Sengstaken-Blakemore Research Articles

Successful surgical treatment for aortoenteric fistula after esophagectomy: a case report

BackgroundAn aortoenteric fistula (AEF) is a rare and lethal complication of esophagectomy. Fistulas frequently result from problems regarding acute infections or leaks, which are typically evident weeks after the treatment. However, some cases exhibit AEF years after the initial operation. Here, we describe a rare case of AEF caused by chronic friction of the stapler toward the aortic arch, in which stent graft repair and surgery were successful.Case presentationA 71-year-old man had undergone esophagectomy for esophageal carcinoma and reconstruction with a gastric conduit through the posterior mediastinal route 11 years previously. He visited our outpatient clinic with the chief complaint of hematemesis. However, after arrival, he experienced massive hematemesis and severe shock due to bleeding from an AEF. Endoscopic hemostasis using a Sengstaken-Blakemore tube followed by stent graft repair controlled the bleeding. We performed a partial resection of the gastric conduit, including the fistula, followed by digestive reconstruction using a jejunal interposition graft. The patient recovered gradually after receiving intensive care and was discharged 115 days after hospitalization.ConclusionsWe present a rare case of bleeding due to AEF long after esophagectomy, which was successfully treated with endovascular stent graft repair and surgery. Endoscopic hemostasis using a Sengstaken-Blakemore tube followed by stent graft repair was effective.

Thoracoscopic enucleation of an esophageal glomus tumor in the prone position: a case report and literature review

BackgroundGlomus tumors (GT) generally occur in the skin. However, esophageal GT, an extremely rare condition, has no established standardized treatment guidelines. Herein, we report the case of an esophageal GT successfully removed by thoracoscopic enucleation in the prone position using intra-esophageal balloon compression.Case presentationA 45-year-old man underwent an annual endoscopic examination and was found to have a submucosal tumor in the lower esophagus. Endoscopic ultrasound (EUS) revealed a hyperechoic mass originating from the muscular layer. Contrast-enhanced computed tomography identified a 2 cm mass lesion with high contrast enhancement in the right side of the lower esophagus. Pathologic findings of EUS-guided fine needle aspiration biopsy (EUS–FNA) revealed round to spindle shaped atypical cells without mitotic activity. Immunohistochemically, the tumor was positive for alpha-smooth muscle actin, but negative for CD34, desmin, keratin 18, S-100 protein, melan A, c-kit, and STAT6. He was diagnosed with an esophageal GT and a thoracoscopic approach to tumor resection was planned. Under general anesthesia, a Sengstaken–Blakemore (SB) tube was inserted into the esophagus. The patient was placed in the prone position and a right thoracoscopic approach was achieved. The esophagus around the tumor was mobilized and the SB tube balloon inflated to compress the tumor toward the thoracic cavity. The muscle layer was divided and the tumor was successfully enucleated without mucosal penetration. Oral intake was initiated on postoperative day (POD) 3 and the patient discharged on POD 9. No surgical complications or tumor metastasis were observed during the 1-year postoperative follow-up.ConclusionsAs malignancy criteria for esophageal GT are not yet established, the least invasive procedure for complete resection should be selected on a case-by-case basis. Thoracoscopic enucleation in the prone position using intra-esophageal balloon compression is useful to treat esophageal GT on the right side of the esophagus.

Effectiveness of Balloon Tamponade with a Condom Catheter versus Using a Sengstaken-Blakemore Tube in Patients with Primary Postpartum Hemorrhage

Balloon tamponade or Sengstaken-Blakemore tube, are gaining fame because of its low complications, low invasiveness, rapid approach, painless removal, and rapid identification of failed cases in primary postpartum hemorrhage. Objective: To compare the efficacy of balloon tamponade versus Sengstaken-Blakemore tube in patients with primary postpartum hemorrhage. Methods: This comparative/cross-sectional was conducted at the department of Obstetrics and Gynaecology at Bahawal Victoria Hospital, Bahawalpur from July 2023 to December 2023. A total of 64 patients (32 in each group) females aged between 18 and 40 years of parity 1-6, gravida 1-6, gestational age 31 to 41 weeks, with primary postpartum hemorrhage were recruited. Females in balloon tamponade group underwent balloon tamponade, and those in Sengstaken-Blakemore tube group underwent Sengstaken-Blakemore tube insertion and balloon removal after 24 hours. The effectiveness was labelled as yes where there was no blood loss for 24 hours after the removal of the pack or foleys. Results: The mean age was 31.05 ± 5.92 years. The effectiveness of the treatment was observed among 51 (79.7%) females. In balloon tamponade group, mean blood loss was 787.81 ± 265.11 ml and 791.34 ± 254.78 ml in Sengstaken-Blakemore tube group. In balloon tamponade group, 29 (90.6%) patients had effectiveness of treatment while 22 (68.8%) females in Sengstaken-Blakemore tube group reported effectiveness (p=0.030). Conclusion: Tamponade with a balloon attached to a condom catheter were more successfully in stop bleeding after delivery of primary PPH cases.

