Primary Esophageal Repair Research Articles

Surgical management of atrioesophageal fistula after catheter ablation of atrial fibrillation: A French nationwide study

ObjectiveThe study objective was to assess the efficacity of different surgical strategies for atrioesophageal fistula after catheter ablation of atrial fibrillation. MethodsBetween January 2010 and April 2023, all patients with a diagnosis of atrioesophageal fistula or pericardo-esophageal fistula after catheter ablation of atrial fibrillation were analyzed retrospectively from the French database EPITHOR. Patients without surgical management were excluded. ResultsEighteen patients were included, 15 with atrioesophageal fistula and 3 with pericardo-esophageal fistula. Median follow-up was 89.5 days with an overall survival of 50%. Five patients underwent esophageal stenting, 2 as a bridge-to-esophagectomy with 50% of survival and 3 in association with esophagus and left atrial direct repair with 66% survival. Primary esophageal repair with flap coverage was performed in 8 patients with 25% survival, most of them with sepsis and neurological failure. Seven patients had an esophagectomy with 71% survival, only 2 of them having a neurological failure. Among them, 5 patients underwent a restorative surgery and are still alive. Four patients had a retrosternal colon interposition, and 1 patient had an esogastric anastomosis. Risk factors for death were neurological failure (hazard ratio [HR], 4.91, 95% CI, 0.95-25.22; P = .0057) in univariate analysis and sepsis (HR, 6.25, 95% CI, 1.17-33.3; P = .032) in multivariate analysis. Esophagectomy tended to offer a survival benefit (HR, 0.163, 95% CI, 0.019-1.340; P = .092). The use of cardiopulmonary bypass did not significantly impact survival (HR, 1.953, 95% CI, 0.392-9.719; P = .413). ConclusionsAggressive surgical strategies for managing atrioesophageal fistula are mandatory to offer the best chance of survival.

Management of aortoesophageal fistula primarily using esophageal preservation

ObjectiveAortoesophageal fistula is a rare, life-threatening condition. There is no consensus regarding the surgical management of the esophagus in this condition. MethodsWe retrospectively evaluated 13 patients diagnosed with aortoesophageal fistulas at a single institution from 2003 to 2021. Descriptive statistics were used to analyze patient characteristics, operative characteristics, and patient outcomes. Kaplan–Meier survival analysis was performed. ResultsPatients’ mean age was 63.5 years, and 6 (46.2%) were female. The most common presenting symptoms were hemoptysis/hematemesis (69.2%), chest/back pain (46.2%), and fever (38.5%). Twelve patients (92.3%) had a history of aortic procedures. The median time between the index operation and repair of the secondary aortoesophageal fistula in the 12 patients was 5 months. The index operation was a thoracic endovascular aortic repair in 10 of 12 patients (83.3%). Eleven patients (84.6%) underwent primary esophageal repair with flap coverage (omentum or muscle). One of these patients needed an esophagectomy within 1 year. The primary surgical management of the aorta was graft excision and replacement, aside from 1 patient who underwent primary repair. The 30-day survival was 69.2%, and 1-year and 5-year survivals were 31.7%. There were no recurrent infections at the esophageal fistula site. ConclusionsAortoesophageal fistula remains a rare condition, but its case numbers have increased with thoracic endovascular aortic repair. It continues to be a difficult condition to manage and has a high fatality rate. Esophageal-preserving surgery may be a safe and less-invasive option for patients with a small defect.

Peri- and neonatal factors influencing mortality and morbidity 2years after esophageal atresia primary repair: a single center retrospective study.

Post-operative ventilation and feeding management strategies may represent an opportunity for quality-of-care improvement to positively impact long-term outcomes after primary esophageal atresia repair. • Children operated on for esophageal atresia experience long-term digestive, respiratory, and neurologic morbidity, especially after multiple-stage esophageal repair. • Exclusive oral feeding at discharge is associated with a decreased risk of medical complications in the first years of life, in studies including all types of esophageal atresia repair.Outcomes of children after primary repair (non-long gap populations) have been less documented. • In our retrospective cohort of children with one-stage esophageal atresia repair, ventilatory support for more than 8 days and inability to achieve full oral feeding before hospital discharge in the neonatal period were independently associated with adverse digestive, respiratory, and neurologic outcomes at 2 years in survivors. • Both these factors are potentially modifiable, representing an opportunity for quality-of-care improvement to positively impact long-term outcomes.These results might also help identify children at risk of unfavorable evolution, to customize a multi-disciplinary follow-up program.

