Esophageal Leaks Research Articles

Short-term and mid-term effects of thoracoscopic repair of esophageal atresia: No anastomotic leaks or conversions to open technique.

The frequency rate of esophageal anastomosis leaks after thoracoscopic correction of esophageal atresia (EA) in the current literature is reported as 5.6%-24.7% and a conversion rate of 2%-53%. The objective of this retrospective study was to examine the characteristics of EA and analysis of the safety and efficacy of EA repair with the use of the thoracoscopic approach in a single academic center, as well as risk factors analysis in the context of short-term and mid-term follow-up status. A retrospective analysis of the management of all consecutive newborns affected by EA hospitalized in our department over a period between 2013 and 2022, including preoperative, perioperative, and postoperative management, together with the outcome, complications and long-term follow-up status was performed. A total of 38 patients with a median birth weight of 2,570 g (range; 1,020-3,880) were treated over the study period, including 30/38 (78.9%) with additional congenital anomalies. Overall, 30 patients underwent primary anastomosis of the esophagus and eight underwent a multistaged procedure, with or without an initial ligation of the tracheoesophageal fistula and delayed primary anastomosis. Overall survival for all patients was 0.894 ± 0.050, with a median follow-up of 4.5 years. We noted neither anastomotic leaks nor conversions to open technique in our cohort. Implementation of vancomycin prophylaxis was successful in preventing postoperative central venous access-related infectious complications. At the end of the follow-up, 85% of patients have a Lansky performance score ≥80. Risk factors analysis for length of hospitalization, overall survival, Lansky performance status, and neurological impairment were analyzed. In conclusion, we have found that the outcome of thoracoscopic repair of EA in terms of surgery-dependent morbidity (anastomosis leakage, conversion rate to open surgery), provides benefit to those previously reported in the literature, regardless of the prognostic criteria of the classification system.

Mucosal Injury During Per-oral Endoscopic Myotomy: A Single-Center Experience.

Peroral endoscopic myotomy is associated with a low risk of adverse events. Mucosal injury is the most common intraprocedural adverse event of peroral endoscopic myotomy. Severe mucosal injury may cause serious consequences, such as esophageal leak and mediastinitis, which affect the outcome of the procedure and prolong hospital stay. The aim of the present study was to determine the characteristics, predictors, and management approaches for unintended mucosal injury during peroral endoscopic myotomy. A total of 211 patients who underwent peroral endoscopic myotomy between November 2014 and June 2019 were enrolled in this study. Mucosal injury was defined according to a previous study and maintained in the endoscopy database. Patient-related and procedure-related factors were compared between patients with and without mucosal injury. Multivariate analysis was performed after adjusting for confounding factors. A total of 206 patients were eligible for study enrollment. Of these, 44 experienced mucosal injury, with an overall frequency of 21.4% (44/206). On multivariable analysis, mucosal injury was associated with submucosal fibrosis (odds ratio, 8.33; P = .024), intraprocedural bleeding (OR, 14.29; P < .001), endoscopic diameter of 9.9 mm (OR, 4.389; P = .006), and procedure duration over 60 minutes (OR, 1.016; P = .034). Mucosal injury is a significant event encountered during peroral endoscopic myotomy, affecting its short- and long-term outcomes. Intra-procedural bleeding, endoscopic submucosal fibrosis, and use of an endoscope with a large outer diameter have been found to be significant predictors of mucosal injury. Endoscopists should pay more attention to risk factors associated with mucosal injury to avoid adverse events.

Conservative management of Boerhaave’s syndrome: a case report

The management of esophageal perforation has evolved. The underlying principles of drainage of sepsis, adequate nutrition and repair, or defunctioning of the esophagus remain. We are presenting a case of Boerhaave syndrome, where we have successfully managed conservatively with endoscopic stenting. Endoscopic therapy and VATS are used with increasing frequency and in appropriately selected patients with good results. Careful selection of patients for such procedures are important. Implantation of self-expanding metallic stent in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.

