Improvement of surgical methods for the treatment of spontaneous rupture of the esophagus ­complicated by purulent mediastinitis

Aim. To improve surgical treatment outcomes of patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis. Methods. Over the past 30 years, we have experience in the surgical treatment of 31 patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis. Depending on the tactics and techniques of surgical treatment, we identified two groups of patients. The first group (n=8) consisted of patients operated with conventional techniques: thoracotomy, transpleural mediastinotomy according to Dobromyslov, suturing of the esophagus with drainage of the mediastinum and pleural cavities, blind mediastinal drainage. The second group (n=23) consisted of patients treated with programmed re-thoracotomy. Re-thoracotomy was performed along with the postoperative thoracotomy wounds. The delimited foci of purulent mediastinitis were opened and sanitized (necrotic tissues were excised and removed). Preventive hemostatic methods were used in the area of pressure ulcers from drainage tubes. Replacing and changing the position of the drainage tubes in the mediastinum was a strictly compulsory technique. Pus and necrotic soft tissue that appeared in the thoracotomy wound were subsequently eliminated by a device consisting of two titanium brackets connected by a lock embodied in the form of an oval ring during the wound suturing at the stage of programmed re-thoracotomy. The groups were comparable in age and comorbidities. The average diagnosis of spontaneous esophageal rupture took 3.5 days; the maximum time is 10 days. The statistical significance of differences in immune status indicators was assessed by using the Student's t-test and Pearson's 2 test. Results. A systematic approach using the tactical and technical surgical techniques developed by us (such as suturing esophageal wall defects regardless of the rupture time, multifunctional nasoesophagogastric tube installation; the imposition of a purse string suture to prevent reflux from the stomach into the esophagus; programmed re-thoracotomy using the method of temporary fixation of the ribs) allowed to reduce the number of complications, such as haemorrhage from the mediastinal vessels, by 3 times, sepsis 1.5 times, mortality almost 2 times. Conclusion. The introduction of patented techniques allowed to reduce the number of life-threatening complications and mortality in patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis.

Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes

Background Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown. Methods This is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015. Results We identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046). Conclusions Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.

Spontaneous esophageal rupture following perforated peptic ulcer: a report of two cases

Background Spontaneous esophageal rupture, also called Boerhaave’s syndrome, is relatively uncommon but may result in high morbidity and mortality. Synchronous presentation of spontaneous esophageal rupture and perforated peptic ulcer was rare and may contribute to the difficulty of achieving a correct diagnosis. Case presentation We reported two patients with spontaneous esophageal rupture following perforated peptic ulcer. Both patients were successfully treated with thoracoscopic primary repair of esophageal rupture. The first patient underwent peptic ulcer repair via laparotomy. The second patient underwent laparoscopic duodenorrhaphy. Both patients resumed oral intake smoothly and were discharged uneventfully. Conclusion Minimally invasive approaches are safe and feasible for both esophageal rupture and perforated peptic ulcer in patients diagnosed within 24 h and without shock.

Laparoscopic surgery by spontaneous rupture of the esophagus, a case report of treatment Boerhaave syndrome

Spontaneous rupture of the esophagus, Boerhaave syndrome, is a rare pathology and emergency condition for the patient. Patient, 63-year-old, on the 6th day of the disease falls into the clinic, where a Boerhaave syndrome was diagnosed. Laparoscopic surgery was performed. Sanitation and drainage of the mediastinum, suturing of the perforation hole were performed. After the operation, а positive response to treatment was observed. A group of authors believes that a minimally invasive approach to the treatment of spontaneous esophageal rupture is the alternative method for patients with severe somatic status and a small perforated opening of the esophagus.