Endoscopic Reconstruction of an Oral Feeding Route Using a Rendezvous Approach

<b><i>Background:</i></b> The approach to esophageal obstruction or discontinuity remains challenging and often involves complex reconstructive surgeries. The rendezvous endoscopic technique might be interesting in cases of complete esophageal obstruction. <b><i>Case Presentation:</i></b> Herein we describe a successful case of endoscopic recanalization of the esophageal lumen in a patient with a long-standing esophageal discontinuity resulting from several surgeries and chemoradiation for a squamous cell carcinoma of the hypopharynx, ending in a major cervical amputation, construction of a neopharynx, and definitive surgical closure of the superior esophagus with a PEG placement. With a rendezvous technique (peroral and through the gastrostomy) and under radiographic guidance, puncture from the neopharynx into the distal esophagus was performed, followed by balloon dilation and covered metal stent placement in order to reconstruct a neoesophagus. Five weeks later, the stent was removed (using a stent-in-stent technique). No complications occurred. The patient has been able to eat soft food and is being kept under regular endoscopic surveillance to control/treat a luminal stenosis of the neoesophagus. <b><i>Conclusions:</i></b> This case report illustrates a successful endoscopic treatment of post-surgical complete esophageal obstruction. This approach should be considered in the therapeutic armamentarium of these difficult clinical settings.

Modern approaches to the diagnostics and potentials of endoscopic treatment of esophageal stenoses in children

Introduction. Esophageal stenosis in childhood is quite a common disease characterized by different etiology, specific clinical picture, wide range of differential diseases and a variety of approaches to its treatment.Material and methods. The review analyzes scientific literature presented in such search engines as Medline, PubMed, Cochrane Library, eLibrary, 20 years deep. The most significant works of the last century were included too. Keywords were used for search.Results. There were selected 60 literary sources which included the description of modern concepts of etiopathogenesis, classification, diagnostic and curative techniques for the treatment of esophageal stenosis in children. A particular attention is paid to the safety and effectiveness of minimally invasive endoscopic interventions (bougienage, balloon dilation) as well as to the topical application of Mitomycin C in the treatment of esophageal stenosis in children.Conclusion. Innovative endoscopic technologies applied for the restoration of the esophageal lumen seem to be promising, effective and safe. In the overwhelming majority of cases, they allow to reduce surgical aggression and avoid complex reconstructive surgeries.

149 DIFFERENCES IN TRANSABDOMINAL ULTRASONOGRAPHIC PARAMETERS AMONG PATIENTS COMPLAINING OF ESOPHAGEAL DYSPHAGIA

Dysphagia is a symptom suggestive of severe underlying pathology, although its causes include organic and non-organic disorders. A balance must be struck between the potential complications of any invasive investigation and its diagnostic utility, especially for elderly patients with dysphagia. The aim of this study was to investigate whether transabdominal ultrasonography (TUS) can differentiate among patients complaining of esophageal dysphagia including achalasia, distal esophageal spasms (DES), neoplasms involving the esophagogastric junction (EGJ) and healthy controls. Methods All patients complained of esophageal dysphagia, while healthy controls had no symptoms originating from esophagus. TUS was performed in 50 patients with achalasia, 17 DES patients, 10 patients with neoplasms, and 39 sex- and age-matched controls. All studies were performed with a 3.5 MHz real time curved array scanner and using an electronic caliper to measure esophageal wall thickness and the maximum esophageal diameter at 3 cm from EGJ. Manometric diagnoses were made based on the Chicago classification ver.3. The cutoff value of each TUS parameter was then calculated. Specificity and sensitivity in making a diagnosis of each disease were determined. Results There were significantly differences in the TUS parameters among four groups (Fig). The cutoff value of diameter of esophageal lumen to differentiate achalasia from other 3 groups was calculated as 13.1 mm (sensitivity, 0.96; specificity, 0.93), with an area under the curve (AUC) of 0.99, and that of esophageal wall thickness to differentiate both the tumor and DES groups from the other two groups was 3.5 mm (sensitivity, 0.64; specificity, 0.62), respectively. Using these parameters, sensitivity and specificity of diagnosis was 0.56 and 0.95 in achalasia, 1.00 and 0.24 in DES, and 1.00 and 0.21 in tumors. Conclusion TUS is a useful, non-invasive diagnostic aid in differentiating patients with primary achalasia from those with other causes of dysphagia.

Fatal bleeding in a 1.5-year-old child with aortoesophageal fistula: case report and review of the literature

Aortoesophageal fistula in children is a very uncommon disease, which in most cases leads to death during the first days from the moment it occurs. Its high mortality is due to the lack of knowledge among doctors about the similarity of the disease in children and the lack of experience treating it. This paper presents the case history of a 1.5-year-old child who was admitted with bleeding from the upper gastrointestinal tract and died 36 hours after admission due to continued massive bleeding at the diagnostic measure stages. An autopsy revealed an aortic aneurysm with a diameter of 1.5 cm, which penetrated the esophageal lumen and formed an aortoesophageal fistula. This article analyzes the treatment results of 17 cases of successfully treating children with aortoesophageal fistula, which we found in the literature. It describes the leading causes and mechanisms of the development of this pathology in children. Also, the article describes the diagnostic and treatment methods for children with aortoesophageal fistula.

