Surgery of very late intrathoracic esophgeal ruptures and perforations

Objective: The reasons of delay and a more selective management of 7 unusually late esophageal disruptions is evaluated in this study. Material and methods: In case of a 13 day-old rupture, left transthoracic debribement, primary repair with hiatusplasty was done. In a 6 week-old postpneumonectomy leak, esophageal exclusion, fenestration, chemotherapy and Roux-en-Y bypass was performed. Closure with serratus anterior flap was used in a small esophageal leak with empyema which occured 4 months after pneumonectomy. In a iatrogenic, 9 day-old esophageal injury, suture, than Urchel type temporary exclusion was carried out. In a 6 week-old iatrogenic leak with localised empyema, Urchel-Ergin type exclusion with thoracostomy was used. As a first step esophageal exclusion and than decortication was performed in a 13 day-old rupture with empyema,followed by substenal colonic bypass 2 months later. In a 7 day-old transfixion esophgeal wound, suture with drainage was performed. The patient with closed esophagus was lost, for irreversibile sepsis. Results. Recovery time was 9 to 28 days. Conclusion: Even in such unique esophageal disruptions individual approach prove to useful.

Utility of repeated therapeutic endoscopies for pediatric esophageal anastomotic strictures

Summary Anastomotic stricture is a common complication of esophageal atresia (EA) repair. Such strictures are managed with dilation or other therapeutic endoscopic techniques such as steroid injections, stenting, or endoscopic incisional therapy (EIT). In situations where endoscopic therapy is unsuccessful, patients with refractory strictures may require surgical stricture resection; however, the point at which endoscopic therapy should be abandoned in favor of repeat thoracotomy is unclear. We hypothesized that increasing numbers of therapeutic endoscopies are associated with increased likelihood of stricture resection. We retrospectively reviewed the records of patients with EA who had an initial surgery at our institution resulting in an esophago-esophageal anastomosis between August 2005 and May 2019. Up to 2 years of post-surgery endoscopy data were collected, including exposure to balloon dilation, intralesional steroid injection, stenting, and EIT. Primary outcome was need for stricture resection. Receiver operating characteristic (ROC) curve analysis and univariate and multivariable Cox proportional hazards regression analyses were performed. There were 171 patients who met inclusion criteria. The number of therapeutic endoscopies was a moderate predictor of stricture resection by ROC curve analysis (AUC = 0.720, 95% CI 0.617–0.823). With increasing number of therapeutic endoscopies, the probability of remaining free from stricture resection decreased. By Youden’s J index, a cutoff of ≥7 therapeutic endoscopies was optimal for discriminating between patients who had versus did not have stricture resection, though an absolute majority of patients (≥50%) remained free of stricture resection at each number of therapeutic endoscopies through 12 endoscopies. Significant predictors of needing stricture resection by univariate regression included ≥7 therapeutic endoscopies, Foker surgery for long-gap EA, fundoplication, history of esophageal leak, and length of stricture ≥10 mm. Multivariate analysis identified only history of leak as statistically significant, though this regression was underpowered. The utility of repeated therapeutic endoscopies may diminish with increasing numbers of endoscopic therapeutic attempts, with a cutoff of ≥7 endoscopies identified by our single-center experience as our statistically optimal discriminator between having stricture resection versus not; however, a majority of patients remained free of stricture resection well beyond 7 therapeutic endoscopies. Though retrospective, this study supports that repeated therapeutic endoscopies may have clinical utility in sparing surgical stricture resection. Esophageal leak is identified as a significant predictor of needing subsequent stricture resection. Prospective study is needed.

DOZ047.14: Endoscopic incisional therapy and other novel strategies for treatment of congenital esophageal stenosis

Summary Management of congenital esophageal stenosis (CES) often involves dilation with reversion to myotomy or stricture resection in refractory cases.1,2 However, surgery often fails to produce durable response, with anastomotic strictures requiring ongoing dilation and stenotic symptoms plaguing more than half of the patients in published series.3 Methods In this study, the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and October 2018 were retrospectively reviewed. Success was defined as full when the diet included all age-appropriate textures with dysphagia once per month or less, or partial when the diet included most textures with dysphagia at most 1–2 times per week. Results Thirty patients with CES had at least one endoscopic intervention. All patients had balloon dilation(s) and at least one other therapy such as endoscopic incisional therapy (EIT), steroid injection, or stenting. Esophageal vacuum-assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Of patients who had EIT at their CES (N = 18), 14 (77.8%) achieved full (N = 13) or partial (N = 1) success with endoscopic therapy alone; 3 (16.7%) required surgery to achieve full (N = 3) success; 1 nonsurgical patient does not yet eat by mouth due to oral aversion. Of patients who did not undergo EIT at their CES (N = 12), 5 (41.7%) achieved full success with endoscopic therapy alone; 7 (58.3%) required surgery (2 full success, 4 partial success, and 1 does not eat by mouth due to airway comorbidities). The rate of surgical intervention was significantly lower in the group that received EIT (Fisher's exact test, P = 0.045). Twenty-five endoscopies (8.9%) were associated with complications, including esophageal leak (N = 21) or stent migration (N = 4). Of endoscopies with a complication, 16 (64%) involved EIT. Odds of complications after therapeutic endoscopies involving EIT were significantly higher than those without EIT (odds ratio 6.15; 95% CI (2.44, 15.52); P < 0.001). The rates of esophageal leak significantly decreased over time as the use of EVAC increased (P = 0.003). Conclusion EIT shows promise as an alternative to surgery in CES; however, further study is needed. Complementary endoscopic techniques such as injection, stenting, and EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES.