Esophageal Leaks Research Articles

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score.

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score. This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally. Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification. The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

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

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

124: DETERMINING SEVERITY OF ESOPHAGEAL ANASTOMOTIC LEAK IN PATIENTS AFTER ESOPHAGECTOMY: DEVELOPMENT OF THE SEAL SCORE

Abstract Background and aim Anastomotic leakage (AL) is a common and severe complication after esophagectomy, but it is largely unknown how to assess leakage severity at the time of diagnosis. We aimed to develop the Severity of Esophageal Anastomotic Leak (SEAL) score, a tool to predict leakage severity at the time of diagnosis. Methods The TENTACLE—Esophagus study is an international retrospective cohort study, in which 1509 patients with AL after esophagectomy between 2011 and 2019 were included in 71 centers from 20 countries. Potential predictors of mortality were patient parameters at diagnosis (e.g. diet at diagnosis, organ failure) and leakage parameters (e.g. fluid collections, gastric tube condition, leakage circumference). Primary outcome was 90-day mortality. Logistic regression was used to develop the SEAL score, comprising four grades of leakage severity (i.e. mild, moderate, severe and critical). Severity grade cut-offs were predefined and based on the individually predicted risk of 90-day mortality: 0–5%, 5–15%, 15–25% and 25–100%, respectively. Internal validation was performed by bootstrapping. The study protocol is accessible at www.tentaclestudy.com. Results The 90-day mortality rate in the included 1509 patients was 11.7%. The model had good discrimination (c-index 0.77; 95%CI 0.73–0.82) and calibration (calibration intercept 0.00; 95%CI -0.17– 0.17; calibration slope 1.14; 95%CI 0.95–1.33) after internal validation. The model classified 25.9% leakage patients as mild, 50.6% as moderate, 13.1% as severe and 10.4% as critical. The in-hospital, 30-day, 90-day and 180-day mortality rates, length of (ICU) stay, time to leak healing, Comprehensive Complication Index and Esophageal Complication Consensus Group classification worsened statistically significantly with higher classes of AL severity. Conclusion Anastomotic leakage is a severe complication with a 90-day mortality rate of 11.7%. The Severity of Esophageal Anastomotic Leak (SEAL) score is a tool which combines 12 patient and leak parameters at time of leak diagnosis and comprises four classes of leakage severity based on individual predictions of mortality. The SEAL score is instrumental in understanding AL severity in clinical practice and may be used to correct for leakage severity when assessing the efficacy of different treatments of AL after esophagectomy.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center.

Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients. An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed. There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22. Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

The largest report on thoracoscopic surgery for recurrent tracheoesophageal fistula after esophageal atresia repair

BackgroundAlthough thoracoscopic surgery has become the routine surgical method for esophageal atresia/tracheoesophageal fistula (EA/TEF), thoracoscopic treatment for recurrent tracheoesophageal fistula (rTEF) is far from popularized. ObjectivesWe aimed to explore the safety and efficacy of thoracoscopic treatment for rTEF with a large-cohort study. MethodsWe retrospectively analyzed the clinical characteristics and outcomes of 103 consecutive patients who underwent thoracoscopic surgery for rTEF by one surgeon after EA/TEF repair at two different institutions in China from 2014 to 2021. ResultsOne hundred and three pediatric patients (67 boys) were enrolled and the primary operations were performed via thoracoscopic (n = 75, 72.82%) or open surgery (n = 28, 27.18%). The median age at rTEF diagnosis was 5 (3, 10) months after the primary repair. Patients were diagnosed with recurrent fistula to the trachea (n = 97, 94.17%), bronchi (n = 4, 3.88%), and lung parenchyma (n = 2, 1.94%), and all of them underwent thoracoscopic surgery at a median age of 7 (5, 14) months with a median weight of 6200 (4870, 7650) g. After the repair of rTEF, the incidence of esophageal leakage, esophageal stricture, and TEF recurrence were 12.8%, 33.4%, and 10.8%, respectively. After the follow-up, 87 patients survived, 6 died, and 10 were lost to follow-up. ConclusionsThe results of thoracoscopic surgery for rTEF were comparable with previously reported thoracotomy surgery. Owing to the clear field during the operation, rapid patient recovery and esthetic results, the thoracoscopic approach could be a better choice for experienced pediatric surgeons. Level of EvidenceLEVEL IV

Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience

The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option. To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation. Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile. Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% ( n = 17). Among the complications, stent migration was present in 21.7% of the patients ( n = 5), in whom the incident was solved by endoscopic means. According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery. El uso de prótesis esofágicas para el manejo endoscópico de fístulas y perforaciones se ha convertido en un procedimiento habitual. Una de sus limitaciones es su alta tasa de migración. Para resolver esta situación, se ha propuesto el uso de prótesis cubiertas de doble malla. Analizar nuestra experiencia práctica en el empleo de prótesis esofágicas cubiertas de doble malla (PECDM) (modelo Niti S™ DOUBLE™ Esophageal Metal Stent) en pacientes con fístula o perforación esofágica. Estudio retrospectivo, descriptivo y unicéntrico, donde se incluyen pacientes con diagnóstico de fístula o perforación esofágica, desde noviembre 2010 hasta octubre 2018. Como objetivo primario, se evaluará su eficacia en términos de éxito técnico. Como objetivo secundario, se analizará su perfil de seguridad. Se incluyeron inicialmente un total de 31 pacientes, siendo 8 de ellos excluidos por fallecimiento por causas ajenas a la técnica. Se detectó un éxito técnico del 100%, con un éxitoprimario del 75% tras la recolocación de la prótesis. Entre sus complicaciones, la migración ocurrió en un 21,7% de los pacientes (n = 5), resolviéndose vía endoscópica en el 100% de los casos. Según nuestros hallazgos, las PECDM suponen una alternativa en el tratamiento de fístulas y perforaciones esofágicas, con una alta tasa de éxito en la resolución de fístulas y baja de complicaciones, en contraste con lo expuesto en las series publicadas. En todos los casos, la migración de la prótesis se resolvió mediante recolocación endoscópica, sin requerir nueva prótesis ni cirugía.

Per Oral Endoscopic Myotomy (POEM) for pediatric achalasia: Institutional experience and outcomes

BackgroundThe surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia. MethodsAn IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained. ResultsDuring the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2–18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8–100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4–10 (mean ± SD: 6.73 ± 1.5). Operative time was 64–359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%). ConclusionsPOEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development. Level of evidenceII.

Development of the Severity of Esophageal Anastomotic Leak (SEAL) score: a tool to predict mortality at time of diagnosis in patients with anastomotic leakage after esophagectomy

Background: Anastomotic leakage (AL) is a common and severe complication after esophagectomy, but it is largely unknown how to assess leakage severity at the time of diagnosis. We aimed to develop the Severity of Esophageal Anastomotic Leak (SEAL) score, a tool to determine leak severity at diagnosis of AL.

The Role of Esophageal Stenting in the Management of Anastomotic Leaks after Esophageal and Esophago-Gastric Cancer Resections. Literature Review.

Introduction: Anastomotic fistulas after surgery for esophageal cancer, remain a challenge for both the surgeon and the gastroenterologist. The aim of the study is to highlight the role of esophageal stenting in the management of leaks after esophagectomy for malignancies. Materials and Methods: We reviewed the available literature on the endoscopic treatment of esophageal anastomotic leaks, especially articles on endoscopic stenting in the management of this complication. Pubmed and ClinicalKey databases were searched using keywords such as esophageal anastomotic leaks, fully covered self-expanding metal stents, esophageal neoplasm. The relevant literature has been reviewed and included in the article. Results and Conclusions: The insertion of self-expanding stents in the fistulas of the esophageal anastomosis, represents an efficient method of treatment both for the closure of the fistula and in the control of sepsis. The morbidity and mortality associated with this method of treatment may be significant.

Combined surgery and endoluminal vacuum therapy for bronchial fistula and esophageal leakage after surgery for synchronous lung and esophageal cancer.

Combined surgery and endoluminal vacuum therapy for bronchial fistula and esophageal leakage after surgery for synchronous lung and esophageal cancer.