Pediatric pneumomediastinum: Symptom-based management

BackgroundPediatric spontaneous pneumomediastinum is known to have a benign course. Despite this, there is no consensus or standardization for the workup and management. There are often a variety of imaging studies performed for patients with similar presentations. MethodsThis is a retrospective chart review evaluating the presentation, workup, and management of all pediatric patients with a primary diagnosis of spontaneous pneumomediastinum over a 5-year period at a children's hospital. ResultsOf the 62 patients, the initial workup consisted of either a chest x-ray (CXR) only (n = 31, 50%), a chest computed tomography scan only (n = 11, 18%) or both (n = 14, 23%); additionally, some patients came with ‘other’ imaging only (n = 3, 5%) or no imaging (n = 3, 5%). Twenty-seven patients (44%) underwent an additional CXR and 19 (31%) underwent an esophagram. All esophagrams were negative for an esophageal leak. A presenting symptom of pain was associated with a hospital stay of less than 24 h (p = 0.008) while shortness of breath (p = 0.0005) and emesis (p = 0.0006) were associated with a hospital stay of greater than 24 h. Associated diagnoses of respiratory infections (p = 0.02) and gastrointestinal issues (p = 0.006), such as hyperemesis, were associated with inpatient admission. ConclusionPediatric patients with spontaneous pneumomediastinum benefit from evaluation, management, and treatment based on their presenting symptoms. There is an opportunity to decrease unnecessary radiation exposure in this patient population with fewer CXRs and avoidance of esophagrams, neither of which alter management. Level of EvidenceLevel III.

Minimally Invasive Techniques in the Contemporary Management of Esophageal Diverticula

INTRODUCTION: Management of esophageal diverticulum has shifted from an expansive, open operative approach to a varied open and select endoscopic intervention. This study examines operative outcomes in patients with esophageal diverticula treated with varied approaches at a single academic center. METHODS: A retrospective review of a prospectively maintained database was performed for all patients who underwent operation for esophageal diverticula at a single institution. The patients were grouped by location: Group A (Zenker’s), group B (mid-esophageal), and group C (epiphrenic diverticula). Measured outcomes include postoperative complication, symptoms, and recurrence. RESULTS: A total of 27 patients who underwent operation for symptomatic esophageal diverticula from June 2010 to June 2018 were identified. The mean age was 66.6 years, and 29.6% were women. Mean follow-up was 14 months. Group A consisted of 14 patients, group B 7, and group C 6. Preoperative dysphagia occurred in 81.5% of all patients. Underlying motility disorders were present in 92.3% of group B and C patients. A total of 92% of patients in group A underwent attempted endoscopic resection, with 42.9% converting to open. Robotic-assisted surgery was performed in 100% of group B and 83.3% of group C patients. One esophageal leak occurred in group A; there were no mortalities. Only group A demonstrated radiographic recurrence at 42.8%. Recurrent dysphagia in group A was 50%, group B 28.6% (2/7), and group C 0%. CONCLUSION: Minimally invasive management of esophageal diverticula provides effective symptom resolution. This study verifies the safety of endoscopic, laparoscopic, and robotic approaches with a 0.04% leak rate.

