidence of EP due to penetrating injuries, such as FAI, is very rare and highly destructive. Here we report cases of EP due to FAI in childhood during the Syrian war and elucidate a new suture technique.

Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx

CASE REPORT A 53-year-old woman with a history of neurofibromatosis, Hodgkin's lymphoma, and C3-T2 fusion 4 years prior for swan-neck cervical deformity was admitted for evaluation of left frontal skull mass and progressively worsening dysphagia of solid foods and thick liquids over 6 weeks. Computed tomography (CT) of the abdomen, pelvis, and lumbothoracic spine showed multiple hypodense liver lesions and diffuse sclerotic bone lesions within the thoracic and lumbar spine, ribs, sacrum, and ischium suspicious for metastatic malignancy. Fine-needle aspiration of the liver lesions yielded immunochemistry positive for focal CA 19-9 staining suggestive of adenocarcinoma of upper gastrointestinal (GI) origin. Serum CEA and CA 19-9 were within normal limits. Esophagogastroduodenoscopy did not reveal an upper GI tumor; however, a metal object was seen in the hypopharynx just above the upper esophageal sphincter (Figure 1). It appeared to be fixed and could not be moved with grasping forceps. The adult gastroscope could not be advanced beyond the object; however, the ultraslim could. A sagittal CT view of the neck with contrast showed the offset of the anterior cervical internal fusion plate with direct communication to the hypopharyngeal airway and suggesting erosion through the posterior hypopharyngeal soft tissue (Figure 2). Given the patient's multiple comorbidities and presumably metastatic cholangiocarcinoma, neurosurgery service recommended medical management rather than surgical management. A 6-week course of intravenous ertapenem was initiated due to the high risk of abscess formation. The patient underwent gastric tube placement for feeding and was eventually discharged under hospice care.Figure 1.: Esophagogastroduodenoscopy showing a foreign metal object in the hypopharynx above the upper esophageal sphincter.Figure 2.: Sagittal view of the neck with contrast-enhanced computed tomography showing direct communication between the anterior cervical internal fusion plate and the hypopharyngeal airway.Dysphagia is an underrecognized but significant complication of cervical fusion surgeries.1 The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02% and 1.49% with a mortality rate of 6%.2 Most esophageal erosions occur in the intraoperative or immediate postoperative setting, although there has been an increase in cases with delayed presentation, which often lead to dramatic clinical deterioration with a higher mortality risk of 20-50%.3 Most esophageal injuries are due to iatrogenic injury intraoperatively from inappropriate placement or dislodgement of retractors or hardware migration. Delayed injuries are typically due to chronic compression, abscess formation, repetitive friction of the plating system, or hardware dislodgement and chronic migration.4 Diagnosis can be made with cervical radiographs; however negative imaging does not rule out esophageal injury. Operative intervention is recommended, but conservative medical treatment is appropriate depending on the patient and the clinical circumstances.5 Although cervical endplate erosion of the esophagus has been well documented in the literature, hypopharyngeal erosion has only been reported once previously.6 It is imperative that health care providers are vigilant and complete a thorough workup in patients with persistent or worsening dysphagia who have undergone a previous anterior cervical surgery. DISCLOSURES Author contributions: S. Kothari and T. Almouradi wrote the manuscript. T. Almouradi is the article guarantor.

Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx

CASE REPORT A 53-year-old woman with a history of neurofibromatosis, Hodgkin's lymphoma, and C3-T2 fusion 4 years prior for swan-neck cervical deformity was admitted for evaluation of left frontal skull mass and progressively worsening dysphagia of solid foods and thick liquids over 6 weeks. Computed tomography (CT) of the abdomen, pelvis, and lumbothoracic spine showed multiple hypodense liver lesions and diffuse sclerotic bone lesions within the thoracic and lumbar spine, ribs, sacrum, and ischium suspicious for metastatic malignancy. Fine-needle aspiration of the liver lesions yielded immunochemistry positive for focal CA 19-9 staining suggestive of adenocarcinoma of upper gastrointestinal (GI) origin. Serum CEA and CA 19-9 were within normal limits. Esophagogastroduodenoscopy did not reveal an upper GI tumor; however, a metal object was seen in the hypopharynx just above the upper esophageal sphincter (Figure 1). It appeared to be fixed and could not be moved with grasping forceps. The adult gastroscope could not be advanced beyond the object; however, the ultraslim could. A sagittal CT view of the neck with contrast showed the offset of the anterior cervical internal fusion plate with direct communication to the hypopharyngeal airway and suggesting erosion through the posterior hypopharyngeal soft tissue (Figure 2). Given the patient's multiple comorbidities and presumably metastatic cholangiocarcinoma, neurosurgery service recommended medical management rather than surgical management. A 6-week course of intravenous ertapenem was initiated due to the high risk of abscess formation. The patient underwent gastric tube placement for feeding and was eventually discharged under hospice care.Figure 1.: Esophagogastroduodenoscopy showing a foreign metal object in the hypopharynx above the upper esophageal sphincter.Figure 2.: Sagittal view of the neck with contrast-enhanced computed tomography showing direct communication between the anterior cervical internal fusion plate and the hypopharyngeal airway.Dysphagia is an underrecognized but significant complication of cervical fusion surgeries.1 The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02% and 1.49% with a mortality rate of 6%.2 Most esophageal erosions occur in the intraoperative or immediate postoperative setting, although there has been an increase in cases with delayed presentation, which often lead to dramatic clinical deterioration with a higher mortality risk of 20-50%.3 Most esophageal injuries are due to iatrogenic injury intraoperatively from inappropriate placement or dislodgement of retractors or hardware migration. Delayed injuries are typically due to chronic compression, abscess formation, repetitive friction of the plating system, or hardware dislodgement and chronic migration.4 Diagnosis can be made with cervical radiographs; however negative imaging does not rule out esophageal injury. Operative intervention is recommended, but conservative medical treatment is appropriate depending on the patient and the clinical circumstances.5 Although cervical endplate erosion of the esophagus has been well documented in the literature, hypopharyngeal erosion has only been reported once previously.6 It is imperative that health care providers are vigilant and complete a thorough workup in patients with persistent or worsening dysphagia who have undergone a previous anterior cervical surgery. DISCLOSURES Author contributions: S. Kothari and T. Almouradi wrote the manuscript. T. Almouradi is the article guarantor.

Conservative management of a case of transesophageal echocardiogram-induced esophageal perforation

Esophageal injury or perforation is a rare but life threatening complication of transesophageal echocardiography (TEE). Most of the patients manifest symptoms within 24 hours of the procedure and upper esophagus is the most common site of injury. Incidence of esophageal perforation is relatively rare, in a large series of 10,000 cases of TEE, the incidence of esophageal perforation was reported in 3 cases (0.03%) and in another study it was found to be 1 in 5,000 TEEs, 0.02%. This is a case report that highlights a case of esophageal perforation and false passage discovered accidentally 24 hours postoperatively, in contrast to most of the previous esophageal perforation case reports, a conservative management was undertaken successfully since the discovery of the complication until the full recovery and the discharge of the patient from the cardiac ICU, a follow up upper gastrointestinal endoscopy and CT chest showed progressive resolution of the hematoma surrounding the esophagus, healing of the false passage and recovery of the mediastinal gas locules.

Tu1397 Utility of NBI Magnifying Endoscopy in Patients With Reflux Disease- the Asian Perspective

(2 in dCRT VS 1 in non-dCRT group), 4 pneumonia and 3 GI hemorrhage. Overall complication rate was higher in dCRT group (55% VS 19% with p valueZ 0.017). Four patients (9.7%) had mild retrosternal pain. Recurrent dysphagia occurred in 14 patients (34.14% )[7 stent migrations and 7 tumor ingrowths]. Mean duration of recurrent dysphagia symptom after stent placement was 81 days (121.5 vs 18 days, dCRT vs non dCRT, respectively, pZ0.022). Overall survival was 102.11 days (106.55 in dCRT VS 92.78 days in non-dCRT with pZ 0.189). Conclusion: SEMs placement combined with definite chemoradiation is effective for palliation of dysphagia in advanced esophageal cancer. Dysphagia-free interval after SEMs placements was significantly longer after dCRT compared to those without. However, incidence of esophageal perforation and overall complication seem higher in SEMs after dCRT.

