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Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy.

ABSTRACT: A 46 years old male smoker was admitted to our hospital with a three-month history of chest discomfort and burning sensations due to regurgitation of food. The gastroenterologist tried multiple attempts to pass the endoscope through the lower end of the esophagus but failed. Post endoscopy Chest -X-ray showed right hemithorax fluid collection. A 28Fr chest drain was inserted, and fluid analysis revealed chyle. A contrast computed tomographic scan of the chest (CT) revealed esophageal perforation. The patient was managed conservatively by the primary physician on TPN, Antibiotics, and keeping him nil by mouth. After two weeks of failed conservative management, they referred the patient to the thoracic surgeon. We planned two-stage surgery because the patient was critically sick, septic, and hemodynamically unstable on inotropic support.

SUBMITTER: Chaudhry IUH

PROVIDER: S-EPMC9142553 | biostudies-literature | 2022 May

REPOSITORIES: biostudies-literature

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Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy.

Chaudhry Ikram Ul Haq IUH M Al Ghamdi Abdullah A M Al Fraih Othman O Al Maimon Hisham H A Alqahtani Yousif Y Tariq Khan Farjad F A Al Rasheed Fathi F A Al Abdulhai Meenal M

Annals of medicine and surgery (2012) 20220412

A 46 years old male smoker was admitted to our hospital with a three-month history of chest discomfort and burning sensations due to regurgitation of food. The gastroenterologist tried multiple attempts to pass the endoscope through the lower end of the esophagus but failed. Post endoscopy Chest -X-ray showed right hemithorax fluid collection. A 28Fr chest drain was inserted, and fluid analysis revealed chyle. A contrast computed tomographic scan of the chest (CT) revealed esophageal perforation ...[more]

PMID: 35637995

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Project description:BackgroundSpontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations.MethodsWe retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material.ResultsThere were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation.ConclusionsA hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Project description:Gastrointestinal (GI) cytomegalovirus (CMV) disease is a major cause of morbidity and mortality in immunocompromised patients. Diagnosis of GI CMV disease mostly relies on endoscopy examination and histopathologic findings. There are limited data on the need for follow-up endoscopy with histopathologic examination in patients with upper gastrointestinal (UGI) CMV disease. All adult patients with confirmed and probable UGI CMV disease at a tertiary hospital over a 16-year period whose follow-up endoscopy was available were enrolled. The patients were classified as endoscopic responders if they showed complete or partial improvement on follow-up endoscopy, and as endoscopic nonresponders if there was no improvement or worsening. CMV tissue clearance was defined as absence of any visible CMV inclusion bodies, negative CMV immunohistochemistry and negative CMV polymerase chain reaction in follow-up biopsy tissues. During the study period, 77 patients with UGI CMV disease were analyzed. The median time to follow-up endoscopy was 19 days (interquartile range, 14-27). Of these 77 patients, 52 (68%) were classified as responders, and the remaining 25 (32%) as nonresponders. GI bleeding was more common in the nonresponders than the responders (36% vs 12%, respectively; P = 0.02). There was no significant difference in CMV tissue clearance between the responders and nonresponders (56% vs 69%, respectively; P = 0.38), median durations of treatment (20 days vs 21 days, respectively; P = 0.48), and relapse rates (10% vs 8%, respectively; P > 0.99). Multivariate analysis showed that the only independent predictive factor for relapse of CMV antigenemia or CMV GI disease was multiorgan CMV disease (odds ratio = 12.4, 95% confidence interval 1.6-97.9; P = 0.02). Endoscopic responses were obtained in about two-thirds of patients with UGI CMV disease 2 or 3 weeks after antiviral therapy. However, these follow-up endoscopic findings neither reflected CMV tissue clearance nor predicted disease relapse. These findings suggest that the routine follow-up endoscopy may not be warranted in patients with UGI CMV disease.

Project description:BackgroundThe quality of gastrointestinal (GI) endoscopy has been recently identified as a major priority being associated with many outcomes and patient's experience.ObjectiveTo assess adherence of endoscopists to the European Society of Gastrointestinal Endoscopy (ESGE) quality performance measures for upper and lower GI endoscopy in Italy.MethodsAll endoscopist members of the Italian Society of Digestive Endoscopy (SIED) were invited from October 2018 to December 2018 to participate to a self-administered questionnaire-based survey. The questionnaire included questions on demographics and professional characteristics, and the recent ESGE quality performance measures for upper and lower GI endoscopy.ResultsA total of 392 endoscopists participated in the study. Only a minority (18.2%) of participants recorded the duration of esophagogastroduodenoscopy (EGD) and 51% provided accurate photo documentation in the minimum standard of 90% of cases. Almost all endoscopists correctly used Prague and Los Angeles classifications (87.8% and 98.2%, respectively), as well as Seattle and Management of precancerous conditions and lesions in the stomach (MAPS) biopsy protocols (86.5% and 91.4%, respectively). However, only 52.8% of participants monitored complications after therapeutic EGD, and 40.8% recorded patients with a diagnosis of Barrett's esophagus (BE). With regard to colonoscopy, almost all endoscopists (93.9%) used the Boston Bowel Preparation Scale for measuring bowel preparation quality and reported a cecal intubation rate ≥90%. However, about a quarter (26.2%) of participants reported an adenoma detection rate of <25%, only 52.8% applied an appropriate polypectomy technique, 48% monitored complications after the procedure, and 12.4% measured patient's experience.ConclusionThe adherence of endoscopists to ESGE performance measures for GI endoscopy is sub-optimal in Italy. There is a need to disseminate and implement performance measures and endorse educational and scientific interventions on the quality of endoscopy.

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Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy.

Publications

Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy.

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