S2278 Black Esophagus: A Striking Etiology of Gastrointestinal Bleeding

Introduction: Black esophagus, or acute esophageal necrosis (AEN), is an uncommon etiology of upper gastrointestinal bleeding with incidence 0.01%-0.2% and poor prognosis. AEN is characterized by endoscopic findings of diffuse circumferential black discoloration of distal esophageal mucosa with sharp demarcation at the GEJ. The pathophysiology of AEN is unknown, however current hypotheses implicate ischemia, thromboembolic injury, critical illness, and corrosive injury. We describe a case of black esophagus in a patient with hemorrhagic shock. Case Description/Methods: An 83-year-old woman with hypertension presented to an outside hospital after a fall with lethargy, acute hypoxic respiratory failure, and shock. CT chest revealed right sided hemothorax. The patient was intubated, resuscitated with IV fluids and blood products, initiated on vasopressors, and a chest tube was placed prior to transfer to our institution. Repeat CT chest was concerning for the right thoracostomy tube traveling through the right middle lobe parenchyma and terminating within the mediastinum between the left atrium and the distal esophagus. The chest tube was removed and replaced in the operating room. Double contrast esophogram was without esophageal leak. The patient subsequently developed melena and worsening anemia. EGD demonstrated sharply demarcated circumferential black ulceration of the distal esophagus consistent with black esophagus without obvious signs of perforation. IV PPI and therapy aimed at reversing the underlying shock was pursued. Unfortunately, after a prolonged hospital course with worsening acute respiratory distress syndrome and inability to liberate from the ventilator, the patient’s family elected to pursue comfort measures and the patient expired (Figure). Discussion: In this case, AEN was most likely caused by ischemia secondary to hemorrhagic shock. Black esophagus carries a very poor prognosis, usually related to the underlying condition. Timely recognition of AEN and treatment aimed at reversing the underlying etiology can help prevent complications such as infection, esophageal stricture, and perforation. AEN is managed with aggressive IV PPI, NPO, and avoiding passage of nasogastric tubes due to risk of perforation. In rare instances, surgical intervention may be warranted. This case highlights the need to maintain a wide differential diagnosis for gastrointestinal bleeding and the importance of early recognition and treatment of this rare condition to prevent complications.Figure 1.: EGD indicating circumferential black ulceration of the distal esophagus with clear demarcation (arrow).

Esophageal Magnetic Anastomosis Device (EMAD) to Simplify and Improve Outcome of Thoracoscopic Repair for Esophageal Atresia with Tracheoesophageal Fistula: A Proof of Concept Study

BackgroundWe designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy. MethodsSynthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students (n = 10) and surgical trainees (n = 10) were asked to perform thoracoscopic repair of an “EA” with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3–4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5–3 kg) esophagi (n = 25 in each test series). BP and PF were measured and compared against each other. ResultsMedical students were unable to complete HA, but were successful with the EMAD in 11.1 ± 2.78 min. Surgical trainees completed EMA in 4.6 ± 2.06 min vs. HA 30.8 ± 4.29 min (p<0.001). The BP following a HA (14.1 ± 3.32 cmH2O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH2O), whereas the BP with the EMAD was extremely high (>90 cmH2O) (p<0.001). The PF of an EMA (1.8 ± 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 ± 0.43 N) (p<0.0001). ConclusionThe EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation.

