Endoscopic T-tube placement in the management of lye-induced esophageal perforation: Case report of a safe treatment strategy

Esophageal perforation is associated with a significant risk of morbidity and mortality. We report herein a case of lye-induced esophageal perforation managed successfully by employing endoscopic T-tube placement with a successful outcome.     

Tension pneumoventricle after placement of a ventriculoperitoneal shunt: a novel treatment strategy. Case report

A case of pneumoventricle following insertion of a ventriculoperitoneal shunt for hydrocephalus is described. The pneumoventricle was associated with significant morbidity, which improved with treatment. The authors propose a rational treatment for this condition, which, as far as they know, has not previously been described. They also discuss potential mechanisms involved in the pathogenesis of pneumoventricle.     

Surgical management of esophageal perforation: role of esophageal conservation in delayed perforation

Definitive repair of esophageal perforation is considered the preferred treatment for patients presenting early (<24 hours). However, the optimal management of delayed presentation (>24 hours) has not been well defined. This study examined the management of esophageal perforation and compared the outcomes of early versus delayed presentation. Records of patients admitted with the diagnosis of esophageal perforation were reviewed. Contrast studies were used to confirm the diagnosis in all cases. Patient demographics and outcome were analyzed to determine differences between early and delayed presentation. A total of 22 cases of esophageal perforation were identified (eight early vs 14 delayed presentations). Operative interventions included primary repair (four), reinforced repair (14) either with intercostal muscle or pleural flap, and a complete esophageal resection (one). Debridement and drainage without repair were done in two patients and a proximal intramural tear was treated with antibiotics and observation. Two patients died during hospitalization. All surviving patients had near-normal restoration of esophageal function. Follow-up at 3 years has shown minimal gastrointestinal problems. One patient required repeat esophageal dilatations and two patients underwent antireflux therapy. Esophageal repair should be considered in all cases of nonmalignant esophageal perforation and should not be influenced by the time of presentation.     

Advances in the management of esophageal perforation

Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.     

Conservative management of esophageal perforation after a fall

INTRODUCTIONEsophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury.PRESENTATION OF CASEWe present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4–C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation.DISCUSSIONEarly diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively.CONCLUSIONIn the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.     

Case report: right subclavian artery pseudoaneurysm due to perforation of esophageal cancer.

A 51-year-old man presented with massive hematemesis. Perforation of upper esophageal cancer, which had already occurred at least six days earlier, progressed to upper mediastinitis. The mediastinitis contiguous to the right subclavian artery was considered to have caused a pseudoaneurysm. Rupture of the pseudoaneurysm into the esophagus resulted in massive hematemesis. Both enhanced computed tomography and angiography were diagnostic for the pseudoaneurysm. Transluminal endovascular stent-grafts placement was successful in preventing subsequent hemorrhage.     

Evolving options in the management of esophageal perforation

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.     

Endoscopic treatment of benign esophageal tumors: case report of three patients

Benign esophageal tumors are rare. Enucleation of the tumor is considered when the patient reports problems. The traditional approach is to use thoracotomy or laparotomy if the tumor is located in the distal esophagus. The use of minimally invasive techniques permits enucleation with all the concomitant advantages. Our experience with the minimally invasive management of three benign esophageal tumors is described. The methods and results of preoperative studies are reported. The surgical technique is described. Two patients could be managed using thoracoscopy, and one patient required conversion to laparoscopy. All the patients had complete and quick recoveries.     

Endoscopic biliary stenting facilitates safe and early removal of T-tube in liver transplant patients