Swallowing-related quality of life in children with oesophageal atresia: a national cohort study

Swallowing and feeding disorders are a major concern for children with oesophageal atresia (OA) after primary or staged OA repair. Primary OA repair is associated with higher rates of short-term complications in preterm infants with very low birth weight (VLBW) or extreme low birth weight (ELBW). On the other hand, primary repair may have the benefit of early commencement of oral feedings. We hypothesize that also in the medium-term, swallowing-related quality of life is better after primary oesophageal repair. We conducted a prospective cross-sectional study on swallowing quality in a national cohort of former VLBW and ELBW children with OA, using the structured paediatric swallowing quality of life (pedSWAL-QOL) questionnaire. Results were correlated with surgical approach and baseline clinical data. Principal component analysis of pedSWAL-QOL domains was performed. In total, 44 complete data sets of 78 children were available. The mean age of children was 8.5 years (SD = 7.4), and 23 children (52%) had primary OA repair. The overall median pedSWAL-QOL score was 2 (IQR = 0–3), representing a high swallowing-related quality of life, independent of surgical technique (p = 0.086). Children with a history of intracranial haemorrhage (ICH) (p = 0.002) and those with VACTERL association (p = 0.008) had significantly decreased enjoyment with eating. In addition, children with VACTERL association had problems to find suitable foods (p = 0.04). Conclusion: In this national cohort of VLBW and ELBW preterm-born children with OA, swallowing-related quality of life is good, mostly independent of initial surgery. Children with OA and ICH or VACTERL association may require more intense support with feeding.What is Known:• Dysphagia, resembling feeding and swallowing disorders, is common in children and adults with repaired oesophageal atresia. Nevertheless, dysphagia in children with oesophageal atresia decreases with age.• Parents of younger children suffer from increased anxiety and fear regarding eating and swallowing abilities of their children.What is New:• Swallowing-related quality of life in former preterm children with oesophageal atresia is good, independent of initial surgical approach (primary vs. staged repair), even in very low birth weight or extreme low birth weight infants. • Children suffering from VACTERL association or intracranial haemorrhage show decreased enjoyment with eating.

162. EXPERIENCE IN PRIMARY REPAIR OVER T TUBE IN IATROGENIC OESOPHAGEAL PERFORATION

Abstract Iatrogenic oesophageal perforation can be a devastating event following endoscopic or surgical procedures. It remains a challenge for the surgeon to intervene. The most common cause of oesophageal perforation which accounts for about 70% of the cases is iatrogenic perforation with mortality ranging from about 10 to 25%. Most of the iatrogenic perforations are from endoscopic procedures. This case report like to highlight one of the treatments for iatrogenic oesophageal perforation. A 73-year-old female presented to the ORL team with the inability to swallow and associated with choking sensation and drooling of saliva for 2 days. The patient developed intrascapular pain post-Rigid Esophagoscopy which intensified postprandially, and developed respiratory distress with excruciating pain over the centre of the chest anteriorly and intrascapular region. Examination revealed reduce air entry of the right lung with Xray revealed right pneumothorax with a collapsed lung. CT Thorax revealed mid-oesophageal injury at above the carina with extravasation of oral contrast. Oesophagogastroduodenoscopy, Right Thoracotomy, Primary Oesophageal perforation repair over T-tube, Right Thoracic Decortication, and Washout were done. Defect at mucosa anteriorly with stricture 23 cm and submucosal flap 28 cm from the incisor into the left thoracic cavity with perforation at the right lateral wall of the oesophagus 5 cm below the azygos vein crossing point. Myotomy performed and T-tube catheter inserted as control fistula. Oesophageal repair done and 2 chest tubes inserted at the site of perforation and base of thorax. Intraoperatively right lung expanded well. A contrast swallow study on day 46 shown no evidence of fistula between trachea and oesophagus or leak. The surveillance endoscope showed remarkable healing. Iatrogenic oesophageal perforation remains amongst the main causes for oesophageal emergencies which require proper planning, and prompt management. Proper selection of both non-operative and operative management are interchangeable with the time, and progression of a patient’s conditions. As these cases are rarely encountered thus such cases should be managed at a centre that is equipped with a trained, and experienced specialist unit, thus preventing misdiagnosis, undertreated treatment, and unwanted outcomes.

