Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting

Endoscopic clipping of a complicated esophageal perforation following pneumatic dilation for achalasia: A case study and literature review

A transmural esophageal tear complicated by large size and unusual location was diagnosed in a 59-year-old man after undergoing pneumatic balloon dilation for achalasia. It was closed with six endo-clips. The patient recovered and was discharged with ordinary diet 8 days later, after receiving supportive care for a week.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery

Introduction:

We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function.

Patients and Methods:

Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated.

Results:

No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux.

Conclusions:

The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

Iatrogenic Esophageal Perforation After Laparoscopic Heller's Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review

Patient: Male, 37-year-old

Final Diagnosis: Achalasia

Symptoms: Dysphagia

Medication:—

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Non-surgical treatment of esophageal perforation after pneumatic dilation for achalasia: a case series

Esophageal perforation is the most serious complication of pneumatic dilation for achalasia and is traditionally managed by conservative therapy or surgical repair. We present four achalasia patients who underwent pneumatic dilatation, complicated by an esophageal perforation. All patients were treated successfully with endoscopic treatment: two patients with Eso-SPONGE^® vacuum therapy, in the other two patients, esophageal defects were closed endoscopically using Endoclips. The time between dilatation and detection of the perforation was less than 24 h in all cases. Non-surgical treatment resulted in a relatively short hospital stay, ranging from 5 to 10 days, and an uneventful recovery in all patients. Based on our experience, endoscopic clipping and/or vacuum therapy are relatively new, valuable, minimally invasive techniques in the management of patients with small, well-defined esophageal tears with contained leakage and should be considered as primary therapeutic option for iatrogenic perforation in achalasia.

Mediastinal fluid as a predictor for esophageal perforation as the cause of pneumomediastinum

PURPOSE

Pneumomediastinum is not an uncommon finding on emergency CTs and is seen in a variety of settings, including acute trauma, recent repeated emesis and recent thoracic surgery, and after EGD (Kouritas et al. J Thorac Dis 7(Suppl 1):S44-S49, 2015). The purpose of this study was to examine cases of CT pneumomediastinum for distinguishing features which could support or exclude esophageal injury as a cause, which in turn could help guide evaluation of these patients.

METHODS

CT chest scans showing pneumomediastinum performed in the emergency department between January 2013 and December 2018 were included. The presence or absence of fluid within the mediastinal compartments was correlated with esophageal perforation and subdivided into the clinical scenarios of trauma, suspected Boerhaave's syndrome, recent surgery or EGD, and other. Accuracy of this finding was compared with fluoroscopic esophagography.

RESULTS

Twenty-two cases of esophageal perforation were identified out of a total of 324 included cases. The cases were subdivided into four categories: trauma, suspected Boerhaave syndrome, suspected iatrogenic perforation from recent procedure or surgery, and other. Two hundred fourteen cases of pneumomediastinum occurred in the setting of trauma, and 2 had esophageal perforation. Both showed mediastinal fluid. Twenty-two cases had mediastinal fluid without perforation. Seventeen cases of pneumomediastinum occurred in the setting of suspected Boerhaaves, and 3 had esophageal perforation. Every case with esophageal perforation had mediastinal fluid, and every case without perforation had no mediastinal fluid. Nine cases of pneumomediastinum occurred in the setting of suspected iatrogenic perforation after recent surgery or procedure. Six cases had esophageal perforation, and 5 of these had mediastinal fluid. All three cases without perforation also had mediastinal fluid. Eighty-six cases were classified as other and included a variety of clinical histories. This category contained 8 esophageal perforations, 7 of which had mediastinal fluid. One case of mediastinal fluid was not associated with esophageal perforation in this category.

CONCLUSION

The presence of mediastinal fluid, specifically within the visceral compartment, strongly suggests esophageal injury, and its absence strongly argues against it. An important caveat is in the setting of recent surgery, in which mediastinal fluid can be seen normally. An esophagography study can supplement the evaluation if there is a discrepancy between the clinical suspicion and the original CT findings.