AIM: Duct to duct anastomosis in orthotopic liver transplant (OLT) patients have been traditionally performed with a t-tube in place for 3 to 6 months. Following removal of the t-tube a high incidence of biliary leakage has been reported. METHODS: Prospective study to evaluate the role of endoscopic biliary stenting to facilitate early and uncomplicated t-tube removal. All patients with duct to duct biliary anastomosis who had a t-tube in situ, from January 1998 to December 2002 were included in this study. RESULTS: There were 29 patients eligible for the study. Eight patients were not included due to early death. A protocol t-tube cholangiogram was performed in all patients, (median 12 days; range 4-47 days) followed by an endoscopic stent insertion (median 37 days; range 20-55 days). The stent was removed later (median 84 days; range 45-133 days). All complications related to the procedure were noted. Stent insertion was successful in all cases. In 2 patients a second endoscopic retrograde cholangiopancreatography (ERCP) was necessary, either because of failure to cannulate the papilla or to reposition the stent. There was a patient who presented a biliary leak due to stent displacement requiring a laparotomy. There were two further biliary leaks, one of them in an asymptomatic patient, which were managed conservatively. In addition 1 patient developed a mild case of postERCP pancreatitis. CONCLUSIONS: In liver transplants patients with an end-to-end choledochostomy with a t-tube, endoscopic biliary stenting allows an early removal of the T tube, with few complications.     

External perforation of the esophagus: Case report

A case of external esophageal perforation treated conservatively is reported with a brief review of the literature.     

Endoscopic management of pancreatic duct injury by endoscopic stent placement: a case report and literature review

ABSTRACT: Recently, the diagnostic evaluation of pancreatic injury has improved dramatically. On the other hand, it is occasionally difficult to diagnose pancreatic injury, because there are no specific signs, symptoms, or laboratory findings. Radiological imaging also often fails to identify pancreatic injury in the acute phase. Delayed diagnosis results in significant morbidity and mortality. Most cases of pancreatic injury with suspicion or pancreatic duct disruption require surgery. Endoscopic retrograde cholangiopancreatography is one of the most accurate modalities for ductal evaluation and therapy and might enable one to avoid unnecessary surgery. We describe endoscopic management of pancreatic duct injury by endoscopic stent placement. A 45-year-old woman was admitted after a traffic accident. A computed tomography scan showed pancreatic parenchyma disruption at the pancreatic head. Endoscopic retrograde cholangiopancreatography demonstrated disruption of the pancreatic duct with extravasation into the peripancreatic fluid collection. A 5-French endoscopic nasopancreatic drainage (ENPD) tube was placed. Her symptoms dramatically improved. ENPD tube was exchanged for a 5-French 5-cm pancreatic stent. Subsequent follow-up CT revealed remarkable improvement. On the 26th day, the patient was discharged from the hospital without symptoms or complications. In this report, a pancreatic stent may lead to rapid clinical improvement and enable surgery to be avoided. On the other hand, the reported complications of long-term follow-up make the role of stenting uncertain. Thus, close attention should be paid to stenting management in the follow-up period. A pancreatic stent is useful for pancreatic ductal injury. If pancreatic ductal injury is managed appropriately, a pancreatic stent may improve the clinical condition, and also prevent unnecessary surgery.     

Double esophageal perforation by ingested foreign body: Endoscopic and surgical approach. A case report.

IntroductionEsophageal perforation in adults is most frequently caused by ingested foreign bodies. They can migrate through the esophageal wall, damaging the nearby organs such as the aorta or the trachea, with fatal outcome. After the diagnosis, the viable treatments for extracting the foreign body and repairing the perforation are several. The appropriate treatment, may be endoscopic, surgical or combined, depending on the level of the perforation, on the co-morbidities of the patient and on the available resources.Presentation of caseThis paper describes a case of a 68 years old patient with a double EP caused by a meat-bone that perforated the thoracic esophageal wall, approaching the aorta on the left side and the azygos vein on the right side.DiscussionBecause of the double transfixion and the position near the aorta and the azygos, it was not possible to remove safely the bone during the endoscopy. The management required a combined endoscopic and surgical approach. This way it was possible to detect easily the location of the perforation, to remove safely the foreign body, to repair the perforation both from the outside and from the inside, and to place the nasogastric tube under direct vision.ConclusionEven when the type of esophageal perforation requires surgical treatment, the simultaneous use of endoscopy proved to be an advantage in order to extract the foreign body safely, to perform a double repair of the perforation and to place the nasogastric tube under direct vision.     

Stent placement provides safe esophageal closure in thoracic NOTESTM procedures

Background  

Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent.