Mediastinal Abscess Research Articles

Pre-Procedural Predictors of Successful Endoscopic Sleeve Gastroplasty: A Retrospective Study

Objective: Obesity is a major risk factor for the morbidity and mortality of cardiovascular disease and predicts the development of hypertension, diabetes mellitus and other various diseases. Methods: A retrospective study evaluated predictors for higher total body weight loss following endoscopic sleeve gastroplasty (ESG). Adults (>18 years old) with BMI > 30 kg/m2 who underwent ESG from January 2019 to July 2022 were included. Patients under the age of 18 were excluded from the study. Results: This retrospective cohort included 76 patients, of whom 62 women (81.6%) and 14 were men (18.4%) with a mean age of 46.3 ± 10.4. The mean BMI baseline was 36.6 ± 4.21. Out of the included patients, 10% were lost to follow-up at 1 month, 33% at 3 months, 50% after 6 months, and only 30% met 12 months follow-up. During the follow-up period, no mortality was documented. Three major adverse events (3.9%) were documented (one mediastinal abscess, one lower gastrointestinal bleeding and one pulmonary embolism), all of them in female patients. Among the demographic clinical and laboratory data examined, smoking (N = 6, p < 0.001) was associated with successful ESG, which was determined as total body weight loss (TBWL) above 15%. The rest of the variables examined were not shown to be statistically significant to sleeve success. Overall, 65 of the 76 patients which were studied in this research had more than 5% TBWL, 42 patients had more than 10% TBWL, 21 patients had more than 15% TBWL and 7 patients lost more than 20% of their weight during 1 year of follow-up. Maximal TBWL was achieved 3 months following the procedure. During the first month following ESG, the average weight lost was 8.6% (N = 69); at 3 months, it was 12.3% (N = 48); at 6 months, it was 11.3% (N = 33); and at 12 months, it was 9.8% (N = 13). Smoking was associated with higher weight loss. Conclusions: The current study showed a positive correlation between ESG weight loss above 15% and smoking. Older patients (>50) gained weight earlier, within 3 months, and by 1 year of follow-up almost returned back to their original weight. Females sustained weight loss over 1 year of follow-up compared to males. Patients with lower BMI continued losing weight during the follow-up period (12 months). This study tries to summarize pre-procedural prediction of ESG success.

A case of recurrent posterior mediastinal abscess after COVID-19 successfully treated with thoracoscopic surgery

A case of recurrent posterior mediastinal abscess after COVID-19 successfully treated with thoracoscopic surgery

Conservative management of complicated retropharyngeal abscess with Antitubercular Therapy

Retropharyngeal abscess, the infection of deep neck spaces, extends from the base of the skull to the posterior mediastinum. It develops as a sequela of dental infection, upper respiratory tract infection, or any interventional procedure like laryngoscopy, endotracheal intubation, etc. Retropharyngeal abscess is a rare presentation of Tuberculosis (TB), with an annual incidence rate of 2.64 per 100,000 population, and gender-based incidence rates of 3.34 for males, and 1.94 for females per 100,000 population.1 It, as a part of head and neck TB, has a prevalence of 0.1-1% among all forms of TB. If not managed timely, it may lead to the spread of its infection to the mediastinum, which can be life-threatening at times, owing to airway compromission and other catastrophic complications like mediastinitis, mediastinal abscess, pericarditis, pyopneumothorax pleuritis and empyema. We hereby present a case of a middle-aged woman diagnosed with a complicated retropharyngeal abscess but managed conservatively with Antitubercular Therapy (ATT).

Exclusive Transcervical Drainage for Posterior Mediastinal Abscess Originating from a Mandibular Molar.

The progression of a cervical abscess toward the mediastinum is rare but remains one of the most serious diseases, even in the era of antibiotics. A mediastinal abscess can originate from an odontogenic infection and presents a challenge for otolaryngologists and craniofacial surgeons, particularly when it spreads caudally to the tracheal bifurcation. For successful treatment of such an abscess, patients are generally referred to a thoracic surgeon for drainage. We present a distinctive case of an odontogenic infection-induced wide mediastinal abscess that could be drained only through cervical manipulation by using a sump-type tube. The patient was discharged on postoperative day 55 without any complications. This is the first report showing that descending mediastinal abscesses extending below the tracheal bifurcation could be drained by head and neck surgeons alone. The technique is easy and hence reproducible, safe, and convenient to perform.