Determining the factors that predict the feasibility of one-stage primary esophageal repair versus staged repair in neonates with type C esophageal atresia: Developing some new criteria

Background: Several factors can predict the feasibility of primary repair or a staged repair should be done from the start in patients with esophageal atresia with distal tracheoesophageal fistula (Type C TEF) to avoid unnecessary lengthy operations which may result in high morbidity and mortality in such condition.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair ameliorate tracheomalacia in neonates: a single-center retrospective comparative cohort study

BackgroundEsophageal atresia (EA) is often associated with tracheomalacia (TM). The severity of TM symptoms varies widely, with serious cases requiring prolonged respiratory support and surgical treatment. Although we performed thoracoscopic posterior tracheopexy (TPT) during primary EA repair to prevent or reduce the symptoms of TM, few studies have investigated the safety and effectiveness of TPT during primary EA repair. Therefore, this study aimed to evaluate the safety and efficacy of TPT in neonates.MethodsWe retrospectively reviewed the records of all patients diagnosed with TM who underwent primary thoracoscopic EA repair between 2013 and 2020 at the Nagoya University Hospital. Patients were divided into two groups: TPT (TPT group) and without TPT (control group). TPT has been performed in all patients with EA complicated by TM since 2020. We compared patient backgrounds, surgical outcomes, postoperative complications, and treatment efficacy.ResultsOf the 22 patients reviewed, eight were in the TPT group and 14 were in the control group. There were no statistically significant differences in the surgical outcomes between the groups (operation time: p = 0.31; blood loss: p = 0.83; time to extubation: p = 0.30; time to start enteral feeding: p = 0.19; time to start oral feeding: p = 0.43). Conversion to open thoracotomy was not performed in any case. The median operative time required for posterior tracheopexy was 10 (8–15) min. There were no statistically significant differences in postoperative complications between the groups (chylothorax: p = 0.36; leakage: p = 1.00; stricture: p = 0.53). The respiratory dependence rate 30 days postoperative (2 [25%] vs. 11 [79%], p = 0.03) and the ratio of the lateral and anterior–posterior diameter of the trachea (LAR) were significantly lower in the TPT group (1.83 [1.66–2.78] vs. 3.59 [1.80–7.70], p = 0.01).ConclusionsTPT during primary EA repair for treatment of TM significantly lowered respiratory dependence rate at 30 days postoperative without increasing the risk of postoperative complications. This study suggested that TPT could improve TM associated with EA.

The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

IntroductionPreservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions. Operative TechniqueTwo approaches using the Connect-EA are described – a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device. OutcomesSalvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy. ConclusionThe Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

Telementoring in Minimally Invasive Esophageal Atresia Repair: Results of a Case-Control Study and Lessons Learned from the TIC-PEA Study (Telemedical Interdisciplinary Care for Patients with Esophageal Atresia).

Minimally invasive esophageal atresia (EA) repair is deemed one of the most demanding procedures in pediatric surgery. Open repair is considered the gold standard and learning opportunities for minimally invasive repairs remain scarce. “Telemedical Interdisciplinary Care for Patients with Esophageal Atresia (TIC-PEA)” offers free access to an interdisciplinary network of experts for telemedical consultation (telementoring). The aim of this study was to determine the frequency of minimally invasive surgery (MIS) in TIC-PEA patients compared to the general population. TIC-PEA patients were matched and compared to controls regarding the use of MIS, patient characteristics, and complications. Patients (n = 31) were included at a mean age of 62.8 days (95%-CI: 41.4–84.3, 77% after the primary esophageal repair). The odds-ratio to have MIS was 4.03 (95%-confidence interval: 0.79–20.55) for esophageal anastomosis and 4.60 (95%-confidence interval: 0.87–24.22) for tracheoesophageal fistula-repair in the TIC-PEA group. Telementoring offered the chance to select the ideal candidate for MIS, plan the procedure, and review intraoperative images and videos with the expert. Telementoring as offered is ideal to promote MIS for EA and helps to address the individual learning curve. In order to maximize benefits, patients need to be included prior to the first esophageal procedure.

Video-assisted thoracoscopic resection of a giant esophageal schwannoma: A case report.