Tu1396 Longer Term Follow up After Endoscopic Treatment of GERD With the Medigus SRS™ Endoscopic Stapling Device

(2 in dCRT VS 1 in non-dCRT group), 4 pneumonia and 3 GI hemorrhage. Overall complication rate was higher in dCRT group (55% VS 19% with p valueZ 0.017). Four patients (9.7%) had mild retrosternal pain. Recurrent dysphagia occurred in 14 patients (34.14% )[7 stent migrations and 7 tumor ingrowths]. Mean duration of recurrent dysphagia symptom after stent placement was 81 days (121.5 vs 18 days, dCRT vs non dCRT, respectively, pZ0.022). Overall survival was 102.11 days (106.55 in dCRT VS 92.78 days in non-dCRT with pZ 0.189). Conclusion: SEMs placement combined with definite chemoradiation is effective for palliation of dysphagia in advanced esophageal cancer. Dysphagia-free interval after SEMs placements was significantly longer after dCRT compared to those without. However, incidence of esophageal perforation and overall complication seem higher in SEMs after dCRT.

Esophageal Perforation, the Most Feared Complication of TEE: Early Recognition by Multimodality Imaging

Esophageal perforation is the most feared complication of transesophageal echocardiography (TEE), although the overall risk is extremely low. We report a case of esophageal perforation in a 77-year-old woman who had no apparent contraindications to TEE. Chronic steroid therapy for symptoms of asthma as well as osteophytic changes of the cervical vertebrae contributed to her increased risk of perforation. Unlike in prior reports, the perforation in this case was fortuitously recognized rapidly due to ingestion of a carbonated beverage for evaluation of a hiatal hernia suspected during a subsequent transthoracic echocardiogram performed because of inadequate TEE images after a difficult intubation. The incidence of esophageal perforation in our series (1 in 5,000 TEEs, 0.02%) is similar to that reported in the literature. Early recognition and prompt surgical repair of the esophageal perforation led to favorable outcome in our patient.

Robotic-assisted Heller myotomy for esophageal achalasia: feasibility, technique, and short-term outcomes.

Laparoscopic Heller myotomy is the standard surgical treatment for esophageal achalasia. The incidence of esophageal perforation is about 5-10%. Robotic-assisted Heller myotomy (RAHM) offers results at least as good as those from laparoscopic procedures, additionally yielding fewer intraoperative complications. The aim of this study was to demonstrate the safety and feasibility of RAHM and its value in the treatment of esophageal achalasia. We analyzed demographics, preoperative symptoms, esophagograms, esophageal manometry, intraoperative and postoperative data of all the patients who underwent RAHM for achalasia at three institutions: 36 women and 37 men, mean age 45±16 (13-87) years. Dysphagia was present in 100% of patients. Thirty-three patients (45%) had had previous endoscopic treatment: 23 patients had pneumatic dilation, four patients had Botox injections, and six patients had both. Surgical time averaged 119min (range of 62-211); blood loss averaged 23ml; no mucosal perforations were observed; length of hospitalization was 1.5days; there were no deaths. At 12months, 96% of patients had relief of their dysphagia. In conclusion, RAHM is safe and effective since there were no intraoperative esophageal perforations and relief of symptoms was achieved in 96% of the patients.