RoSE: A Robotic Soft Esophagus for Endoprosthetic Stent Testing

Soft robotic systems are well suited for developing devices for biomedical applications. A bio-mimicking robotic soft esophagus (RoSE) is developed as an in vitro testing device of endoprosthetic stents for dysphagia management. Endoprosthetic stent placement is an immediate and cost-effective therapy for dysphagia caused by malignant esophageal strictures from esophageal cancer. However, later stage complications, such as stent migration, could weaken the swallow efficacy in the esophagus. The stent radial force (RF) on the esophageal wall is pivotal in avoiding stent migration. Due to limited randomized controlled trials in patients, the stent design and stenting guidelines are still unconstructive. To address the knowledge deficit, we have investigated the capabilities of the RoSE by implanting two stents (stent A and B) of different radial stiffness characteristics, to measure the stent RF and its effect on the stent migration. Also, endoscopic manometry on the RoSE under peristalsis has been performed to study the impact of stenting and stent dysfunctionality on the intrabolus pressure signatures (IBPSs) in the RoSE, and further its effects on the swallowing efficacy. Each implanted stent in the RoSE underwent a set of experiments with various test variables (peristalsis velocity and wavelength, and bolus concentrations). In this study, the conducted tests are representative of the application of RoSE to perform a wide-ranging assessment of the stent behavior. The usability of RoSE has been discussed by comparing the results of stent A and B, for various combinations of the test variables mentioned earlier. The results have demonstrated that the stiffer stent B has a higher RF, whereas stent A maintained its RF at a low profile due to its lesser stiffness. The results have also implicated that a high RF is necessary to minimize the stent migration under prolonged peristaltic contractions in the RoSE. For the manometry experiments, stent A slightly increased the IBPS, but the stiffer stent B significantly decreased the IBPS, especially for the higher concentration boluses. It was found that if a stiffer stent buckles, it can reduce the swallow efficacy and cause recurrent dysphagia. Therefore, RoSE is an innovative soft robotic platform that is capable of testing various endoprosthetic stents, thereby offering a solution to many existing clinical challenges in the area of stent testing.

Perforation following pneumatic dilation of achalasia cardia in a university hospital in northern India: A two-decade experience

Pneumatic dilation (PD) is a cost-effective first-line treatment for achalasia. The most feared complication of PD is esophageal perforation (EP). As data on EP after PD for achalasia are not widely reported, we present the frequency, risk factors, and treatment-outcome of EP. Records of patients undergoing PD for achalasia (January 1995 to September 2015) were retrospectively reviewed. Of 433 patients (age 38 years, 13-88, 57% male), and 521 dilations, 12 were complicated by EP (2.7% of patients and 2.3% of PD). EP occurred in 7 (3.4%), 4 (1.7%), and 1 (4.1%) with use of balloon diameters 30, 35, and 40 mm, respectively. In most (11/12, 92%), EP occurred during the first PD. No risk factor for EP was identified (p = 0.65 for the first dilation vs. > 1 dilation, and 0.75 for balloon size of 30 mm vs. > 30 mm). Seven patients with contrast leak on esophagogram and/or computed tomography scan underwent surgery. One other with contrast leak was successfully treated with a fully covered self-expandable metal stent (FC-SEMS); the remaining four with small leak/pneumomediastinum were managed conservatively. The median duration of hospital stay following perforation was 13 days (7-26) and 8 days (6-10) in surgery and conservative groups, respectively. No mortality was observed in either group. The frequency of EP with PD was 2.3%. Though most EP (92%) occurred during the first dilation, neither the balloon size nor repeated dilations were identified as risk factors. Both surgical and conservative approaches had a favorable outcome in appropriate settings.

A Rare Case of Acute Phlegmonous Esophagogastritis Complicated with Hypopharyngeal Abscess and Esophageal Perforation

Patient: Female, 60

Final Diagnosis: Acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess • esophageal perforation

Symptoms: Fever • painful swallowing • chest pain

Medication: —

Clinical Procedure: Drainage • debridement • esophageal reconstruction

Specialty: Surgery

A case report of esophageal perforation: Complication of nasogastric tube placement

PATIENT

Male, 70 FINAL DIAGNOSIS: Esophageal perforation Symptoms: Abdominal pain • nausea • vomiting

MEDICATION

- Clinical Procedure: - Specialty: Surgery.

OBJECTIVE

Unusual clinical course.

BACKGROUND

Esophageal perforation is a well-defined and severe clinical condition. There are several etiologies of esophagus perforation.

CASE REPORT

We report the case of a 70-year-old Caucasian man who underwent an emergency cholecystectomy due to acute cholecystitis. Two days after surgery, his condition deteriorated. Thorax computerized tomography revealed an esophageal perforation.

CONCLUSIONS

Esophageal perforation due to nasogastric application is relatively rare but the consequences are potentially serious. The anatomy of the upper gastrointestinal system should be understood by all healthcare professionals involved in the treatment.