Compression Hemostasis in Refractory Esophageal Bleeding

RELEVANCE. Efficiency and safety of compression hemostasis with esophageal self-expanding nitinol stents Danis compared to the Sengstaken–Blakemore tube in the treatment program of refractory esophageal bleeding still remains a controversial issue. AIM OF THE STUDY. To conduct a comparative analysis of the effectiveness of Danis self-expanding compression hemostasis nitinol stent and the Sengstaken-Blakemore tube for variceal esophageal bleeding refractory to drug and endoscopic treatment. MATERIAL AND METHODS. The first comparison group included 44 patients, in whose complex treatment program tamponade with a Sengstaken-Blakemore tube was used to save lives. The second main group of the study consisted of 15 patients in whom compression hemostasis was performed using Danis self-expanding nitinol stent. Statistical processing was carried out using the Kolmogorov-Smirnov, Student, χ2 and Fisher exact tests. Differences were considered statistically significant at p ≤ 0.05. RESULTS. In the comparison group, complications occurred in 44 (100 %), in the main group complications were observed in 8 patients (53.3 %). Accordingly, reliable mechanical hemostasis was achieved in 33 (75.0 %) and 13 clinical observations (86.7 %); trophic changes in the esophageal mucosa were detected in 12 (27.2 %) and 8 patients (53.3 %). When assessing the function of external respiration, 5th and 2nd degrees of decrease in the ventilation capacity of the lungs, as well as 3rd and 1st degrees of decrease in the vital capacity of the lungs were established. The overall mortality was 56.8 % in the comparison group and 26.7 % in the main group. CONCLUSION. Self-expanding compression hemostasis nitinol stent Danis as a bridge to the choice of definitive therapy compared to tamponade with the Sengstaken–Blakemore tube is a promising alternative first-line treatment for patients with refractory esophageal bleeding. At the same time, it is necessary to conduct randomized controlled studies to confirm the safety and effectiveness of self-expanding nitinol stents.

Research Progress on Modified Sengstaken-Blakemore Tube Fixation and Insertion Method for the Treatment of Rupture and Bleeding of Esophagogastric Varices

Research Progress on Modified Sengstaken-Blakemore Tube Fixation and Insertion Method for the Treatment of Rupture and Bleeding of Esophagogastric Varices

Factors influencing in-hospital mortality for salvage percutaneous transjugular intrahepatic portosystemic shunting in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention

Background. Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB). In high-risk patients with persistent AVB despite pharmacological treatment and endoscopic intervention, percutaneous transjugular intrahepatic portosystemic shunting (TIPS) provides a minimally invasive salvage method to reduce portal pressure and control bleeding. Objectives. To evaluate factors influencing in-hospital mortality after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding despite medical treatment and endoscopic intervention. Methods. Clinical and laboratory data were analysed in all patients treated with sTIPS following failed endoscopic therapy for AVB between August 1991 and November 2020. Factors associated with and predictors of death were determined using bivariate analysis and univariate logistic regression analysis. Results. Thirty-four patients (29 men, 5 women), mean age 52 years (range 31 - 80), received sTIPS for uncontrolled (n=11) or refractory (n=23) AVB. The causes of portal hypertension were alcohol-related (n=24) and non-alcohol-related cirrhosis. Salvage TIPS controlled bleeding in 32 patients, with recurrence in 1. Ten patients died in hospital (mean 4.8 days, range 1 - 10) of liver failure (n=4), multiorgan failure (n=3), alcoholic cardiomyopathy (n=2) and uncontrolled gastric variceal bleeding (n=1). On bivariate analysis, factors associated with death were Child-Pugh (C-P) score ≥10 (p=0.006), sodium Model for End-stage Liver Disease (MELD-Na) score ≥22 (p<0.001), ≥8 units of blood transfused (p<0.001), Sengstaken-Blakemore balloon tube placement (p<0.001), endotracheal intubation (p<0.001), inotropic support (p<0.001) and endoscopically uncontrolled bleeding (p<0.001). Univariate logistic regression analysis showed that the most significant predictors of mortality were inotrope dependency (odds ratio (OR) 134; p<0.001), endotracheal intubation (OR 99; p<0.001), endoscopically uncontrolled bleeding (OR 28; p=0.001), grade 3 ascites (OR 20.9; p=0.012) and C-P grade C (OR 8.8; p=0.011). Conclusion. Salvage TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 29% in-hospital mortality. The most significant predictors of mortality were C-P grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding.

Modifying the Sengstaken-Blakemore tube to treat variceal bleeding

Modifying the Sengstaken-Blakemore tube to treat variceal bleeding

A novel approach to spontaneous retropharyngeal hematoma—a case report

BackgroundRetropharyngeal hematoma is a rare but life-threatening situation and may require emergency tracheostomy or surgical drainage if the airway is compromised. We present a case of a retropharyngeal hematoma with shown active submucosal bleeding and describe the novel approach taken for compression and control of the hemorrhage.Case presentationA 76-year-old man presented to our institution complaining of dysphagia and pharyngeal discomfort hematoma since that morning. The laryngoscopy showed a hematoma of the posterior wall of the hypopharynx. A computerized tomography scan with contrast was done, demonstrating a collection in the retropharyngeal space, and a small active vessel could be identified.The patient was intubated, and compression was performed in the location of the retropharyngeal hematoma using the esophageal balloon of a Blakemore tube, with successful control of the active bleed.ConclusionsRetropharyngeal hematoma can be fatal, and we present a unique solution that can be used to successfully stop the bleeding while avoiding more invasive strategies, by performing compression with a Blakemore esophageal balloon to stop the bleeding.

Management of delayed bleeding of upper gastrointestinal endoscopic submucosal tunneling procedures: a retrospective single-center analysis and brief meta-analysis.

Delayed bleeding is a rare but important major adverse event (mAE) after endoscopic submucosal tunneling procedures (ESTP), which is scarcely reported. We aimed to characterize the clinical characteristics of delayed bleeding and provide better management of this mAE. From August 2010 to October 2022, we reviewed 3852 patients with achalasia receiving peroral endoscopic myotomy (POEM) and 1937 patients with upper gastrointestinal tumors receiving submucosal tunneling endoscopic resection (STER). Among these, records of 22 patients (15 POEM, 7 STER) with delayed bleeding were collected. Clinical characteristics, treatment, and outcomes of delayed bleeding were analyzed. The mean age was 43.6years. Ten patients (45.5%) were intratunnel bleeding, seven (31.8%) were intratunnel bleeding accompanied by mucosal bleeding, and five (22.7%) were mucosal bleeding. The most common accompanied symptoms were hematemesis, fever, and melena. The most common accompanied mAEs were fistula, pulmonary inflammation, and pleural effusion with atelectasis. The mean duration from ESTP to endoscopic intervention was 5.3±4.9days. Active bleeding was identified in 21 patients (95.5%). The bleeding was successfully controlled by electrocoagulation (19 cases), endoscopic clipping (six cases), and Sengstaken-Blakemore tube insertion (three cases), and no patient required surgical intervention. The mean hemostatic procedure duration was 61.8±45.8min. The mean post-bleeding hospital stay was 10.0±6.2days. A brief meta-analysis of previous studies showed the pooled estimate delayed bleeding rate after POEM, STER, and G-POEM was 0.4%. Delayed bleeding is uncommon and could be effectively managed by timely emergency endoscopic procedures without requiring subsequent surgical interventions.