S1112 Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study

Introduction: Endoscopic advancements in stenting and tissue plication have proven to be viable alternatives to surgical management of esophageal perforations and are increasingly being used in clinical practice. We aim to assess the efficacy and outcome of different endoscopic treatment modalities in patients with esophageal perforations. Methods: We performed a retrospective analysis of patients with esophageal perforations from an endoscopic database since 2007. Patients with esophageal fistula, stricture, or stenosis were excluded. Patients were categorized into four treatment groups: primary closure (endoscopic suturing), primary bypass (stenting), combination (suturing defect and stenting), and conservative therapy (NPO, trans-nasal feeding tubes). Baseline demographics, patient characteristics, and treatment modality outcomes were collected. Predictors of success were identified using logistic regression. Results: 95 patients (mean age 64 ±15, 67% male) with esophageal perforations were included. The most common etiology was iatrogenic after dilatations or endoscopic myotomy (40%). 64% of perforations were in the distal esophagus. Regardless of strategy employed, 49% of patients had successful endoscopic repair of perforation. Only 7 patients required subsequent operative intervention. The combination approach achieved the greatest clinical success (66%), defined as no need for surgical intervention, when compared to the other modalities (primary bypass 35%, closure 57%, and conservative 25%, p=0.05). Patients with concomitant systemic inflammatory response syndrome had greater clinical success if they were treated with combination approach compared to primary bypass approach (18% vs. 64%, p=0.01). If the perforation was greater than or equal to 20mm, combination therapy had greater clinical success compared to primary bypass approach (0% vs. 50%, p=0.04). Early stent migration was associated with greater need for rescue surgery (p=0.02). (Table) Conclusion: Esophageal perforations can be managed effectively with endoscopic therapy. Larger, prospective trials are needed to clarify ideal individualized endoscopic strategies. Patients with systemic inflammatory response and/or perforation ≥20 mm are managed most effectively with combination therapy. Table 1. - Demographics, Presentation and Outcomes by Treatment Group Variables (%) All (n=95) Primary bypass (n=43) Primary closure (n=12) Combination(n=29) Conservative(n=11) Demographics All Primary bypass (n=43) Primary closure (n=12) Combination (n=29) Conservative (n=11) p-value Age (± SD) 63 ±14 66 ±13 61 ±13 61 ±15 64 ±15 0.23 Sex (Male) 64(67) 16(70) 10 (83) 19(65) 7(63) 0.61 History of EC 14 (16) 6(26) 1(8.3) 3(10) 2(18) 0.31 History of Radiotherapy 15 (19) 6(26) 0(0) 4(14) 2(18) 0.245 Diabetes 14(15) 2(9) 7 (43) 3(10) 2(18) 0.686 Hypertension 48(51) 12(52) 7(58) 13(45) 5(46) 0.927 Sleep apnea 16(17) 5(22) 2(17) 5(17) 0(0) 0.45 Site of Perforation Proximal 4(9.3) 0 2(6.9) 6(54.5) Middle 7(6.3) 3(25.0) 7(24.1) 0 Distal 29 (67.4) 8(66.7) 20(69.0) 5(45.5) Etiology of perforation SpontaneousIatrogenicFood impactionAnastomotic leakEsophageal cancer Boerhaave syndrome 7(16.3)22(51.2)2(4.7) 4(9.3) 2(4.7)6(14.0) 1(8.3)9(75.0)1(8.3) 0 01(8.3) 021(72.4)2(6.9) 3(10.3) 01(3.4) 2 (18.2)7(63.6)1(9.1) 0 01(9.1) Symptoms at time of diagnosis DysphagiaChest painAbdominal painFeverOther 10(23.3)11(25.6)1(2.3) 4(9.3)10(23.3) 1(8.3)4(33.3)0 1(8.3)2(16.7) 4(13.8)4(13.8)1(3.4) 5(17.2)8(27.6) 4(36.4)1(9.1)1(9.1) 02(18.2) Outcomes by Treatment Group Pittsburgh Perforation Severity Score (n=47) 3.17 ±2.1 3.59 ±2.2 2.5±2.0 2.72±1.8 3.45±2.25 0.225 Operative intervention required 7(5.7) 2(4.7) 1(8.3) 3(10.3) 1(9.1) 0.95 Mortality 9(7.4) 4(9.3) 0 3(10.3) 2(18.2) 0.652 SIRS 44(36.1) 19(44.2) 4(33.3) 16 (55.2) 5(45.5) 0.635 Stent migration 11 10(23.3) 0 2(6.9) 0 0.182 LOS* (days) 16±15 19 ±15 11±10 18±19 7.9±7.0 0.123 LOF* (months) 4.6±4.1 4.25±1.5 6±8.8 3.5±2.1 9.3±6.4 0.07 *LOS – Length Of Stay In The Hospital; LOF - Time From Diagnosis To Last-Follow Up; SIRS - Systemic Inflammatory Response Syndrome)

S2371 Ripped by Chips: A Case Report of Esophageal Perforation After Consumption of Chips