Effect of sternocleidomastoid flap repair and endoscopic injection of emulsified adipose tissue stromal vascular fraction in the treatment of refractory cervical anastomotic leak contaminating mediastinum.

Mediastinal infection caused by anastomotic leak is hard to cure, mainly because the poor drainage at the site of mediastinal infection leads to persistent cavity infection, which in turn becomes a refractory mediastinal abscess cavity after minimally invasive esophagectomy (MIE)-McKeown. Herein, we explored sternocleidomastoid (SCM) muscle flaps and emulsified adipose tissue stromal vascular fraction containing adipose-derived stem-cells to address this issue. We studied 10 patients with esophageal cancer who underwent MIE-McKeown + 2-field lymphadenectomy and developed anastomotic and mediastinal leak and received new technology treatment in the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to March 2022. The clinical data and prognosis of the patients were collected and analyzed. A total of 5 patients received this surgery, and no other complications occurred during the perioperative period. Among the 5 patients, 1 patient was partially cured, and 4 patients were completely cured. During the follow-up 3 months postoperatively, all these 5 patients could eat regular food smoothly, and no relapse of leak and mediastinal infection occurred. The new surgical method has achieved good results in the treatment of anastomotic leak. Compared with the traditional thoracotomy, it is a less invasive and feasible surgical approach, which can be used as a supplement to the effective surgical treatment of cervical anastomotic leak contaminating the mediastinum.

Translocation of a fish spike from the pharynx to the thyroid gland: A case report

BACKGROUND A fish spike stuck in the throat is a common ear, nose, and throat (ENT) emergency. However, it is very rare for a fish spike to reach the thyroid tissue through the throat, which is very dangerous and can lead to pharyngeal fistula, cervical abscess, mediastinal abscess, and thyroid abscess. Proper and timely management can help reduce complications, especially in elderly patients. CASE SUMMARY In the case presented here, the causative factor was dentures, but improper management aggravated the condition. In the case presented here, an elderly woman with a history of accidentally swallowing fish bones for 20 d had a sensation of foreign bodies in her throat. Eventually, computed tomography (CT) of the neck showed that the left side of the thyroid gland had a dense shadow in the form of a stripe. CONCLUSION If a fishbone foreign body is not visible during endoscopic examination but the patient has significant symptoms, the surgeon should be aware that the fishbone may be lodged in the thyroid. To avoid a misdiagnosis, ultrasound, CT, and other tests can be used to clarify the diagnosis. T The first step in treating a fish bone in the thyroid gland is to determine the position of the foreign body and the extent of the infection, and to develop a personalized surgical plan for its removal. At the same time, scientific information should be made available to the general public so that people know that if a fish bone is accidentally lodged, they should not force it to be swallowed or be spit out by inducing vomiting, which are incorrect methods and may aggravate the condition or even cause it to migrate outside the cavity, leading to serious complications, as in this reported case.

A successful endovascular aortic repair of aortoesophageal fistula following esophagectomy: a case report and literature review

BackgroundAortoesophageal fistula (AEF) is an extremely rare and highly fatal complication leading to a high risk of morbidity and mortality. Successful management of AEF after esophagectomy for esophageal carcinoma has rarely been reported in the literature.Case presentationHere we present a rare case of a 44-year-old female with complications of AEF after esophagectomy for esophageal carcinoma, mainly presented as vomiting of blood. Both computed tomographic and computed tomography angiography of the chest showed bilateral pleural effusion and atelectasis, while gastroscopy showed large gastrointestinal bleeding. Emergency surgery was performed that included the removal of the mediastinal abscess, left lower pulmonary wedge resection, and thoracic endovascular aortic repair (TEVAR), followed by supportive treatment. The surgery went successful, and the patient was followed up for 1 year after discharge and showed good recovery. We also reviewed previous literature on the history, causes, pathophysiology, clinical presentation, diagnosis, and treatment of AEF after esophagectomy for esophageal adenocarcinoma.ConclusionsIn our case, thoracotomy combined with TEVAR was effective in treating AEF after esophagectomy for esophageal adenocarcinoma. This case provides successful experiences for clinical diagnosis and treatment of AEF after esophagectomy for esophageal carcinoma.

