Endoscopic clip application for closure of esophageal perforations caused by EMR

BACKGROUND: With increasing use of EMR for early stage esophageal carcinoma, the number of cases of iatrogenic esophageal perforation is likely to increase. This study evaluated the results of endoscopic clip application for treatment of perforations caused by EMR in patients with esophageal carcinoma. METHODS: Among 185 patients who underwent EMR for esophageal carcinoma, esophageal perforation occurred in 3 patients (1.6%). Metallic clips were immediately applied endoscopically to close the perforations. OBSERVATIONS: All 3 patients were observed closely and were managed conservatively (intravenous hyperalimentation, antibiotics) after closure of the perforation. They were discharged without any further serious complication. CONCLUSIONS: When esophageal perforation caused by EMR is immediately recognized, endoscopic application of metallic clips is appropriate therapy. However, patients must be carefully monitored for the development of generalized mediastinitis.     

Successful elimination of Ascaris lumbricoides from the gallbladder by conservative medical therapy

Migration of Ascaris lumbricoides into the gallbladder is rare, unlike ascariasis of the bile duct, and, when it does occur, treatment is generally by endoscopic or surgical extraction. We describe a case of the successful treatment of gallbladder ascariasis with conservative therapy. A 44-year-old Korean man was admitted because of nausea and right upper quadrant pain that did not respond to medical control and had worsened 1 day before admission. Abdominal ultrasonography showed a long, linear, moving echogenic structure in the distended lumen of the gallbladder, but no abnormal dilation of the bile duct. Computerized tomography showed a linear soft-tissue density in the dependent portion of the gallbladder. The patient presented with eosinophilia, and abnormal liver function results, but no fever or hepatomegaly. Based on these findings, and presuming a diagnosis of gallbladder ascariasis, we administered antiparasitic medication (albendazole 400 mg/day for 1 day). Seven days later, we obtained one adult female A. lumbricoides from the feces. The symptoms were fully resolved, and no moving structure could be visualized in the gallbladder by ultrasonography. We recommend that initial therapy for gallbladder ascariasis should involve conservative treatment, unless an associated disease is present or a complication arises. Received: February 13, 2001 / Accepted: June 22, 2001 Reprint requests to: G.S. Lee     

Successful treatment of cervical esophageal leakage by endoscopic-vacuum assisted closure therapy

AIM: To evaluate the efficacy and safety of endoscopic-vacuum assisted closure (E-VAC) therapy in the treatment of cervical esophageal leakage.METHODS: Between May and November 2012, three male patients who developed post-operative cervical esophageal leakage were treated with E-VAC therapy. One patient had undergone surgical excision of a pharyngo-cervical liposarcoma with partial esophageal resection, and the other two patients had received surgical treatment for symptomatic Zenker’s diverticulum. Following endoscopic verification of the leakage, a trimmed polyurethane sponge was fixed to the distal end of a nasogastric silicone tube and endoscopically positioned into the wound cavity, and with decreasing cavity size the sponge was positioned intraluminally to cover the leak. Continuous suction was applied, and the vacuum drainage system was changed twice a week.RESULTS: The initial E-VAC placement was technically successful for all three patients, and complete closure of the esophageal leak was achieved without any procedure-related complications. In all three patients, the insufficiencies were located either above or slightly below the upper esophageal sphincter. The median duration of the E-VAC drainage was 29 d (range: 19-49 d), with a median of seven sponge exchanges (range: 5-12 sponge exchanges). In addition, the E-VAC therapy reduced inflammatory markers to within normal range for all three patients. Two of the patients were immediately fitted with a percutaneous enteral gastric feeding tube with jejunal extension, and the third patient received parenteral feeding. All three patients showed normal swallow function and no evidence of stricture after completion of the E-VAC therapy.CONCLUSION: E-VAC therapy for cervical esophageal leakage was well tolerated by patients. This safe and effective procedure may significantly reduce morbidity and mortality following cervical esophageal leakage.     

Successful laparoscopic splenectomy after living-donor liver transplantation for thrombocytopenia caused by antiviral therapy

Although interferon （IFN） based therapy for recurrent hepatitis C virus （HCV） infection after liver transplantation has been widely accepted, it induces various adverse effects such as thrombocytopenia, resulting in its interruption. Recently, concomitant splenectomy at the time of living donor liver transplantation （LDLT） has been tried to overcome this problem, but this procedure leads to several complications such as excessive intraoperative bleeding and serious infection. A 60-year-old female received LDLT using a left lobe graft from her second son for liver failure caused by hepatitis C-related cirrhosis. Six months after LDLT, she was diagnosed as recurrent HCV infection by liver biopsy. IFN monotherapy was started from 7 mo after LDLT and her platelet count decreased to less than 50000/μL, which thus made it necessary to discontinue the treatment. We decided to attempt laparoscopic splenectomy （LS） under general anesthesia. Since intra-abdominal findings did not show any adhesion formations around the spleen, LS could be successfully performed. After LS, since her platelet count immediately increased to 225000/μL 14 d after operation, IFN therapy was restarted and we could convert the combination therapy of IFN and ribavirin, resulting in no detectable viral marker. In conclusion, LS can be performed safely even after LDLT, and LS after LDLT is a feasible and less invasive modality for thrombocytopenia caused by antiviral therapy.     

Endoscopic therapies for acute esophageal perforations and leaks

Esophageal perforation is a serious condition with high morbidity and mortality. Management is optimized by prompt recognition and intervention in the context of a multidisciplinary approach. Specific treatment is dependent upon several factors, including clinical status, type and location of perforation, concomitant esophageal pathology, time delay to intervention, and available expertise. From a technical perspective, the principles of therapy include perforation closure, diversion, and drainage. Minimally invasive endoluminal therapy, including clips, stents, endoscopic suturing, and vacuum-assisted sponge therapy, represents a viable option in selected cases. Proper patient selection, technical proficiency, and recognition of the advantages and caveats of available devices are important determinants of successful endotherapy and clinical outcome.     

Successful conservative therapy of hepatorenal syndrome with vasopressin-1-receptor antagonist ornipressin

A 47-year-old male patient with alcoholic cirrhosis Child-Pugh grade C was admitted to our center for evaluation of liver transplantation. Serum creatinine had increased from 1.6 to 4.3 mg/100 ml within the previous two weeks, creatinine clearance was 12 ml/min, and urinary sodium 12 mmol/24 h. The diagnosis of HRS type I was established. Diuretic treatment was discontinued. Following albumin infusion, central venous pressure was increased to above 10 cm H2O and dopamine (2 micrograms/kg/min) infusion was started. However, renal function did not improve. An i.v. infusion of ornipressin (POR8, Sandoz; 6 IU/h) was started and dopamine infusion continued. During a four-hour interval, urinary volume and sodium excretion doubled. Therefore treatment was continued for three weeks. After 22 days, renal function had normalized (creatinine 1.2 mg/100 ml, creatinine clearance 65 ml/min, urinary sodium 62 mmol/24 h) and diuretic therapy was resumed. No adverse effects were observed. Ornipressin/dopamine infusion was discontinued and renal function remained normal. Three weeks later, the patient underwent liver transplantation with normal renal function. Ornipressin infusion had no effect on circulating endothelin, but decreased the activation of the renin-aldosterone system and of the sympathetic activity. So far, no noninvasive therapy of hepatorenal syndrome has been established. This is the first report of successful medical treatment of HRS type I with a three-week infusion of the vasopressin-l-receptor agonist ornipressin.     

Dysphagia caused by esophageal tuberculosis

This report describes two patients with dysphagia who appeared to have esophageal tuberculosis. One patient had a fistula draining into a mediastinal mass. Both patients responded promptly to treatment with tuberculostatics. Surgery was not required. Esophageal tuberculosis is a rare entity.     

A fatal case of acute mediastinitis caused by periodontal infection]

A 57-year-old man had suffered from poorly controlled diabetes mellitus and liver cirrhosis due to alcohol and hepatitis C for about 10 years. He developed fever and swelling of the right cheek and neck due to periodontal infection. The symptoms worsened in spite of antibiotic therapy and were accompanied by dyspnea. He was therefore referred to our hospital. Chest radiographs and computed tomographs revealed widening of the superior mediastinum, pulmonary infiltrates and right pleural effusion. He was diagnosed as having mediastinitis, right pyothorax and pneumonia caused by periodontal infection. Tracheotomy and mechanical ventilation were performed. Antibiotic therapy resulted in improvement of the mediastinitis and pyothorax. However, renal and liver dysfunction developed and the patient died of multiorgan failure after 35 days of hospitalization. Death due to periodontal infection is rare. We give a review of the literature.     

A case of hepatic portal venous gas caused by chemo-radiation therapy for an advanced esophageal cancer

Hepatic portal venous gas(HPVG)is a rare condition with a poor prognosis. A 40-year-old man underwent esophagectomy for stage IV esophageal cancer followed by chemotherapy. Four months later, he admitted to our hospital because of the increases of residual tumors and started chemoradiotherapy(CRT)with 5-FU, CDDP and radiation. Computed tomography(CT)scan revealed PR, and blood examination showed decreases in WBC and platelet counts. Fourty days after CRT, he suddenly complained severe pain in the left chest and abdomen, and vomiting. CT scan showed HPVG in the left lobe of the liver and pneumatosis cystoides intestinalis in the wall of the gastric tube. He died of multiple organ failure. To our knowledge, this is a first case of HPVG associated with CRT for esophageal cancer.