Introduction: Eosinophilic esophagitis (EoE) is an uncommon condition defined as a chronic, immune-mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.1 Patients typically present with esophageal dysphagia and food impaction. We present a unique and rare case presentation of a young male patient who presents with pneumomediastinum in the setting of undiagnosed EoE. Case Description/Methods: A 31-year-old male with no significant past medical history presents to the emergency department with lower neck pain. He reports sudden onset of pain after consuming a sandwich containing potato chips. This was followed by 2 immediate episodes of hematemesis. Vital signs were within normal limits. Physical exam was significant for bilateral crepitus on exam. CT Chest with contrast was significant for extensive pneumomediastinum around the esophagus suggestive of an esophageal perforation. CT neck was significant for extensive emphysema in the neck and pneumomediastinum with esophageal wall emphysema suggestive of esophageal rupture (Figure). An esophagram revealed no evidence of gross esophageal leak suggesting a contained micro perforation, so he was managed conservatively with IV pain medications, initial period of nil by mouth followed by slow escalation to a liquid diet. His diet was slowly escalated, and he was discharged home in stable condition. Two months later at an outpatient gastroenterology follow up, an esophagogastroduodenoscopy was significant for ringed esophagus, longitudinal furrows, white plaques and white specks throughout the entire esophagus. Biopsies were consistent with eosinophilic esophagitis with increase eosinophil count in the proximal esophagus. He was started on a daily proton pump inhibitor with ongoing follow up. Discussion: The incidence of EoE appears to be increasing, in part due to rising recognition of the disorder. It is important for physicians to identify its features early to prevent further complications. Esophageal perforation is a rare but serious complication of eosinophilic esophagitis, occurring in ∼2% of cases.2 Ongoing inflammation from longstanding untreated EoE has previously been reported to have led to esophageal perforation but rarely in such a dramatic fashion.3Figure 1.: 1. Significant emphysema in the neck and pneumomediastinum with thinning of the posterolateral aspect of esophagus concerning for esophageal rupture.

S347 Endoscopic Suture Repair of a Transmural Esophageal Perforation

Introduction: Iatrogenic esophageal perforations during endoscopic procedures are associated with considerable morbidity and mortality. Traditional management of large esophageal perforations included an aggressive approach involving surgery, but despite advances in techniques, postoperative complications remain high. Conservative management with endoscopic suturing and stenting has drastically improved patient outcomes. Herein, we present a patient with a guidewire associated 12 cm full thickness esophageal perforation that was successfully repaired by endoscopic suturing and stent placement. Case Description/Methods: A 60-year-old female with pmhx of GERD and chronic dysphagia presented s/p outpatient EGD empiric guidewire assisted dilation to 54Fr that was complicated by an approximately 12cm full thickness esophageal tear/perforation and pneumomediastinum. On endoscopic evaluation a large esophageal perforation was found 40 cm from incisors. A total of 4 endoscopic sutures were used to approximate the edges of the perforation in an interrupted fashion. A 15 cm fully covered stent was then endoscopically deployed over the defect with 2 sutures used for stent fixation. Following the procedure, CT esophagram showed absence of an esophageal leak. She underwent repeat EGD 2 weeks later for stent removal which showed adequate healing of the esophagus and no evidence of ongoing defect or perforation. Discussion: Endoscopic suturing was first approved by the USDA in 1998 and its uses have expanded to the repair of fistulas, perforations and anastomotic leaks. The closure technique involves approximating the defect edges using continuous and interrupted sutures, via an endoscopic suturing device. The size of the perforation limits other endoscopic interventions including over the scope clips (OTSC) which are effective in closing perforations up to 1-2 cm in size. Sharaiha et al. reported the successful closure of esophageal perforations in 13 patients using endoscopic suturing. However, the defect size ranged from 25 to 50 mm in length, much smaller than the case we present which included a 12 cm transmural defect. Further, endoscopic suturing alone is not as effective in perforation closure when compared to the addition of stent placement. Watch the video at https://tinyurl.com/ACGAbstractS347