Tuberculous Mediastinitis with Mediastinal Abscess in an Immunocompetent Man Presented with Fever, Acute Dyspnoea, Chest Pain, Chest Wall Swelling, Acute Kidney Injury, Transaminitis and DIC: Rare Case Report

Tuberculous Mediastinitis with Mediastinal Abscess in an Immunocompetent Man Presented with Fever, Acute Dyspnoea, Chest Pain, Chest Wall Swelling, Acute Kidney Injury, Transaminitis and DIC: Rare Case Report

EGS P17 Expanding the technical armamentarium to treat complex oesophageal perforations with Endoluminal Vacuum Therapy

Abstract Background Endoluminal vacuum therapy (EVT) is increasingly the default treatment modality for oesophageal leaks. If the leak cavity is large or has a dependent element, placement of the endoluminal vacuum device within the leak cavity facilitates healing. However, accessing the leak cavity can be challenging when the oesophageal defect communicating with the leak cavity is small, and it is tempting to default to luminal EVT. This can lead to a EVT failure. We present a case where luminal EVT in the presence of an established leak cavity with a narrow inlet resulted in stagnation of therapy requiring an alternative technical approach. Methods An 80-year-old high-risk female with Boerhaave's syndrome presented with a 4cm esophageal defect and a large mediastinal leak cavity. An ad-hoc endovacuum therapy (EVT) device, consisting of V.A.C granufoam (KCI) attached to a 14Fr nasogastric (NG) tube, was placed in the leak cavity at -125mmHg pressure. The EVT device was replaced every 3-8 days. After 101 days, luminal EVT was adopted due to cavity narrowing. Partial closure of the esophageal defect was achieved, but a persistent mediastinal abscess communicated through a residual pinhole defect. Additional luminal EVT and image-guided drainage couldn't resolve the persistent esophageal fistula, confirmed by contrast-enhanced CT. Results Endoluminal access to the leak cavity was re-established by dilating the fistula using a TTS 12mm radial expansion wire-guided balloon catheter enabling re-establishment of intra-cavity EVT. Having regained access, further intra-cavity EVT using an ad-hoc EVT device fashioned from black granufoam (KCI) sutured to a 10Fr or 12Fr ng tube with 125mmHg negative pressure was applied. The EVT device was changed every 3-6 days. After further 25 days of EVT complete healing was observed. Conclusions Whilst intraluminal EVT has a role in oesophageal leaks associated with small leak cavities which have no dependent element, larger leak cavities require intra-cavity EVT. If access to the leak cavity is challenging due to the small size of the oesophageal defect, endoscopic measures to facilitate endoluminal access to the leak cavity such as dilation of the defect can be safely employed to enable delivery of intra-cavity EVT. This should be considered when endoluminal access to the leak cavity is prevented due to the small size of the defect obviating the need for other more invasive interventions such as surgery.

Transoral traumatic perforation of the pyriform sinus by a marker pen: report of an infant case

BackgroundPerforation of the pyriform sinus, included in hypopharyngeal injury, is a rare condition typically caused by iatrogenic factors. We present a case of an infant who developed deep cervical and mediastinal abscesses due to a traumatic pyriform sinus perforation caused by accidentally falling with a marker pen in the mouth.Case presentationAn 11-month-old healthy male infant fell on a trampoline with a marker pen in his mouth. The patient developed swelling in the neck 3 h after the incident and was taken to a regional general hospital. Although a laryngoscopy showed no perforation in the oral cavity or posterior pharynx, a computed tomography (CT) scan revealed significant emphysema extending from the cervix to the mediastinum. The patient was transferred to our tertiary hospital and admitted to the intensive care unit, where he was mechanically ventilated, and antibiotic therapy was initiated. On day 3 of admission, a CT scan revealed deep abscesses in the cervical and upper posterior mediastinum with pneumomediastinum. Although his respiratory status stabilized and he was temporarily weaned, the fever recurred. Pharyngoesopagography revealed significant leakage of contrast from the left pyriform sinus to the mediastinum. Consequently, surgical drainage of the abscess was performed on day 10. Two low-pressure continuous suction drains were placed, one in the posterior mediastinum and the other close to the pyriform sinus. Pharyngoesophagography on postoperative day (POD) 7 demonstrated decreased contrast leakage into the posterior mediastinum. The patient was initiated on enteral nutrition through a nasogastric tube. The patient was discharged on POD 31 after the suction drains were replaced with open Penrose drains, and enteral nutrition via nasogastric tube was continued at home. The Penrose drains were removed on POD 54, and salivary leakage ceased on POD 111.ConclusionsAlthough injuries to the oral cavity and posterior pharynx are more easily recognized, the existence of injury in the pyriform sinus can be challenging to evaluate. However, prompt and appropriate management, including intubation, antibiotic therapy, surgical drainage, and nutritional support, is critical in preventing life-threatening complications.