S2767 Unanticipated Esophageal Rupture: A Complication Following Blakemore Tube Insertion in a Severe Esophageal Variceal Bleeding Case

S2767 Unanticipated Esophageal Rupture: A Complication Following Blakemore Tube Insertion in a Severe Esophageal Variceal Bleeding Case

Uniportal thoracoscopic thorough debridement for tubercular empyema with abscess of the chest wall

Objective: To examine the feasibility and technical considerations of thorough debridement using uniportal thoracoscopic surgery for tuberculous empyema complicated by chest wall tuberculosis. Methods: A retrospective analysis was conducted on 38 patients who underwent comprehensive uniportal thoracoscopy debridement for empyema complicated by chest wall tuberculosis in the Department of Thoracic Surgery, Shanghai Pulmonary Hospital, from March 2019 to August 2021. There were 23 males and 15 females, aged (M(IQR)) 30 (25) years (range: 18 to 78 years). The patients were cleared of chest wall tuberculosis under general anesthesia and underwent an incision through the intercostal sinus, followed by the whole fiberboard decortication method. Chest tube drainage was used for pleural cavity disease and negative pressure drainage for chest wall tuberculosis with SB tube, and without muscle flap filling and pressure bandaging. If there was no air leakage, the chest tube was removed first, followed by the removal of the SB tube after 2 to 7 days if there was no obvious residual cavity on the CT scan. The patients were followed up in outpatient clinics and by telephone until October 2022. Results: The operation time was 2.0 (1.5) h (range: 1 to 5 h), and blood loss during the operation was 100 (175) ml (range: 100 to 1 200 ml). The most common postoperative complication was prolonged air leak, with an incidence rate of 81.6% (31/38). The postoperative drainage time of the chest tube was 14 (12) days (range: 2 to 31 days) and the postoperative drainage time of the SB tube was 21 (14) days (range: 4 to 40 days). The follow-up time was 25 (11) months (range: 13 to 42 months). All patients had primary healing of their incisions and there was no tuberculosis recurrence during the follow-up period. Conclusion: Uniportal thoracoscopic thorough debridement combined with postoperative standardized antituberculosis treatment is safe and feasible for the treatment of tuberculous empyema with chest wall tuberculosis, which could achieve a good long-term recovery effect.

Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report.

We treated a case of gastroesophageal varices due to decompensated liver cirrhosis associated with Wilson's disease. The varicose veins penetrated the paraesophageal vein. We performed endoscopic variceal ligation (EVL) on the perforating vein and endoscopic injection sclerotherapy (EIS) distally. However, 5 days after treatment, the patient vomited blood. Esophagogastroduodenoscopy showed bleeding from the ulcer after EVL at the perforating vein. We performed EVL and stopped the bleeding. However, the next day, she vomited blood again and developed hemorrhagic shock. We were able to achieve hemostasis and save the patient's life with combination therapy consisting of percutaneous transhepatic obliteration and Sengstaken-Blakemore tube placement.

Bougie-Facilitated Tamponade Balloon Placement for Massive Esophagogastric Variceal Hemorrhage: A Case Series and Novel Procedural Technique Description

BackgroundBalloon tamponade of esophagogastric variceal hemorrhage is a lifesaving but challenging procedure. One difficulty that often arises is coiling of the tube in the oropharynx. We describe a novel use of the bougie as an external stylet to help guide placement of the balloon to help overcome this challenge. DiscussionWe describe four cases in which the bougie was successfully utilized as an external stylet to place a tamponade balloon (3 Minnesota tubes, 1 Sengstaken-Blakemore tube) without any apparent complication. The straight end of the bougie is inserted approximately 0.5 cm into the most proximal of the gastric aspiration ports. The tube is then inserted into the esophagus under direct or video laryngoscopic visualization using the bougie to help “push” the tube into place as an external stylet. Once the gastric balloon is fully inflated and withdrawn to the gastroesophageal junction, the bougie is gently removed. ConclusionThe bougie may be considered as an adjunct for placement of tamponade balloons for massive esophagogastric variceal hemorrhage when placement proves refractory to traditional techniques. We think this can be a valuable tool in the emergency physician's procedural repertoire.

Use of a Compact, Lightweight X-ray Unit to Reduce the Risk of Five Invasive Procedures in the Emergency Room.