Endoscopic management of esophageal leak post-heller myotomy for achalasia cardia in children

A 9-year-old male child diagnosed to have achalasia cardia when he presented with a history of vomiting of undigested food particles with poor weight gain. He underwent lap Heller myotomy and Dor fundoplication. The immediate postoperative period was uneventful. After discharge, he presented with peritonitis and septic shock. On contrast-enhanced computed tomography abdomen, leak at the lower end of esophagus with intra-abdominal pus collection was identified. After intra-abdominal pus drainage and stabilizing the child, endoscopic covered stent was placed. He recovered well. Endoscopic esophageal covered stent placement is a viable and best option for a sick child with esophageal leak post-Heller myotomy.

P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair

Abstract Background Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management. Methods A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube. Results The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation. Conclusions Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract. Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.

Endoscopic negative pressure therapy as stand-alone treatment for perforated duodenal diverticulum: presentation of two cases

BackgroundEndoscopic negative pressure therapy is a novel and successful treatment method for a variety of gastrointestinal leaks. This therapy mode has been frequently described for rectal and esophageal leakages. Duodenal diverticular perforations are rare but life-threatening events. The early diagnosis of duodenal diverticular perforation is often complicated by inconclusive symptoms. This is the first report about endoscopic negative pressure therapy in patients with perforated duodenal diverticula.Case presentationWe present two cases of duodenal diverticula perforations treated with endoscopic negative pressure therapy as stand-alone treatment. Start of symptoms varied from one to three days before hospital admission. Early sectional imaging led to the diagnosis of duodenal diverticular perforation. Both patients were treated with endoluminal endoscopic negative pressure therapy with simultaneous feeding option. Three respective changes of the suction device were performed. Both patients were treated with antibiotics and antimycotics during their hospital stay and be discharged from hospital after 20 days.ConclusionsThis is the first description of successful stand-alone treatment by endoscopic negative pressure therapy in two patients with perforated duodenal diverticulum. We thus strongly recommend to attempt interventional therapy with endoluminal endoscopic negative pressure therapy in patients with duodenal diverticular perforations upfront to surgery.

Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery

IntroductionGastric leaks constitute some of the most severe complications after obesity surgery. Resulting peritonitis can lead to inflammatory changes of the stomach wall and might necessitate drainage. The inflammatory changes make gastric leak treatment difficult. A common endoscopic approach of using stents causes the problem of inadequate leak sealing and the need for an external drainage. Based on promising results using endoscopic vacuum therapy (EVT) for esophageal leaks, we implemented this concept for gastric leak treatment after bariatric surgery (Ahrens et al., Endoscopy 42(9):693–698, 2010; Schniewind et al., Surg Endosc 27(10):3883–3890, 2013).MethodsWe retrospectively analyzed data of 31 gastric leaks after bariatric surgery. For leak therapy management, we used revisional laparoscopy with suturing and drainage. EVT was added for persistent leaks in sixteen cases and was used in four cases as standalone therapy.ResultsTwenty-one gastric leaks occurred in 521 sleeve gastrectomies (leakage rate 4.0%), 9 in 441 Roux-en-Y gastric bypasses (leakage rate 2.3%), and 1 in 12 mini-bypasses. Eleven of these gastric leaks were detected within 2 days after bariatric surgery and successfully treated by revision surgery. Sixteen gastric leaks, re-operated later than 2 days, remained after revision surgery, and EVT was added. Without revision surgery, we performed EVT as standalone therapy in 4 patients with late gastric leaks. The EVT healing rate was 90% (18 of 20). In 2 patients with a late gastric leak in sleeve gastrectomy, neither revisional surgery, EVT, nor stent therapy was successful. EVT patients showed no complications related to EVT during follow-up.ConclusionEVT is highly beneficial in cases of gastric leaks in obesity surgery where local peritonitis is present. Revisional surgery was unsuccessful later than 2 days after primary surgery (16 of 16 cases). EVT shows a similar healing rate to stent therapy (80–100%) but a shorter duration of treatment. The advantages of EVT are endoscopic access, internal drainage, rapid granulation, and direct therapy control. In compartmentalized gastric leaks, EVT was successful as a standalone therapy without external drainage.

Endoscopic stenting for esophageal anastomoses leakage (review of literature)

Esophageal anastomoses leakage is a serious and urgent problem of surgical complications with high mortality rates. With the development of endoscopic technologies, minimally invasive methods of treatment are widely introduced into clinical practice with the development of endoscopic technologies in various non-standard situations, including esophageal anastomoses leakage. Stenting is one of the methods of choice in this case. However, the indicators of their effectiveness differ significantly across studies. A retrospective analysis of the stenting results in this severe complication demonstrates many factors influencing the success of esophageal stent implantation. Stents are often selected without due regard to their characteristics, which may affect the results of implantation. One of the most frequent and unfavorable outcomes of stenting is stent migration, which significantly affects the prognosis of the treatment. In this regard, in Russian practice, stenting, as a method of treating for esophageal anastomoses leakage, is introduced only in some institutions. However, many complications can be avoided at present due to the development in endoscopy and the constant improvement of stent designs. The objective of this review was to highlight the main advantages and problemsof stenting in esophageal anastomoses leakage today.

The use of grape juice in the detection of esophageal leaks.

BackgroundEsophagectomies and repair of esophageal perforations are operations used for a variety of clinical indications. Anastomotic leaks are a major post-operative complication after these procedures. At our institution, we routinely use grape juice to detect esophageal leaks in the post-operative setting in addition to other standard imaging modalities. We hypothesize that grape juice can provide similar diagnostic sensitivity and specificity to other modalities for leak detection.MethodsA retrospective review of all patients who underwent an esophagectomy or repair of esophageal perforations from 2013–2019 by the thoracic surgery service at our institution was performed. All patients underwent a barium swallow study, CT imaging or upper endoscopy, as well as ingesting purple grape juice on post-operative day 5 or greater. Purple grape juice observed in the tube thoracostomy drainage system was identified as a positive esophageal leak.ResultsSixty-four patients were included in the study period (25% female, 88% white, median age 62 years old). Sixty-three patients had both a barium swallow study and grape juice test, while one patient underwent CT imaging and grape juice study. Grape juice test sensitivity and specificity were found to be 80% and 98.3%, respectively.ConclusionsThis pilot study demonstrates the effectiveness of using grape juice in detecting esophageal leaks after esophageal operations in patients with tube thoracostomies. Grape juice may be cheaper and potentially less morbid than other studies performed to detect esophageal leaks. Further research is needed to justify the increased use of grape juice in patients who undergo esophageal operations.

Oesophageal lengthening by traction in oesophageal atresia: The UK experience

AIMSPreliminary reports suggest a promising role for oesophageal lengthening by traction (OLBT) in long gap oesophageal atresia (LGOA). Nevertheless, these encouraging results originate from specialist centres, and real-world experience is unquantified. We report the first multicentre, nationwide study of OLBT. METHODSCumulative experience of OLBT was recorded through a questionnaire sent to all UK paediatric surgery centres. OLBT was defined as “any attempt to increase oesophageal length using tension sutures”. Contributors submitted all cases of attempted OLBT, regardless of outcome. Demographics, surgical detail, and outcomes were analysed with summary statistics. RESULTSThe response rate was 23/26 centres. Eleven centres reported using OLBT in 22 patients (2003-2020) with 117 LGOA treated by other means. One patient died from complications of cardiac surgery and was excluded. OLBT enabled oesophageal anastomosis in 16 (76%), of which 2 died of complications of surgery, and another died of unrelated disease. Of the survivors, 7 required oesophageal dilatation 2-14 times. Oesophageal anastomosis was not achieved in 5 (24%) patients. All had pouch leak or disruption pre- or peri-operatively and underwent cervical oesophagostomy with subsequent gastric pull-up. One patient required dilatation of the oesophagogastric anastomosis. CONCLUSIONOLBT is being carried out in the UK in a limited number of centres in a minority of patients. These data suggest OLBT enables oesophageal anastomosis in 76% of infants with LGOA. Oesophageal pouch leak or disruption was common to all instances of failure to anastomose. Our findings will inform discussions between surgeons and families of babies born with LGOA.