A DEVASTATING COMPLICATION OF DENTAL EXTRACTION: LEMIERRE’S SYNDROME WITH NECK AND MEDIASTINAL ABSCESS

A dental extraction is a frequently performed procedure in daily routine. Fatal infections may occur after dental extraction due to the richness of the oropharyngeal flora from aerobic and anaerobic microorganisms. Oropharyngeal infections can extend into the neck and mediastinum via cervical fascia leading to severe inflammation in soft tissues and vessels with life-threatening complications. We present a patient with complications after dental extraction procedure including severe deep neck inflammation, thrombophlebitis of jugular vein (Lemierre’s syndrome), mediastinal abscess, and empyema. A dental extraction is the most frequent cause of the oral infection that may cause coexisting and individually life-threatening complications in diabetic patients.

Post-extubation use of high-flow nasal oxygenation induces upper airway leak and intrathoracic sepsis after successful Bentall procedure: A case report.

In recent few years, high-flow nasal oxygenation (HFNO) has been widely used for management of acute hypoxemic respiratory failure and during postextubation periods, including after endotracheal intubation general anesthesia (ETGA). However, HFNO generates positive pressure in the injured airway following removal of endotracheal tube may cause airway leaks. This is the first case report of severe airway leak syndrome following postextubation use of HFNO in surgical patients. This case report describes a 75-year-old female with critical aortic stenosis who underwent an emergency Bentall procedure. HFNO (flow rate of 45 L/min) was applied after weaning from mechanical ventilation and removal of the endotracheal tube. At 6 hours after HFNO application, subcutaneous emphysema in the neck bilaterally and face was noted, and the emphysema extended into the supraclavicular regions. The HFNO cannula was removed soon after and the patient was re-intubated with an endotracheal tube the following day due to progressive respiratory insufficiency. Unfortunately, the patient general condition deteriorated, as the subcutaneous air collections progressed into deep tissue infections of the neck, mediastinal abscesses, and left-sided empyema. Patient received surgical interventions repeatedly to drain the mediastinal abscess and empiric antimicrobial therapy was given. The patient passed away about 2 months later due to uncontrollable sepsis. Air leaks in the upper airway can occur during the use of post-extubation HFNO use, and the resulting subcutaneous emphysema can progress to severe intrathoracic infections in surgical patients who have a sternotomy wound. Therefore, HFNO-induced subcutaneous emphysema should be treated more aggressively in open thoracic or sternotomy surgeries to prevent the development of intrathoracic sepsis.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BackgroundHere, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.Case presentationA 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.ConclusionsIntercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Psoas and Mediastinal Abscesses During Intravenous Tocilizumab Treatment in Multicentric Castleman Disease.

Tocilizumab has been used to treat idiopathic multicentric Castleman disease (iMCD). As tocilizumab prevents interleukin-6 from exerting pro-inflammatory effects, there is some concern about a delayed diagnosis of severe infections during tocilizumab treatment. Although serious infections during tocilizumab therapy have been previously described in patients with rheumatoid arthritis, they have not been reported in iMCD. We herein report a case of disseminated Staphylococcus aureus infection after a superficial skin wound followed by psoas and mediastinal abscesses with pyogenic spondylodiscitis in an iMCD patient with diabetes. Physicians should be alert for the occurrence of disseminated S. aureus infection after even minor skin injury during tocilizumab therapy.

Mediastinal Abscess Induced by Group B Streptococcus.

Mediastinal Abscess Induced by Group B Streptococcus.

Iatrogenic Neonatal Esophageal Perforation: A European Multicentre Review on Management and Outcomes.

The aim of this multicenter retrospective study and literature review was to review management and outcomes of neonatal esophageal perforation (NEP). Protocol data were collected from four European Centers on gestational age, factors surrounding feeding tube insertion, management and outcomes. The 5-year study period (2014-2018) identified eight neonates with median gestational age of 26 + 4 weeks (23 + 4-39) and median birth weight 636 g (511-3500). All patients had NEP from enterogastric tube insertions, with the perforation occurring at median 1st day of life (range 0-25). Seven/eight patients were ventilated (two/seven-high frequency oscillation). NEP became apparent on first tube placement (n = 1), first change (n = 5), and after multiple changes (n = 2). Site of perforation was known in six (distal n = 3, proximal n = 2 and middle n = 1). Diagnosis was established by respiratory distress (n = 4), respiratory distress and sepsis (n = 2) and post-insertion chest X-ray (n = 2). Management in all patients included antibiotics and parenteral nutrition with two/eight receiving steroids and ranitidine, one/eight steroids only and one/eight ranitidine only. One neonate had a gastrostomy inserted, while in another an enterogastric tube was orally successfully re-inserted. Two neonates developed pleural effusion and/or mediastinal abscess requiring chest tube. Three neonates had significant morbidities (related to prematurity) and there was one death 10 days post-perforation (related to prematurity complications). NEP during NGT insertion is rare even in premature infants after evaluating data from four tertiary centers and reviewing the literature. In this small cohort, conservative management seems to be safe. A larger sample size will be necessary to answer questions on efficacy of antibiotics, antacids and NGT re-insertion time frame in NEP.

Risk Factors of Descending Necrotizing Mediastinitis in Deep Neck Abscesses.

Background and Objectives: Cervical space infection could also extend to the mediastinum due to the anatomical vicinity. The mortality rate of descending necrotizing mediastinitis is 85% if untreated. The aim of this study was to identify risk factors for the progression of deep neck abscesses to descending necrotizing mediastinitis. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing surgical treatment of deep neck abscesses from August 2017 to July 2022. Computed tomography (CT) was performed in all patients. Before surgery, lab data including hemoglobulin (Hb), white blood cell count, neutrophil percentage, C-reactive protein (CRP) level, and blood glucose were recorded. Patients' characteristics including gender, age, etiology, and presenting symptoms were collected. Hospitalization duration and bacterial cultures from the wound were also analyzed. Results: The C-reactive protein (CRP) level was higher in patients with a mediastinal abscess than in patients without a mediastinal abscess (340.9 ± 33.0 mg/L vs. 190.1 ± 72.7 mg/L) (p = 0.000). The submandibular space was more commonly affected in patients without a mediastinal abscess (p = 0.048). The retropharyngeal (p = 0.003) and anterior visceral (p = 0.006) spaces were more commonly affected in patients with a mediastinal abscess. Conclusions: Descending necrtotizing mediastinitis results in mortality and longer hospitalization times. Early detection of a mediastinal abscess on CT is crucial for treatment. Excluding abscesses of the anterior superior mediastinum for which transcervical drainage is sufficient, other mediastinal abscesses require multimodal treatment including ENT and thoracic surgery to achieve a good outcome.

Primary tracheobronchial necrosis after esophagectomy: A nationwide multicenter retrospective study in Japan.

The clinical features of postoperative primary tracheobronchial necrosis (P-TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P-TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort. As a study of the Japan Broncho-Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P-TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation. P-TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P-TBN for pharyngo-laryngo-cervical esophagectomy (PLCE; n=1650), total pharyngo-laryngo-esophagectomy (TPLE; n=205), and subtotal esophagectomy (SE; n=4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P=0.016) and the higher level of the tracheal resection (P=0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P=0.009) and Grade 3 (P=0.004) than in those with Grade 1. The incidence of TBN restricted to P-TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P-TBN, especially in PLCE and TPLE. Our new P-TBN severity grade may predict the outcome of patients with P-TBN.