Introduction and importanceIntrathoracic schwannomas are rare and difficult to diagnose. However, they are the most common type of neurogenic tumor in the chest. Most patients are incidentally diagnosed or develop symptoms from mass effect, such as chest pain, dysphagia or dyspnea. Larger tumors have been resected using open approaches, while smaller ones are often excised with minimally invasive approaches.Case presentationA 60-year-old woman with a prior Roux-en-Y gastric bypass and a history of dysphagia, decreased appetite, and weight loss was referred for evaluation. CT chest revealed an 8 cm soft tissue mass centered in the distal esophagus. Gastroscopy showed the tumor to be 8 cm as well, with 2 cm of normal esophagus prior to the gastric pouch. A right-sided video-assisted thoracoscopic (VATS) approach for enucleation was successfully completed with primary esophageal repair for an 8.0 × 5.5 × 6.5 cm schwannoma.Clinical discussionSurgical resection for schwannomas is often indicated due to symptoms from mass effect (Moro et al., 2017). There are reports of VATS and robotic-assisted thoracic surgery approaches for small tumors. These techniques are appealing due to shorter length of stays and less post-operative pain. None have been described for lesions larger than 6 cm.ConclusionMinimally invasive approaches such as VATS for large schwannomas are technically feasible and safe to perform without the need for a thoracotomy.

Associations of perioperative characteristics with motor function in preschool children born with esophageal atresia.

BackgroundChildren born with esophageal atresia experience long‐term neurodevelopmental deficits, with unknown origin.AimsTo find associations between perioperative variables during primary esophageal atresia repair and motor function at age 5 years.MethodsThis ambidirectional cohort study included children born with esophageal atresia who consecutively had been operated on in the Erasmus MC‐Sophia Children's Hospital, University Medical Center, Rotterdam, from January 2007 through June 2013. The perioperative data of this cohort were collected retrospectively; the motor function data prospectively.ResultsAfter exclusion of patients with syndromal congenital diseases (n = 8) and lost to follow‐up (n = 10), the data of 53 children were included. The mean (SD) total motor function impairment z‐score at 5 years of age was −0.66 (0.99), significantly below normal (p < .001). In multivariable linear regression analysis, number of postoperative days endotracheal intubation (B = −0.211, 95% CI: −0.389 to −0.033, p = .021) was negatively associated with motor outcome, whereas high blood pressure (B = 0.022, 95% CI 0.001 to 0.042, p = .038) was positively associated. Preoperative nasal oxygen supplementation versus room air (B = 0.706, 95% CI: 0.132 to 1.280, p = .016) was positively associated with motor outcome, which we cannot explain.ConclusionsMotor function in 5‐year‐old esophageal atresia patients was impaired and negatively associated with the number of postoperative days of endotracheal intubation and positively associated with high blood pressure. Prospective studies with critical perioperative monitoring and monitoring during stay at the intensive care unit are recommended.

Primary Repair of Esophageal Perforation Following Anterior Cervical Fusion.

IntroductionAnterior cervical fusion has been performed safely and effectively for decades for the treatment of multiple pathologies, with low rates of morbidity and mortality. Esophageal perforation is a rare but potentially serious complication of anterior cervical spine approaches. There is no consensus regarding the best treatment strategies for this complication.ObjectivesTo determine the prevalence of esophageal perforation following anterior cervical fusion in a single institution and to describe two cases of this complication that were treated with primary repair.MethodsWe retrospectively analyzed all consecutive patients who underwent anterior cervical fusion in a single private institution from January 1999 to August 2017. Patients who developed esophageal perforation per- or postoperatively were included in the analysis.ResultsA total of 830 anterior cervical fusion surgeries were performed during the analyzed period. Two cases (0.24%), both of male patients, were complicated by esophageal perforation, one intraoperatively and the other four years after the first surgery. Both patients were treated with primary esophageal repair, and good outcomes were obtained.ConclusionPrimary repair is a therapeutic option in cases of esophageal perforation after anterior cervical fusion. Satisfactory results were obtained in both cases. Further studies are necessary to elucidate the best therapeutic options for this rare complication.

