Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

Background Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation. Case presentation We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis. Conclusion Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

Individually designed fully covered self-expandable metal stents for pediatric refractory benign esophageal strictures

To share our institutional experience of placing individually designed fully covered self-expandable metal stents (FCSEMSs) for the treatment of refractory benign esophageal strictures (RBESs) in pediatric patients. A 10-year retrospective study between May 2009 and July 2020 that includes 14 children with RBESs who were treated with individually designed FCSEMSs. Patients were followed-up regularly after stent placement to observe the improvement of vomiting and dysphagia, changes in stenosis diameter and complications. A total of 20 stents were successfully placed in 14 patients. During a follow-up period ranging from 5 to 83 months, except for one 4-year-old child who could not endure chest pain, the remaining 13 patients all benefited from stenting. Their Ogilvie & Atkinson scores improved from grade III–IV to grade 0-I, and the diameters of the stenosis’ were enlarged from 2–5 mm to 9–14 mm. Two patients developed restenosis and granulation tissue hyperplasia was found in 2 patients and stent migration and malapposition in 2 patients with esophageal perforations that required further endoscopic intervention. The use of FCSEMS for RBES is safe and effective in selected pediatric patients. Rationally designed stents and timely management of postoperative complications are critical to ensure the success of this new method.

Bovine xenograft pericardial patch use for definitive single stage repair of a large esophageal defect: a case report

Background Large esophageal perforations are challenging and often treated with exclusion or resection. This case demonstrates the feasibility of definitive surgical repair of a large esophageal perforation using large bovine pericardial patch. Case A patient with missed Boerhaave Syndrome underwent transesophageal echocardiography causing worsening perforation and sepsis. At thoracotomy and faced with a large esophageal defect, a large Bovine pericardial patch was used for repair with omentopexy. The patient recovered promptly and at 8 months was asymptomatic with satisfactory studies. Conclusion Xenograft pericardium is available and widely used for vascular reconstructions. It’s use for primary repair of large esophageal perforations should be considered.

ESOPHAGEAL PERFORATIONS: DIAGNOSIS AND TREATMENT

Background. Rendering medical care to patients with damage and failure of esophageal sutures remains a controversial and relevant topic. Objective. To provide a literature review on the diagnosis and treatment of esophageal perforation (EP), paying particular attention to the group of patients with delayed admission to the hospital and with various complications. Material and methods. The data published by domestic and foreign authors are analyzed and treatment outcomes of patients with EP admitted to the Department of thoracic surgery of Brest Regional Clinical Hospital are presented. Results. The literature data on EP treatment options are reflected and clinical outcomes of EP patients treated in the Department of thoracic surgery of the Healthcare Institution ‘Brest Regional Clinical Hospital’ using an original technique involving installation of a collapsible T-shaped drainage system with the formation of a “controlled fistula” are presented. The mortality rate of patients with endoscopic interventions for PN amounted to 10%. Conclusions. Currently, according to various authors, the overall EP mortality rate reaches 67%. The use of videothoracoscopic interventions for EP can reduce the mortality up to 10%.

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.