Síndrome de Plummer-Vinson en un paciente con enfermedad celíaca. Reporte de un caso

Plummer-Vinson syndrome is infrequent and is more common in middle-aged women. There are few reports of its association with celiac disease. Both entities can be linked to hypochromic anemia and esophageal carcinoma. We report the case of a 47-year-old female patient who, since the age of six, presented frequent episodes of iron deficiency anaemia, having required blood transfusions Eight months before the doctor’s appointment, when she swallowed a tablet, she presented a choking episode due to obstruction. Since then, she has been eating only soft foods. She had iron deficiency anemia, with low ferritin levels. A video swallow performed three months earlier showed a lack of fillong of 2 mm by 7 mm, which obliterated 75% of the esophageal lumen, and another similar image, 2 cm below the first one, arranged in the opposite direction, which obliterated the lumen by 50%. A video endoscopy was performed, which showed two membranes causing stenosis of the lumen in the cricopharyngeal region; they were removed. In the duodenal bulb and second portion, a flattened mucosa was observed, compatible with celiac disease. Biopsies were performed and the anatomopathological diagnosis was highly compatible with celiac disease, Marsh Oberhuber 3B. Conclusion. This observation demonstrates that celiac disease can coexist with Plummer Vinson syndrome. Therefore, it should be investigated in the context of this syndrome, with which it shares the relationship with iron deficiency anemia, and also taking into account the possibility of development of esophageal carcinoma in both entities.

Left Atrium With Dysphagia:Case Report

Background: Left atrium in 27 to 38 mm is normal and over 80mm is called giant left atria. Giant left atria is mostly caused by rheumatic mitral valve regurgitation. Pain, dysphagia and reflux are the common symptoms. Case presentation: We report a case with dysphagia for the reason of rheumatic heart disease with left atrium enlargement. He also had difficulty swallowing, but never had an inability to eat. And further the inner diameter did not fit the standard of giant left atria, but there was obvious compressive symptom of the esophagus and severe stricture of the esophageal lumen. Conclusions: There are many reasons for dysphagia, which need to be analyzed on a case-by-case basis. The patient with dysphagia after eating is likely to be confused with an esophageal foreign body, and a careful history should be taken.

Non‐operative management of bilateral contained thoracic esophageal perforation: a case report

Background Despite profound advances in conservative management of esophageal perforation, patients’ selection for this type of treatment requires expert clinical judgment. Surgical intervention has been historically introduced as the optimal management in multifocal ruptures. Case presentation Here, we presented a 30-year-old man whose barium esophagogram confirmed bilateral perforations in the lower third of the esophagus contained in the mediastinum, and contrast drained back into the esophageal lumen. Concerning available contrast imaging studies and thoracic surgeons, conservative non-operative management was considered despite pneumomediastinum, a mild right-sided pleural effusion, and minimal leukocytosis. The patient was followed up for two months without any complications. Conclusions Bilateral and multifocal esophageal perforations can be managed conservatively provided that the leaks are confined to the mediastinum and drain back to the esophageal lumen, and other criteria for conservative management are met.

Endoluminal vacuum-assisted closure (E-Vac) therapy for postoperative esophageal fistula: successful case series and literature review

Background Treatment of esophageal perforations and postoperative anastomotic leaks of the upper gastrointestinal tract remains a challenge. Endoluminal vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years, to the management of upper gastrointestinal tract perforations by using the same principle of vacuum-assisted closure therapy of external wounds. The aim is to provide continuous wound drainage and to promote tissue granulation, decreasing the needed time to heal with a high rate of leakage closure. Cases presentation A series of two different cases with clinical and radiological diagnosis of esophageal fistulas, recorded from 2018 to 2019 period at our institution, is presented. The first one is a case of anastomotic leak after esophagectomy for cancer complicated by pleuro-mediastinal abscess, while the second one is a leak of an esophageal suture, few days after resection of a bronchogenic cyst perforated into the esophageal lumen. Both cases were successfully treated with E-Vac therapy. Conclusion Our experience shows the usefulness of E-Vac therapy in the management of anastomotic and non-anastomotic esophageal fistulas. Further research is needed to better define its indications, to compare it to traditional treatments and to evaluate its long-term efficacy.

CAUSES OF ADVERSE SURGERY EFFECTS IN TREATMENT OF PATIENTS WITH ESOPHAGUS STENOTIC DISEASES

Esophageal stenosis requires a responsible approach to the choice of rational treatment tactics. Intraoperatively, bleeding, interponate necrosis, complications associated with the wrong choice of the path of the interponate imposition to the neck, damage to the nutrient vessel (the arcade rupture), pleural leaves during the formation of the thoracic tunnel, n. vagus and its branches, pneumothorax, hemothorax, uncontrolled mediastinal bleeding, the need for drainage of the pleural cavity due to injury to the latter, iatrogenic splenectomy, membranous tracheal tear. Post−surgery complications are developed at different times after esophagoplasty. Most often, early postoperative complications occur because of the wound: bleeding and failure of the sutures of the anastomosis line. Complications resulted from the respiratory system are as follows: tracheobronchitis, pleurisy, "congestive", nosocomial pneumonia and atelectasis, pleural empyema. In the remote post−surgery period, the patients may experience: stenosis of the esophageal (or pharyngeal) anastomosis, adhesions, fistulas, reflux, peptic ulcers of the esophagus, pain, inflections and excess loops, complications associated with mechanical trauma of implant, scar−altered cancer esophagus, polyposis of the colon, various disorders associated with primary trauma, nonspecific complications. Damage to the recurrent nerve in patients causes constant hoarseness and difficult swallowing. Occasionally there are cardiac arrhythmias in the form of atrial fibrillation, "sympathetic" pleurisy, reflux, post−vagotomy symptom and dumping syndrome, delayed gastric emptying due to insufficient dilated pyloromyotomy in the patients with a combination of stenosis of the esophageal lumen and esophageal lumen hernia. Key words: esophageal stenosis, esophageal anastomosis, postoperative complications.