Repair of aortoesophageal fistula with homograft aortic replacement and primary esophageal closure

ObjectivesThe presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF). MethodsWe retrospectively reviewed patients with AEF who underwent surgery at our institution. ResultsBetween 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively. ConclusionsThe strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

BackgroundOesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population.Case presentationWe report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations.ConclusionsLaparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

DOZ047.66: Thoracoscopic posterior tracheopexy during primary esophageal atresia repair

Abstract Background Esophageal atresia (EA) is usually accompanied by some form of tracheomalacia. During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE’s). Therapeutic strategies for severe tracheomalacia include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. Earlier we have introduced a new approach in which the posterior tracheopexy is performed directly during primary thoracoscopic correction of EA. Methods In the period 2017–2018, all consecutive EA patients (27) underwent a rigid tracheobronchoscopic evaluation during induction of anesthesia prior to the thoracoscopic EA repair. Tracheomalacia was diagnosed in 11 patients. During the subsequent thoracoscopic procedure, the posterior tracheal membrane was fixed to the anterior longitudinal spinal ligament with nonabsorbable sutures. The esophageal ends were then mobilized toward the right hemithorax and anastomosed. Results On preoperative RTB, six patients had a severe (66–99%) mid tracheal collapse and five patients had a moderate (33–66%) collapse. Thoracoscopic posterior tracheopexy with on to three sutures was possible in all 11 patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 minutes (range: 4–12 minutes). All operative procedures were uneventful. A median follow-up of 10 months (range: 2–22 months) revealed that eight patients recovered without any respiratory symptoms, one patient had respiratory symptoms caused by a suture granuloma that was removed by bronchoscopy, one patient had a respiratory syncytial virus bronchiolitis and one patient had a rhinovirus infection. None of the patients experienced any ALTE’s. Conclusion Eleven patients have been treated by thoracoscopic posterior tracheopexy during primary EA repair. This technique could prevent potentially deleterious sequelae of moderate to severe tracheomalacia that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction.

PS01.087: SINGLE STEP TREATMENT OF ESOPHAGEL PERFORATION CAUSED BY HUGE FOREIGN BODY

Abstract Background If a clinician encounters a foreign body in thoracic esophagus, flexible endoscopy is the first treatment modality that comes up in mind. But if the foreign body is too huge to pass the upper esophageal sphincter or stuck in esophageal wall, removal is not easy and could result in iatrogenic injury. Furthermore, esophageal perforation is clinically fatal situation and mandates prompt surgical intervention. Here, we report our successful single step treatment of esophageal perforation caused by huge foreign body. The procedure proceeded in operating room with endoscopic assistance. Methods Medical chart review. Results 69 years old male patient admitted to emergency department complaining of neck pain. About 4 days ago, he had ingested a crab. Since then, foreign body sensation and neck pain had been persisted. Computed Tomography (CT) and endoscopy revealed perforation of cervical esophagus. We performed a surgical exploration. With left cervical collar incision, we were able to exposure the injured esophagus. Simultaneously, a gastroenterologist performed an endoscopic inspection. Foreign bodies had migrated to the thoracic esophagus. With endoscopic forceps, most of foreign bodies were removed through the patient's mouth (including the longest one, about 4centimeter; cm). But, 2.8cm sized foreign body was not able to pass the upper esophageal sphincter. Thus, the gastroenterologist pulled the foreign body to level of perforated esophagus and we removed it without difficulty. Finally, the gastroenterologist checked the total length of esophagus. There was no other perforation. Then, we did primary repair of esophagus. The patient discharged at post operation day 11 without complication. Conclusion In our case, some of foreign body was situated perpendicularly in thoracic esophagus. Therefore, it couldn’t pass the upper esophageal sphincter, which the longer one could. With endoscopic assistance in operating room, single step treatment (foreign body removal and perforation repair) was possible. In addition, full inspection of total length of esophagus was possible, simultaneously. We think this single step approach is feasible in terms of avoiding unnecessary thoracic approach and multistep procedures (endoscopy followed by surgery). Disclosure All authors have declared no conflicts of interest.