Feeding and Growth Outcomes in Infants with Type C Esophageal Atresia Who Undergo Early Primary Repair

To describe growth and feeding outcomes in patients with type C esophageal atresia who underwent early primary repair and to identify predictors for poor growth. This single-center, retrospective, cohort study included all patients with type C esophageal atresia who underwent early primary repair from 2013 to 2019. Weight-for-age z score (WAZ) was calculated at birth, and every 6months until 3years postoperatively. Longitudinal median regression was used to evaluate WAZ over time. A multivariable logistic regression model explored predictors of growth outcomes. Of 46 infants who met the inclusion criteria, 72% were term. The median age at repair was 1.5days of life (IQR, 1-2days of life) and the hospital length of stay was 20days (IQR-14, 30days). Two patients had esophageal leak (4.3%). The median WAZ at birth was below average (-0.72; IQR, -1.37 to -0.40), but improved to reach average by 3years (-0.025; IQR, -0.85 to 0.97, P<.001). At discharge, 72% of patients were receiving full oral nutrition, which improved to 95% by 3years. The only independent predictor of poor growth at 1year (WAZ < -1 [33%]) was WAZ at discharge (P=.02). Infants with esophageal atresia who undergo early primary repair are capable of achieving standard growth curves by 3years of age. However, poor discharge WAZ score was predictive of poor WAZ score at 1year. Efforts to identify at-risk patients and institute targeted inpatient and outpatient nutrition interventions are needed to improve their growth trajectory.

The success of Eso-SPONGE® therapy in the treatment of anastomotic dehiscence after Ivor-Lewis subtotal esophagectomy: A case report.

IntroductionEso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis.Clinical case presentationThe case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions.DiscussionEso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process.ConclusionsEso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence.

A BRIEF HIATUS: PARAESOPHAGEAL HERNIA REPAIR COMPLICATED BY THORACIC HERNIA SAC

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Paraesophageal herniation (PH) is the displacement of abdominal viscera, particularly the stomach, through the diaphragm into the thorax. Surgical fundoplication can infrequently lead to post-operative complications. We present a unique case of stage IV PH complicated by post-fundoplication insufflated hernia sac causing hemodynamic instability. CASE PRESENTATION: A 77-years-old woman with hypertension presented with dysuria and abdominal discomfort and was found to have hypokalemia, atrial fibrillation (AF), and pyuria. A stage IV PH was noted on computed tomography (CT). She underwent laparoscopic Nissen fundoplication for hernia repair. Postoperatively, she had worsening chest pain, dyspnea and tachycardia. CT scan revealed a large hernia sac with air-fluid level within the thorax causing cardiac shift and compression. The patient was intubated for worsening dyspnea and started on pressors for refractory hypotension. A pigtail catheter was placed under radiographic guidance into the displaced hernia sac with decompression of air and retrieval of fluid with rapid improvement in hemodynamics and cardiac shift. Fluid analysis showed low cell counts and negative cytology with yeast in culture. As tube feeds were introduced, the formulation drained through the hernia sac catheter with an elevated fluid amylase level of 895 raising concern for an esophageal leak. The patient was extubated to high-flow nasal cannula but intermittent hypotension, dyspnea, and overall failure to thrive prompted her family to pursue hospice care. DISCUSSION: PH can cause herniation of abdominal contents into the thorax causing significant morbidity with median age of presentation between 65-75 years (1). With large phrenoesophageal membrane defects, organs including stomach, spleen, and small intestine can herniate. Diagnosis is made by barium swallow, endoscopy or CT (2). Treatment for advanced, symptomatic disease refractory to medical treatment is surgical. Given the need to insufflate the peritoneal cavity, laparoscopic repair can occasionally lead to insignificant surgical emphysema and pneumomediastinum or small pneumothorax (3). However, this can infrequently cause hemodynamic instability, and to our knowledge, there is no literature reporting an inflated visceral peritoneal sac protruding into the thorax causing tension physiology as in our patient. Diagnosis is based on clinical findings of shock and imaging showing mediastinal structure compression and shift. Treatment is based on decompression and, in patients stable for surgery, resection of the hernia sac. CONCLUSIONS: Visceral peritoneal sac herniation and insufflation with air-fluid level causing tension physiology is a rare phenomenon post-PE repair that can cause significant hemodynamic instability and morbidity. Clinical exam and radiographic imaging followed by quick decompression play a key role in swift recognition and urgent treatment. REFERENCE #1: Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg. 2015;2:13. REFERENCE #2: Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349(oct23 1):g6154-g6154. REFERENCE #3: Singhal T, Balakrishnan S, Hussain A, Grandy-Smith S, Paix A, El-Hasani S. Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective. Ann Surg Innov Res. 2009;3:1. DISCLOSURES: No relevant relationships by Pavan Bhat, source=Web Response no disclosure on file for Robert Cole; No relevant relationships by Theodore Plush, source=Web Response