S2450 Acute Esophageal Necrosis: Low Flow Leading to Darkness

Introduction: Acute esophageal necrosis (AEN), commonly referred to as black esophagus due to the striking circumferential blackening of the esophageal mucosa, is a rare clinical condition with a prevalence of up to 0.2%. The etiology of this condition is unclear but thought to involve the interplay of ischemia and gastric outlet obstruction with gastroesophageal reflux. As this condition carries with it a mortality rate of nearly 40%, prompt recognition and aggressive management is of the utmost importance to prevent perforation or stricture. Considering this, AEN should be recognized as a possible outcome of an ischemic event and considered a potential cause of spontaneous esophageal perforation. Case Description/Methods: A 43-year-old female with a history of epithelioid hemangioendothelioma status post resection, Crohn’s colitis in remission, and recent hospitalization for a complicated urinary tract infection and abdominopelvic ascites concerning for malignancy with hospitalization complicated by cardiopulmonary arrest presented to the emergency department 8 days after discharge following a near syncopal episode. She was found to be hypotensive with tachycardia concerning for shock. She was started on broad spectrum antibiotics, 3 vasopressors, intubated, and admitted to the ICU. A CT scan of her chest, abdomen, and pelvis showed extensive pneumomediastinum concerning for esophageal perforation and pneumatosis intestinalis. Perforation was confirmed utilizing serial chest x-rays with contrast demonstrating a right-sided esophageal leak at the gastroesophageal junction. Both cardiothoracic surgery and gastroenterology were consulted, she was not deemed a surgical candidate and endoscopy with covered stent placement was planned. Endoscopy revealed a black esophagus consistent with an ischemic process throughout the entire esophagus and pneumatosis intestinalis suggesting small bowel ischemia. Stenting was aborted and the findings were discussed with the patient’s family who decided to pursue comfort measures. The patient died the following day (Figure). Discussion: It has been demonstrated that critically ill patients often experience low flow states, poor nutritional status, and disruption of intrinsic repair mechanisms. Coupled together, these insults increase the risk of developing AEN and must be acknowledged as a possible complication in this patient population. Although this is a rare condition, it should be recognized as a potential outcome of an ischemic event.Figure 1.: Images A-D depicts a diffusely abnormal mucosa throughout the esophagus, characterized by black/brown tissue consistent with ischemia.

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

Abstract Anastomotic leak (AL) is a common and severe complication after esophagectomy, but it is largely unknown how to assess leak severity when diagnosed. We aimed to develop the Severity of Esophageal Anastomotic Leak (SEAL) score, a tool to determine leak severity at diagnosis of AL. The TENTACLE—Esophagus study is an international, retrospective cohort study in 71 centres worldwide and included patients with AL after esophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. To develop the SEAL score, multivariable logistic regression was performed to determining 90-day mortality risk. Leak-related parameters at diagnosis identified as prognostic factors were included as predictors for the SEAL score. Four classes of leak severity were defined (mild, moderate, severe and critical) and the score was internally validated. The study protocol is accessible at www.tentaclestudy.com. 1509 patients with AL were included and the 90-day mortality rate was 11.7%. Twelve leak-related predictors factors were included in the SEAL score, including post-operative day of diagnosis, leucocyte count, organ failure, defect circumference and presence of intrathoracic fluid collections. The score showed good calibration and discrimination with a c-index of 0.77 (95%CI 0.73–0.81). More severe leaks were associated with significant increase in length of (intensive care unit (ICU)) stay, healing time, Comprehensive Complication Index (CCI) and Esophagectomy Complications Consensus Group (ECCG) classification (Table 1). The SEAL score was incorporated in an online tool for use in individual cases: https://www.tentaclestudy.com/seal-score. The SEAL score grades leak severity into four classes based on individual predictions of 90-day mortality by combining 12 leak-related predictors. The SEAL score also reflected morbidity and can be used to assess AL severity, may guide treatment decisions and may be used in research on AL.