Many invasive procedures performed in the emergency room (ER) have potential risks and complications. Because of their limitations, in particular size, portable X-ray devices are generally not used during such procedures. However, miniaturized units enable physicians to obtain X-ray images without assistance. We developed a safe, compact, and lightweight X-ray unit that was used during five invasive procedures in the ER. In all procedures, a chest X-ray image was obtained, to confirm the utility of the unit. Case 1 (central venous catheter placement): After needle and guidewire insertion and catheter placement, the location of the catheter could be confirmed. Case 2 (chest tube insertion): During insertion of a chest tube into the pleural space, the tip of the thoracic tube was confirmed to be at the correct location. Case 3 (percutaneous tracheostomy or cricothyroidotomy): After needle and guidewire insertion, the guidewire was visualized in the right main bronchus and was inserted into the trachea. Case 4 (resuscitative endovascular aortic balloon of the aorta): The captured image revealed that the catheter was located in zone I before balloon inflation. Case 5 (Sengstaken-Blakemore tube): The image revealed that the balloon was located in the stomach. The portable X-ray unit improved medical safety during invasive procedures frequently performed in the ER.

S2590 Endoscopic Sengstaken-Blakemore Tube Placement for Variceal Hemorrhage: A Case Series

Introduction: Management of brisk variceal bleeding is challenging and nerve-racking for both gastroenterologists and intensivists. When visibility is hampered, a Sengstaken-Blakemore (SB) tube is used to tamponade as a temporary bridge to Transjugular intrahepatic portosystemic shunt (TIPS). Traditionally, the SB tube is placed blindly, or with the help of radiography to confirm gastric balloon location. Catastrophic complications are reported with blind approach including distension of the esophagus or trachea leading to rupture. Endoscopic SB placement has been described in literature as a successful technique. We report 3 cases with successful placement of SB tubes in massive variceal hemorrhage as a bridge to TIPS. Case Description/Methods: Case 1: A 36-year-old gentleman with alcoholic cirrhosis presented with hematemesis 2 days after undergoing variceal banding. Bleeding post-banding ulcers were confirmed with endoscopy and treated with hemoclips and epinephrine. Despite the intervention, the patient had recurrence of bleeding the following day with hematemesis. Repeat endoscopic intervention was limited due to poor visibility from brisk bleeding. An SB tube was placed endoscopically, and he underwent emergent TIPS that same day. The SB tube was removed 24 hours later with no recurrence of bleeding, and he was discharged to home. Case 2: A 68-year-old gentleman with alcoholic cirrhosis and history of variceal bleeding presented with hematemesis. Emergency endoscopy found massive bleeding, however the source of bleeding could not be located. An SB tube was endoscopically placed and an emergent TIPS was performed on the same day. The SB tube was removed 24 hours later with no recurrence of bleeding. After a 10-day hospital stay, he was ultimately discharged to hospice. Case 3: A middle-aged woman presented to the hospital with active variceal bleeding. She underwent successful endoscopic SB tube placement as a bridge to TIPS. Although she also had successful placement and no rebleeding, she ultimately succumbed to her disease. Discussion: Endoscopic SB tube placement is an effective bridge to emergent TIPS due to the improved hemostasis and decreased likelihood of rebleeding. This technique also limits the complications of blind placement, such as inadvertently distending the gastric balloon in the wrong location. Therefore, gastroenterologists should consider endoscopic placement of a SB tube when other endoscopic interventions fail to achieve hemostasis in variceal hemorrhage (Figure 1).Figure 1.: Endoscopic placement of a SB tube, confirming correct placement for hemostasis.

S1192 “If You Build It, They Will Come:” A Sengstaken-Blakemore Tube Quality Improvement Initiative

