Large airway complications in COVID-19 pneumonia

COVID-19 pneumonia can cause respiratory failure which requires specialist management. However the inflammatory nature of the condition and the interventions necessary to manage these patients such as endotracheal intubation and tracheostomy can lead to large airway pathology which may go unrecognised. We describe five of the 44 (11%) consecutive patients referred to our specialist ARDS team between April and June 2020 with confirmed COVID-19 pneumonia who developed diverse large airway pathology which comprised of: supraglottic oedema, tracheal tear, tracheal granulation tissue formation, bronchomalacia, and tracheal diverticulum. Large airway pathology may be underappreciated in severely ill patients with COVID-19 pneumonia and should be considered in patients with unexplained air leak, prolonged need for mechanical ventilatory support, and repeated failed extubation or decannulation. If suspected, such patients should be managed by a team with expertise in large airway intervention and early specialist advice should be sought.

Acute tracheal tear – A potential cause of spontaneous pneumomediastinum in patients with COVID-19

Spontaneous pneumomediastinum following prolonged periods of severe coughing should raise the suspicion of tracheal rupture in COVID-19 patients.

Silicone Y-stent insertion under extracorporeal membrane oxygenation (ECMO) in a patient with tracheal tear

Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.

30 Years of Flipping the Coin—Heads or Tails?

Introduction Swallowed coins are a frequent cause of pediatric emergency department visits. Removal typically involves endoscopic retrieval under anesthesia. We describe our 30-year experience retrieving coins using a Foley catheter under fluoroscopy (“coin flip”). Materials and Methods Patients younger than 18 years who underwent the coin flip procedure from 1988 to 2018 were identified. Failure of fluoroscopic retrieval was followed by rigid endoscopic retrieval in the operating room. Detailed subanalysis of patients between 2011 and 2018 was also performed. Results A total of 809 patients underwent the coin flip procedure between 1988 and 2018. Median age was 3.3 years; 51% were male. The mean duration from ingestion to presentation was 19.8 hours. Overall success of removal from the esophagus was 85.5%, with 76.5% of coins retrieved and 9% pushed into the stomach. All remaining coins were retrieved by endoscopy. Complication rate was 1.2% with nine minor and one major complications, a tracheal tear that required repair. In our recent cohort, successful fluoroscopic removal led to shorter hospital lengths of stay (3.2 vs. 18.1 hours, p < 0.001). Conclusion Patients who present with a coin in the esophagus can be successfully managed with a coin flip, which can be performed without hospital admission, with rare complications.

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.