527. A RIGHT CERVICOTOMIC APPROACH TO RETRIEVE A DENTAL PROSTHESIS FROM THE ESOPHAGUS

Abstract Foreign body (FB) ingestion in the upper gastrointestinal (GI) tract is a relatively common emergency presenting numerous diagnostic and therapeutic challenges. Adults most frequently ingest FBs accidentally while eating solid food. The esophagus accounts for 57% to 75% of all FBs impactions in GI tract. More than 80% FB pass spontaneously, around 10-20% require an endoscopic removal, and less than 1% have to be treated surgically, depending on the nature and location of the FB. A 68 years old man presented to the Emergency Department complaining of a mild dysphagia since two days before. A laryngeal endoscopy showed edema of the right aryepiglottic fold; salivary stagnation hiding the pyriform sinus; edema of the right vocal cord; the airway caliber was adequate. A chest radiograph showed a dental prosthesis, probably ingested during a seizure, in the upper esophageal tract. The patient developed dyspnea and phonation difficulty due to neck swelling. An urgent CT scan showed signs of esophageal perforation and diffuse edema. A multidisciplinary equipe was assembled to properly treat the patient. In the operating room, two attempts of retrieval with a flexible and a rigid endoscope failed because the dental prosthesis was stuck in the right pyriform sinus. After a careful evaluation of the FB location, the surgeon performed a right cervicotomy, uncommon when compared with the traditional left side approach to the neck, and retrieved it through an esophagotomy. A nasogastric tube was inserted and a paraesophageal 19 Ch drain in aspiration was placed in situ. Over time, no signs of esophageal leakages were detected post-operatively and eventually the patient was able to feed with solid foods without complications. Any esophageal FB may cause potentially fatal injuries, therefore it must be retrieved within 12 to 24 hours. An endoscopic approach should be attempted first, with surgery being the extrema ratio. The surgical approach depends on the nature and location of the FB. A left cervical approach should not be regarded as dogmatic, and a right-sided approach, being equally safe and effective from a surgical point of view, could be appropriately chosen when clinically indicated.

Delayed diagnosis of thoracic esophageal rupture due to blunt abdominal trauma without chest trauma: A case report

BackgroundThoracic esophageal rupture due to blunt trauma is very rare. Moreover, there have been no reports of thoracic esophageal rupture due to blunt abdominal trauma without chest trauma.Case presentationWe describe a rare case of esophageal rupture due to blunt abdominal trauma in a young female patient. Operation was delayed due to a misdiagnosis of chylothorax, and esophageal repair was performed six days after trauma. Postoperative esophageal leak developed and was treated with esophageal stent. She was discharged two months after surgery without sequelae.ConclusionsIt is important to consider esophageal rupture as a differential diagnosis even in patients with only abdominal trauma, when in doubt.

Magnamosis for long gap esophageal atresia: Minimally invasive “fatal attraction”

BackgroundAim of study is to report our preliminary experience with magnetic anastomosis (magnamosis) treating long-gap esophageal atresia (LGEA), the most challenging condition of esophageal atresia continuum. Magnamosis has been reported in 20 patients worldwide as an innovative and marginally invasive option. MethodsProspective evaluation of all LGEA patients treated with magnamosis was performed (study registration number: 2535/2021). Main outcomes considered were demographic and surgical features, postoperative complications and feeding within 6-month of follow-up. ResultsBetween June 2020 and January 2021, 5 LGEA patients (Type A, Gross classification) were treated. Median preoperative gap was 5 vertebral bodies. Magnetic bullets were placed at an average age of 81 days of life, leading to successful magnamosis in all cases: 4 infants had primary magnetic repair (one after thoracoscopic mobilization of the pouches), 1 patient had a delayed magnamosis after Foker's procedure.Esophageal anastomosis was achieved after an average of 8 days. No anastomotic leak was found. All patients developed anastomotic stenosis at 6-month follow-up, requiring a mean of 6 dilations each. Full oral feeding was achieved in 3 patients, while 2 were still on oral-gastrostomy feeding. One patient experienced small esophageal perforation after dilation (3 months after magnamosis), distal to the anastomotic stricture and subsequently developed oral aversion. ConclusionsOur preliminary results suggest magnamosis a safe and effective minimally invasive option in patients with LGEA. Absence of postoperative esophageal leaks may represent a major advantage of magnamosis over conventional surgery, although possible high rate of esophageal stenosis should be further evaluated. Levels of EvidenceIV (Case series with no comparison group)

