Foregut Diverticula.

Diverticular disease can present anywhere along the gastrointestinal (GI) tract. It can result from various pathologies such as abnormal contraction within the GI tract or inflammation causing scar tissue and the resulting forces surrounding the GI tract. Its clinical presentation can vary from asymptomatic to severe symptoms, with significant decrease in quality of life. The treatment for various diverticula along the GI tract can also vary, depending on the severity of symptoms. This article describes diverticular disease occurring within the foregut, with emphasis on pathophysiology, clinical presentation, and treatment.

Timing of Esophagectomy after Neoadjuvant Chemoradiation Therapy Affects the Incidence of Anastomotic Leaks.

BACKGROUND: Neoadjuvant chemoradiation therapy (nCRT) has become the standard of care for esophageal cancer patients prior to esophagectomy. However, the optimal timing for surgery after completion of nCRT remains unclear. METHODS: A retrospective review was performed of patients who underwent esophagectomy with cervical anastomosis for esophageal cancer at a single institution between January 2000 and June 2015. Patients were categorized into 3 cohorts: those who did not receive nCRT prior to esophagectomy (no nCRT), those who underwent esophagectomy within 35 days after nCRT (≤35d), and those who underwent esophagectomy more than 35 days after nCRT (>35d). RESULTS: A total of 366 esophagectomies were performed during the study period, and 348 patients met the inclusion criteria. Anastomotic leaks occurred in 11.8% of all patients included in the study (41 of 348). Within each cohort, anastomotic leaks were detected in 14.7% of patients (17 of 116) in the no nCRT cohort, 7.3% (13 of 177) in the ≤35d cohort, and 20.0% (11 of 55) in the >35d cohort (p=0.020). Significant differences in the occurrence of anastomotic leaks were observed between the no nCRT and ≤35d cohorts (p=0.044), and between the ≤35d and >35d cohorts (p=0.007). CONCLUSION: Esophagectomy with cervical anastomosis within 35 days of nCRT resulted in a lower percentage of anastomotic leaks.

Role of Barium Swallow in Diagnosing Clinically Significant Anastomotic Leak following Esophagectomy.

BACKGROUND: Barium swallow is performed following esophagectomy to evaluate the anastomosis for detection of leaks and to assess the emptying of the gastric conduit. The aim of this study was to evaluate the reliability of the barium swallow study in diagnosing anastomotic leaks following esophagectomy. METHODS: Patients who underwent esophagectomy from January 2000 to December 2013 at our institution were investigated. Barium swallow was routinely done between days 5-7 to detect a leak. These results were compared to clinically determined leaks (defined by neck wound infection requiring jejunal feeds and or parenteral nutrition) during the postoperative period. The sensitivity and specificity of barium swallow in diagnosing clinically significant anastomotic leaks was determined. RESULTS: A total of 395 esophagectomies were performed (mean age, 62.2 years). The indications for the esophagectomy were as follows: malignancy (n=320), high-grade dysplasia (n=14), perforation (n=27), benign stricture (n=7), achalasia (n=16), and other (n=11). A variety of techniques were used including transhiatal (n=351), McKeown (n=35), and Ivor Lewis (n=9) esophagectomies. Operative mortality was 2.8% (n=11). Three hundred and sixty-eight patients (93%) underwent barium swallow study after esophagectomy. Clinically significant anastomotic leak was identified in 36 patients (9.8%). Barium swallow was able to detect only 13/36 clinically significant leaks. The sensitivity of the swallow in diagnosing a leak was 36% and specificity was 97%. The positive and negative predictive values of barium swallow study in detecting leaks were 59% and 93%, respectively. CONCLUSION: Barium swallow is an insensitive but specific test for detecting leaks at the cervical anastomotic site after esophagectomy.

Anatomic bifurcated reconstruction of chronic bilateral innominate-superior vena cava occlusion using the Y-stenting technique.

This article presents the case of a 42-year-old man who presented with superior vena cava (SVC) syndrome due to fibrosing mediastinitis with multiple failed attempts at recanalization. We initially treated him with unilateral sharp needle recanalization of the right innominate vein into the SVC stump followed by stenting. Although his symptoms improved immediately, they did not completely resolve. Six months later, he returned with worsening symptoms, and venography revealed in-stent restenosis. The patient requested simultaneous treatment on the left side. The right stent was dilated, and a 3-cm-long occlusion of the left innominate vein was recanalized, again using sharp needle technique, homing into the struts of the right-sided stent. Following fenestration of the stent, a second stent was deployed from the left side into the SVC, and the two Y limbs were sequentially dilated to allow a true bifurcation anatomy (figure). The patient had complete resolution of his symptoms and continues to do well 6 months later.

Malignant Cerebral Edema following CT Myelogram Using Isovue-M 300 Intrathecal Nonionic Water-Soluble Contrast: A Case Report.

Lumbar myelogram utilizing nonionic contrast is a commonly performed procedure to identify spinal pathology. Complication rates are low. Cerebral edema has been shown to occur following intrathecal injection of ionic contrast; however, no current literature has documented this complication relating to the ubiquitously used nonionic contrast medium. We report a case of a patient who developed malignant cerebral edema following a lumbar myelogram with Isovue-M 300 nonionic water-soluble intrathecal contrast. We believe this is the first reported case of cerebral edema resulting from the use of a nonionic contrast.

Metastatic synovial sarcoma with cervical spinal cord compression treated with posterior ventral resection: case report.

CONTEXT: Synovial sarcomas, which represent 5% to 10% of all adult soft-tissue sarcomas, usually metastasize to the lungs. Metastasis to the spine is rare. Spinal cord compression due to spinal metastasis occurs in approximately 3% of patients with extraspinal soft-tissue sarcomas. METHOD: Case report. FINDINGS: A 26-year-old woman presented with neck pain, arm weakness, and a history of metastatic synovial sarcoma originating at the right knee. Computed tomography revealed destruction of the odontoid and C2 body. Magnetic resonance imaging revealed tumor in the posterior elements of C2 and in the ventral epidural space from C2-C5. She was treated with C2-C3 laminectomy, posterior C2 corpectomy with occipital-C7 fixation, and fusion. Postoperatively, her neck pain resolved and left upper extremity strength returned to normal. CONCLUSION AND CLINICAL RELEVANCE: Metastatic spinal cord compression from synovial sarcoma is rare. Surgical resection can lead to neurologic improvement.