S2765 Rapid Development of Cervical Adenocarcinoma in a Young Woman With Crohn’s Disease

Introduction: Inflammatory bowel disease (IBD), further characterized into Crohn’s disease or ulcerative colitis, is a chronic condition that involves immune-mediated inflammation and subsequent damage to the gastrointestinal tract. Treatment involves immunosuppression, increasing risk for infections and malignancies. Elevated cervical cancer rates are seen in these patients, and thus guidelines recommend annual cervical cancer screening in women receiving immunosuppressive therapy. Case Description/Methods: A 46-year-old female with Crohn’s disease (diagnosed at 18) presented with left lower quadrant pain and bloating. Her disease was steroid-refractory and did not respond to mesalamine, azathioprine, or adalimumab. She was in remission for four years on infliximab, however, it was discontinued after a spontaneous mediastinal abscess. She was later treated with vedolizumab and eventually ustekinumab. She had a history of recurrent infections with a negative primary immunodeficiency workup. Computed tomography (CT) abdomen/pelvis revealed two large pelvic masses. Surgical pathology confirmed stage IVA cervical adenocarcinoma, human papillomavirus (HPV) independent, with involvement of the bilateral ovaries and fallopian tubes. CT abdomen/pelvis and Papanicolau smear with HPV co-testing performed less than a year prior to her cancer diagnosis were negative for evidence of malignancy. Discussion: Human papillomavirus (HPV) is the most common cause of cervical cancer. It has been hypothesized that HPV underlies the elevated cervical cancer risk in immunosuppressed patients. This case is notable as it involves an HPV-independent cervical cancer, found at an advanced stage, in a relatively young patient on immunosuppression. To the best of our knowledge, no similar reports have been described in the literature. Liquid based cytology pap smear and high risk HPV cotesting have demonstrated high sensitivity for cervical cancer screening. HPV-negative cervical cancers comprise only a small proportion of cervical neoplasms and are almost entirely adenocarcinomas. These cancers are often diagnosed at an advanced stage. ACG guidelines currently recommend annual screening for patients on immunosuppressive therapy. As in the case we have described, immunosuppressed patients can still develop advanced cancers between screening intervals. When caring for immunosuppressed IBD patients, there should be a low threshold for additional evaluation if patients develop signs or symptoms concerning for underlying malignancy.

303. A NOVEL ‘WATERFALL METHOD’ OF FILLING THE POSTERIOR MEDIASTINAL CAVITY AFTER ESOPHAGECTOMY USING OMENTAL FLAP IN RETROSTERNAL GASTRIC TUBE RECONSTRUCTION

Abstract Post-esophagectomized mediastinal dead space can cause not only mediastinal abscess in R2 resection, but also airway trouble in salvage surgery or combined resection of the airway system due to intra-thoracic great pressure fluctuations. Therefore, dead space filling is critical to prevent them. Dead space is filled with an omentum pulled up in posterior mediastinal route along with the gastric tube. However, it causes delayed gastric empty, considerably decreasing the patient’s quality of life (QOL). We have developed a new technique to fill the dead space by dropping the omentum from the anterior to the posterior mediastinum after lifting it in the retrosternal route along with the gastric tube, and named it the waterfall method. When creating a gastric tube, the omentum is taken as many as possible, and is fixed to pull-up thread so that it is about 15 cm below the tip of the gastric tube. After lifting the gastric tube to the neck, pull the omental flap down through a small incision in the anterior mediastinal pleura and fill the mediastinal dead space. Of 630 esophageal cancer patients who underwent surgery from January 2012 to March 2022, this new technique was adopted to 20 patients (mean age: 65Y, male/female: 16/4). The reason for adaptation was R2 resection in 7, salvage surgery in 4, combined resection of the airway system in 8 and other in 1. All patients underwent chemoradiation with more than 50 Gy or triplet chemotherapy preoperatively. Minor anastomotic leakage was observed in 2 and pneumonia and pneumothorax in 3 and 3, respectively. But no development of mediastinal abscess or airway fistula was observed, and no patient complained delayed gastric empty. Our new technique to fill the post-esophagectomized mediastinal dead space by dropping an omental flap from the anterior to the posterior mediastinum was considered useful, safe and feasible to prevent the development of mediastinal abscess or airway fistula. Since there is no symptom of delayed gastric empty, it is considered to be one of the useful surgical procedures that can maintain the patient’s QOL as well as prevent postoperative complications.