672 Endoscopic Laser Pharyngeal Pouch Surgery: Is It Safe?

Abstract Aim Zenker diverticulum can cause significant dysphagia and surgery is the definitive management. NICE guidelines describe inadequate evidence on laser cricopharyngeal myotomy (CPM). This study aimed to assess the safety and efficacy of carbon dioxide laser and stapling CPM to treat Zenker diverticulum. Method Retrospective data was collected from patients who underwent endoscopic CPM at the Royal Berkshire Hospital between 2011 and 2021. Two cohorts were assigned: endoscopic laser (EL) or endoscopic stapling (ES). Primary outcomes evaluated safety. These were surgical complication rates, duration of inpatient stay, readmissions, barium swallow leak and considered case complexity (revision cases). The secondary outcomes, persistence or recurrence of symptoms evaluated efficacy. Results One-hundred and eight patients (mean [range] age 75 [38 – 95] yr, 71 (66%) men, 23 (21%) revision surgeries) underwent CPM. The EL (n = 76) cohort had two (2.63%) surgical complications (mucosal tear requiring no repair, mediastinitis from an oesophageal leak). The ES (n = 32) cohort had one (3.13%) surgical complication (mucosal tear requiring suture repair). The average duration of inpatient stay was 3.61 and 1.53 days for the EL and ES cohorts respectively. 65 patients (60%) underwent a post-operative barium swallow of which 2 (0.03%) patients, both from the EL cohort, had a leak. There were no readmissions. A chi-square test of independence showed no significant association between type of surgery and persistence [X2 (1) = 0.169, p = .681] or recurrence of symptoms [X2 (1) = 0.443, p = .506] Conclusions Treatment of pharyngeal pouches with endoscopic laser CPM is safe and efficacious.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

Endoscopic Vacuum Therapy for iatrogenic esophageal perforation in a child

Esophageal perforation (EP) has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. Here, we present a case of iatrogenic perforation of esophagus successfully treated with Endoscopic Vacuum Therapy (EVT) in a 6-year-old female patient.

Pharyngesophageal Diverticula Following Anterior Cervical Discectomy and Fusion.

Development of traction pharyngesophageal diverticula following anterior cervical discectomy and fusion (ACDF) is a rare but morbid cause of dysphagia and the optimal surgical management is unclear. PubMed, GoogleScholar, Embase database reviews of "traction diverticula/um + anterior cervical/ACDF." Patient demographics, presenting symptoms, surgical technique, and outcomes were compared. Seventeen manuscripts reported 21 cases of pharyngesophageal diverticulum (PED) following ACDF (10 F:11 M, mean age 45 years). Presenting symptoms included dysphagia (n = 18), regurgitation (n = 10), and weight loss (n = 6). The average interval to presentation was 4.5 years after ACDF (range: 6 months-18 years) and ACDF levels most commonly involved were C5-C6 and/or C6-C7 (n = 12). Open diverticulectomy with (n = 12) and without (n = 6) cricopharyngeal myotomy was the most common approach and reinforcement with vascularized tissue was used in 6 patients (29%). Attempted endoscopic diverticula repair was successful in 1 patient, was converted to open repair in 5 patients, and 1 patient did not have surgical repair. ACDF hardware was removed in 11 cases (52%) and was routinely removed when concomitant infection was present. Complications following repair were reported in 6 patients (30%). Traction pharyngesophageal diverticula are a rare cause of dysphagia which occur after a variable interval following ACDF. Open surgical diverticulectomy yields superior outcomes compared to the endoscopic approach. In the setting of infection hardware removal is recommended. Vascularized tissue reinforcement can limit potential esophageal leak; however, the risk of post-operative complications remains high.

Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon.

The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes. A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes. Forty patients were included in the study. Median age was 74years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28kg/m2 (18-43), average procedure length of 64min (41-119), diverticulum size of 28mm (19-90), and average length of stay of 0.9days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7). Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.