Introduction: Sengstaken-Blakemore Tube (SBT) can be a lifesaving temporizing measure in patients with massive esophageal variceal bleeding (EVB). Several key components are not provided in the SBT box which can be a barrier to timely and successful deployment of SBT. We created a Self-Sustainable Novel Blakemore Kit (SSNBK) that has all the components for placement of SBT along with easy-to-follow instruction cards. Our goal was to maintain a SSNBK in all critical care locations as a departmental stand of practice. Methods: The SSNBK with all the components is shown in picture 1. We conceptualized that the use of SSNBK would reduce time and increase accuracy of SBT placement. As proof of concept, we conducted a pilot project in a simulated environment for the GI fellows. SSNBK was then deployed in GI lab, Emergency Department, Medical and Surgical ICU. Charge nurses at each location were tasked with restocking and logging the use of SSNBK. Monthly audits of the SSNBK were performed by investigators. Investigators served an advisory role and offered feedback related to the proper stocking and use of the SSNBK. Results from the monthly audits triggered plan-do-study-act (PDSA) cycles when the standard maintenance was not met. Root cause analysis (RCA) and process mapping were done by investigators to identify areas of improvement. (Figure) Results: Fellows who utilized SNBKK were more likely to place Blakemore tube accurately in under 5 minutes compared to the fellows who did not utilize the kit. Monthly audit results are shown in Table. RCA of third month audit results revealed a lack of knowledge on obtaining certain components of the kit. This was addressed by educating charge nurses at all locations on specifics of attaining all the components from supply storage. At the end of the six-month audit there were 4 fully stocked SNBKK at all locations that were maintained by respective departments. Conclusion: With our QI initiative based on a PDSA model we were able to successfully deploy a SSNBK in all critical care locations of our hospital. GI fellow speed and accuracy with simulated SBT placement was improved with use of the SSNBK. SSNBK is an easily implemented intervention that can reduce time–to-SBT placement. We also noticed increased utilization of SBT placement for massive variceal bleeding after creation and deployment of SSNBK. Further multicenter long-term studies are required to validate the SSNBK reduction in time to SBT placement, increased use of SBT, and its effect on patient outcomes.Figure 1.: Blakemore kit. Table 1. - PILOT Fellow 1 (NSBKK) Fellow 2 (NSBKK) Fellow 3 (No Kit) Fellow 4 (No Kit) Time to SBT (Minutes: Seconds) 4.53 4.20 8.45 10.43 Completion of all the steps (Yes/No) Yes Yes Yes Yes Needed help from Internet search engines No No No Yes Monthly audits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Number of sites with fully stocked SSNBK (%), n=4 100 100 75 100 100 100 Number of times kits were utilized 0 1 1 0 2 1

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

S2635 Novel Technique for Insertion of Balloon Tamponade Tube

Introduction: We introduce the use of an endoscopic injection needle to act as a stiffener for the safe insertion of a balloon tamponade tube in a patient with a known benign upper esophageal stricture. Case Description/Methods: 61 year old male with a past medical history of NASH cirrhosis complicated by known varices, squamous cell carcinoma of the esophagus that underwent radiation therapy resulting in a known upper esophageal sphincter that had been dilated with a through the scope balloon the week prior, presented to the emergency department with complaints of hematemesis and dizziness. While in the ED, the patient begins to have massive hematemesis with associated hypotension dropping his pressures to 64/40 mmHg. The ED performs rapid sequence intubation and begins securing venous access with a central venous catheter and large bore IVs. After RSI, the patient experiences PEA arrest with presumption of cause as hemorrhagic shock. Massive transfusion protocol is initiated and. ROSC is achieved after a total 5 minutes of coding the patient, administering epinephrine, and blood. Gastroenterology attempts to perform an EGD but is met with resistance of what is a known radiation-associated stricture off the upper esophagus at approximately 20 centimeters from the incisors and the scope cannot be passed through. A blakemore is attempted to be placed for stabilization of bleeding from esophageal varices but is met by the same resistance as the scope and is coiled at the back of the oropharynx. An endoscopic needle is gathered from the travel cart and inserted into the gastric suction port of the Blakemore tube in order to stiffen the tamponade balloon. The Blakemore tube is successfully passed into the esophagus and stomach and the gastric balloon is inflated and confirmation occurs via abdominal x-ray. Patient is transferred to the IR suite for emergent TIPS with Blakemore in place (Figure 1). Discussion: A novel technique was used in this case to successfully place a Blakemore tamponade balloon into a patient with an active variceal hemorrhage who also had known esophageal stricture from radiation therapy. Unfortunately the stricture precluded timely-endoscopic interventions to the variceal bleed in an unstable patient and the decision to place a Blakemore assisted in controlling the hemorrhage enough to transfer the patient successfully to IR for TIPS.Figure 1.: Tamponade balloon with visible endoscopic needle in gastric suction channel.