VS02.02: LAPAROSCOPIC TRANS-HIATAL REPAIR FOR BOERHAAVE’S SYNDROME: A CASE REPORT

Abstract Description Introduction Spontaneous esophageal rupture, also known as Boerhaave's syndrome, is an uncommon and potentially life-threatening condition that requires urgent surgical management. We report a case of spontaneous esophageal rupture that was successfully treated by primary closure and drainage laparoscopically. Case report The patient was a 49 year-old man with a history of liver cirrhosis. He experienced sudden-onset epigastric pain triggered by vomiting after drinking alcohol, and transported to our hospital. On admission, a thoracic CT scanning revealed mediastinal emphysema without pleural effusion. We diagnosed BS and performed an emergency operation. We chose laparoscopic trans-hiatal approach as it was thought to be minimally invasive compared with open thoracic surgery. Five trocars were placed in a similar way of gastric cancer surgery. We identified laceration on the left wall of the lower esophagus under assistance of intra-operative upper endoscopy, and conducted drainage and repair by primary closure with continuous barbed suture. Finally, an omental pedicle flap was applied for over sutured site. The operation time was 214 minutes and the amount of blood loss was 50 cc. In the post-operative course, intra-mediastinal abscess was observed and he required antibiotic therapy. However, the patient was discharged on the 16th post-operative day without a serious complication such as anastomotic leakage. Discussion Primary esophageal repair is the gold standard in Boerhaave's syndrome and the approach is usually left thoracotomy. However, if there is no perforation into the thoracic cavity as in our case, less invasive approach should be considered such as laparoscopic trans-hiatal approach. We could observe the lower esophagus completely under a good field of view in this approach. There are several treatments, and it should always be tailored to the patient's condition. Laparoscopic trans-hiatal approach is considered to be useful for the treatment of lower esophageal wall rupture. It is difficult to conduct a comparative study of the various methods that can be used to treat spontaneous esophageal rupture in cases that require emergent surgery, as the number of cases is limited. Therefore, the further accumulation of cases is necessary. Disclosure All authors have declared no conflicts of interest.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair: a new approach to prevent tracheomalacia complications

BackgroundEsophageal atresia (EA) is usually accompanied by some form of tracheomalacia (TM). During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE's) or brief resolved unexplained events (BRUE's). Therapeutic strategies for severe TM include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. In this study, we describe the development of a new approach in which the posterior tracheopexy is performed directly during the primary thoracoscopic correction of EA. MethodsIn 2017, all nine consecutive EA patients with trachea-esophageal fistula underwent a rigid tracheo-bronchoscopy (RTB) evaluation during induction of anesthesia prior to the thoracoscopic EA repair. A floppy posterior membrane was diagnosed in four patients. During the subsequent thoracoscopic procedure, the posterior membranous trachea was fixed to the anterior longitudinal spinal ligament with non-absorbable sutures. Then, the anastomosis was made between the two esophageal pouches. ResultsOn preoperative RTB, two patients had a severe (70–90%) mid-tracheal collapse of the pars membranacea and two patients had a moderate (33–40%) mid-tracheal collapse. Thoracoscopic posterior tracheopexy with two or three sutures was possible in all four patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 min (range 4–12 min). All operative procedures were uneventful. A median follow-up of 6 months (range 4–9 months) revealed that all patients showed further recovery without any TM symptoms or ALTE/BRUE. ConclusionsThis is the first report that introduces a new approach to thoracoscopic posterior tracheopexy during primary EA repair. We believe that this technique can prevent the potentially deleterious sequelae of mild to severe TM that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction. Level of EvidenceIV.

Omental flap repair for re-recurrent tracheoesophageal fistula 21 years after primary esophageal atresia repair

Omental flap repair for re-recurrent tracheoesophageal fistula 21 years after primary esophageal atresia repair

Use of reversed latissimus dorsi muscle flap for primary oesophageal repair reinforcement in Boerhaave's syndrome

AimBoerhaave's syndrome, or spontaneous oesophageal rupture, is a rare but serious condition. The pathology involved is a complete, transmural laceration of the oesophagus. The overall mortality rates are still high (range: 10–60 per cent). Outcomes of oesophageal perforations depend on the duration between diagnosis of perforation and treatment. Primary repair has been identified as the best treatment option, especially for presentation before 24 h. Mediastinal pleura, gastric fundus, pericardial flap and intercostal muscle flap are frequently used. Reversed latissimus dorsi (LD) muscle flap is another feasible option, especially when the intercostal muscle is inadequate and the length of perforation is long.Patients and MethodsA patient presented with Boerhaave's syndrome with left posterolateral thoracotomy done. Intraoperation found a 4‐cm, full‐thickness perforation over the distal oesophagus. Primary repair and reinforcement with reversed LD muscle flap was performed.ResultsThe patient had an uneventful recovery. Water‐soluble contrast enema confirmed no leakage. He was discharged on postoperative day 10.ConclusionPrimary repair and reinforcement with reversed LD muscle flap is a feasible option when the intercostal muscle is inadequate and the length of the oesophageal perforation is long.