Oesophageal Perforations in Iceland: a Whole Population Study on Incidence, Aetiology and Surgical Outcome

Oesophageal perforation is a rare but life-threatening condition with a significant morbidity and mortality. In this retrospective, nationwide study, the results of oesophageal perforation are reported for a well defined cohort, with special emphasis on the incidence, aetiology and results of surgical treatment. 29 consecutive patients (16 males) were diagnosed with perforation of the oesophagus at Landspitali University Hospital between 1980 and 2007. Patients had a mean age of 61 years (range: 7 months-90 years). Type of surgery, complications and survival were recorded. Average follow-up was 76 months. Age-standardised incidence of oesophageal perforation was 3.1/1,000,000 per year during the study period. Out of 29 patients diagnosed with oesophageal perforation, the diagnosis was missed in 5 cases (17%) and first made at autopsy. Iatrogenic injury was the most frequent cause (52%), followed by spontaneous perforation (24%) and foreign body ingestion (17%). Thoracic perforations were seen in 73% of patients, and 14 patients had an underlying oesophageal disease. Nineteen patients were treated surgically, in 16 cases with drainage of the mediastinum via thoracotomy and insertion of chest tubes. The median time from perforation to surgery was 6.5 h and median length of hospital stay was 15 days (range: 9-83). All surgically treated patients survived surgery, and the 5-year overall survival rate was 69%. More than half of all oesophageal injuries in Iceland are caused by a iatrogenic injury. Mortality is significant and is related to a missed diagnosis. Patients treated surgically all survived surgery; however, complications were frequent and their hospital stay was long.

Esophageal perforations

The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.

Endoscopic Closure of Esophageal Perforations By Means of a Retractable Covered Nitinol Stent: A Randomized Controlled Animal Study

Background and Aims: Esophageal perforations during upper endoscopy are rare. However, since endoscopic techniques like EMR and ESD are increasingly used, so may the incidence of esophageal perforations. In addition, Spontanous esophageal perforations can occur due to barotrauma or ingestion of foreign material. Intentional opening of the esophageal wall has been used to perform NOTES mediastinoscopy. Material and Methods: In 12 domestic pigs 15mm oesophageal perforations were created using needle knife incision and a 15mm dilatation balloon with the animals under general anaesthesia. After randomisation pigs were assigned to either surgical repair (n=6) or endoscopic closure (n=6). A self-expandable nitinol stent covered by a plastic membrane preloaded in an emergency delivery system (SX-ELLA stent, ELLA-CS, diameter 25mm, length 135mm) was used for perforation closure. Surgical repair was achieved by open thoracoscopy. Pressurized leak tests of the perforation closures were performed following necropsy. Additionally pressurized leak test were performed in an ex vivo evaluation of hand-sewn closures of 15mm large esophageal scalpel incisions (n=15) and of healthy esophageal tissue (n=20). Tissue for ex vivo evaluation was obtained from freshly killed pigs. Results: Mean time for endoscopic stenting was 7 min. (Range 4-12 min., SD 2.8). No complication occurred during any of the closure procedures. At necropsy and macroscopic examination all perforation sites were completely covered by the stent membrane. Pressurized leak test showed a mean burst pressure of 138 mmHg (Range 100-270, SD 66) for stent closures and a mean burst pressure of 180 mmHg (Range 60-300, SD 103) for surgical sutures. Ex vivo hand-sewn sutures of 15mm scalpel incisions exhibited a mean burst pressure of 174 mmHg (Range 50-300, SD 89) and ex vivo esophageal tissue exhibited a burst pressure of >300 mmHg in 17/20 cases and a burst pressure of 300 mmHg in 3/20 cases. Ex vivo esophageal tissue burst pressure was significantly higher compared to stent closure (p<0.01), in vivo surgical closures (p<0.01), and ex vivo hand-sewn closures (p<0.01). Stent closures were comparable to surgical closures (p=0.428) and to ex vivo hand-sewn closures (p=0.378). In vivo surgical closures were comparable to ex vivo hand-sewn closures (p=0.912). Conclusions: Endoscopic closure of 15mm esophageal perforations by means of the retractable, covered nitionol stent is feasible. Further research in survival studies has to be conducted to evaluate wound healing of the esophageal perforations sites.