S2630 Massive Hematemesis: A Case of Esophageal-Subclavian Fistula

Introduction: Esophageal-subclavian fistulae are rare and are most commonly seen as a complication of congenital aortic arch anomalies. We report a case of an esophageal-subclavian fistula in a patient with a right aortic arch with an aberrant left subclavian artery (ALSA), an uncommon anatomical variant that occurs in approximately 1% of the general population. Case Description/Methods: A 76-year-old man with atrial fibrillation, prior pulmonary embolism, and hyperthyroidism with a multinodular goiter presented to an outside hospital (OSH) after being found down at home. He was intubated for acute hypoxic respiratory failure at the OSH, and transferred to our center for resection of the multinodular goiter causing airway compression. His postoperative course was complicated by multiple infections and prolonged intubation. CT imaging incidentally noted a four vessel aortic arch with retroesophageal ALSA. Two months into the hospitalization, he had large volume hematemesis and subsequent cardiac arrest requiring multiple rounds of resuscitation and Blakemore tube placement into the esophagus. Upon deflation of the Blakemore, he coded again and was started on massive transfusion protocol before successfully deflating the device. Emergent endoscopy was notable for clotted blood in the stomach and active, pulsatile bleeding of the proximal esophagus (25 cm), concerning for arterio-esophageal fistula. Thoracic surgery, cardiac surgery, and vascular surgery were consulted; however, given overall poor prognosis and high risk with invasive surgery, no operative intervention was offered. He was ultimately transitioned to comfort care (Figure 1). Discussion: While arterial-esophageal fistulae are rare, it is important to recognize these cases early as they can lead to fatal hemorrhage if not surgically intervened upon. In the case of ALSA, the vessel takes a retroesophageal course and often forms a dilated segment at the proximal end, called a diverticulum of Kommerell, which compresses the esophagus posteriorly. The vascular pressure on the esophagus can ultimately create a fistula. Prolonged use of indwelling devices, such as nasogastric tubes (NGT) and endotracheal tubes (ETT), may create pressure necrosis and erosion of the posterior esophageal wall, thus contributing to fistula formation. While there are currently no guidelines for screening for aortic arch abnormalities, it has been suggested that those with aortic arch abnormalities noted on CT imaging may benefit from avoidance of prolonged use of NGT or ETT.Figure 1.: Endoscopy image showing upper third of the esophagus with profuse, active bleeding.

S667 Outcomes of Difficult Airway (DA) Patients Presenting With Upper Gastrointestinal Bleed (UGIB): 4-Year Retrospective Study Using National Inpatient Sample (2016 – 2019)

Introduction: Difficult airway patients presenting with upper gastrointestinal bleeding present unique challenge due to increased risk of respiratory complications such as from aspiration or from airway obstruction during anesthesia for urgent upper endoscopy. Limited data are available regarding clinical outcomes in difficult airway patients presenting with Upper gastrointestinal bleed. Methods: Using National Inpatient Sample databases from 2016 to 2019, we identified patients presenting with Upper gastrointestinal bleed, the population were then divided based on the presence and absence of difficult airway using appropriate ICD-10-CM/PCS codes. STATA 17.0 software (3) was used for the analysis. Pearson’s Chi-Square test was used to analyze categorical variable, whereas the student t-test was used to analyze continuous variables. Univariate and multivariate logistic regression was used to adjust for potential confounders. Primary outcome was in hospital mortality due to upper gastrointestinal bleed in patients with and without difficult airway. Results: Amongst total of 1555580 patients admitted with upper gastrointestinal bleed, 140 patients had diagnosis of difficult airway and 1555440 patients did not have difficult airway diagnosis, male gender and white ethnicity was predominant in both populations. The mean LOS was 6.035±5.02 days in difficult airway group, 4.288±4.45 in non-airway group, this result was statistically significant. The mean total hospitalization charges in difficult airway group were 27111$, in the non-difficult airway group were 13183$ and this was found to be statistically significant. There were 45(32.14%) and 36708(2.36%) mortality in patients with and without difficult airway diagnosis. The difference is statistically significant with OR:5.06, 95% CI: 1.62-15.81, and p < 0.001. Odds of using IR intervention and ICU admissions were higher and EGD were lower in difficult airway group, found to be statistically significant. (Table) Conclusion: Patient with diagnosis of difficult airway presenting with upper gastrointestinal bleed symptoms were younger, had higher healthcare utilization and were associated with higher inpatient mortality and complications. Table 1. - In Patient Outcomes of the difficult intubation group presenting with upper gastrointestinal bleed Variables Odds ratio 95% CI P-value In-patient mortality 5.06 1.62-15.81 < 0.001 ALL EGD 0.425 0.131-1.378 <0.001 IR intervention 1.23 0.206-7.31 <0.001 ICU Stay 34.641 13.61-88.11 <0.001 Blood Products Transfusion 0.935 0.408-2.14 <0.001 Blakemore tube insertion 0.95 0.373-2.458 <0.001