Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study.

OBJECTIVE: To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). BACKGROUND: EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. METHODS: Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. RESULTS: Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. CONCLUSIONS: We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.

The outcome of esophageal perforation in neonates and its risk factors: a 10-year study.

PURPOSE: Esophageal perforation is a rare complication in infants that can be difficult to diagnose. The mortality rate due to esophageal perforation is high. This condition is more common in low birth weight premature infants. This study examines esophageal perforation in relation to various demographic and clinical variables. METHODS: This study has a cross-sectional design. All pre-term neonates with esophageal perforation at Valiasr Hospital in Tehran, Iran, were included in the study over the span of ten years, from 2011 to 2021. Factors, such as gestational age, sex, weight, type of delivery, and interventions performed that could contribute to the condition, including intubation and Orogastric (OG) tube insertion, were investigated in the participants. RESULTS: Among the 9924 infants studied over the 10-year period, 15 cases (0.15%) had esophageal perforation. All these infants underwent non-operative management with acceptable results. CONCLUSION:  Learning about the risk factors for iatrogenic esophageal perforation in neonates can help prevent this unwanted event in most cases. Also, the majority of these cases can be managed non-operatively provided that early diagnosis is made.

Esophageal perforations - a population-based nationwide study in Sweden with survival analysis.

BACKGROUND: Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality. METHOD: All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality. RESULTS: 879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide. CONCLUSIONS: 90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.

Delayed Endoscopic Management of Esophageal Sharp-Pointed Food Impaction: An Analysis of 829 Cases in China.

BACKGROUND: Esophageal foreign body impaction is the most common cause of endoscopic emergency. However, there are limited available data on delayed endoscopic management of esophageal sharp-pointed food impaction. AIMS: To investigate cases of esophageal sharp-pointed food impaction with endoscopic removal findings. METHODS: This single-center retrospective study collected medical records to identify patients with esophageal sharp-pointed food impaction who underwent endoscopic removal between April 2018 and April 2020. The patients were divided into the early (endoscopic removal <12 h) and delayed intervention (>12 h) cohorts. RESULTS: Overall, 133 and 696 patients received early and delayed intervention, respectively. The success rate of endoscopic foreign body removal was 96.45%. The most common foreign body was fish bone (66.90%), and the most common shape was "I" (56.26%). Patients from the delayed intervention cohort received general anesthesia with a higher risk for perforation, and no foreign body was identified. The duration of endoscopy, distance between the foreign body/wound and the incisor, and longest diameter of the foreign body were not different between the groups. In multivariate analysis, male sex (odds ratio = 1.792 [1.159, 2.771]; P = 0.009), longer duration of impaction (odds ratio = 2.212 [1.121, 4.365]; P = 0.022) and endoscopy (odds ratio = 1.502 [1.253, 1.800]; P < 0.001), and longest diameter of the foreign body (odds ratio = 1.632 [1.329, 2.003]; P < 0.001) were associated with a higher incidence of perforation in patients with foreign body impaction. CONCLUSIONS: Endoscopic removal is a safe and effective treatment method for sharp-pointed food impaction. Delayed endoscopic removal can increase the risk of esophageal perforation.

High risk and low prevalence diseases: Esophageal perforation.

INTRODUCTION: Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality. OBJECTIVE: This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence. DISCUSSION: Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting. CONCLUSIONS: An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.

Clinical features of idiopathic esophageal perforation compared with typical post-emetic type: a newly proposed subtype in Boerhaave's syndrome.

BACKGROUND: n our previous nationwide survey report on esophageal perforation, we proposed the existence of cases with idiopathic esophageal perforation at a certain rate. AIMS: To elucidate the clinical characteristics of idiopathic esophageal perforation, we performed a comparative analysis between cases with idiopathic type and post-emetic type esophageal perforation. METHODS: This study enrolled 139 patients with esophageal perforation (post-emetic type: idiopathic type = 115:24) as the subjects of nationwide survey on esophageal perforation. We conducted detailed studies on chief complaints, inflammatory responses, initial diagnosis, location and situation of the perforation site, time to therapeutic intervention, and prognosis between the two groups. RESULTS: Compared with post-emetic type, cases of idiopathic type tended to exhibit rear-side perforation (p = 0.052) and significantly less presented chest pain (p = 0.002). Consequently, cases of idiopathic type significantly missed to diagnose as esophageal perforation compared with post-emetic type (p = 0.042). With regard to inflammatory response, cases of post-emetic type experienced hyperthermia compared with idiopathic type (p = 0.033). On the other hand, cases of idiopathic type exhibited significantly higher level of C-reactive protein than post-emetic type (p = 0.004). In addition, it took longer time until starting treatment in the cases of idiopathic type (p < 0.0001) and the cases of idiopathic type showed significantly worse prognosis than the cases of post-emetic type (p = 0.009). CONCLUSION: This study first focused on the characteristics of idiopathic esophageal perforation that have been included in so-called Boerhaave's syndrome. The pathophysiology of the idiopathic type should be separately understood from post-emetic type, because the diagnostic and prognostic features largely differ.

Esophageal perforation in very low birth weight infants.

We aimed to assess the prevalence and outcomes of esophageal perforation in very low birth weight infants. This retrospective cohort study utilized the US National Inpatient Sample dataset for the years 2000 to 2017. A total of 1,755,418 very low birth weight infants were included; of them, 861 (0.05%) were diagnosed with esophageal perforation. The majority (77.9%) of infants were in the birth weight category < 1000 g and 77.7% in infants ≤ 28 weeks of gestation. The majority (73%) of infants were tracheally intubated and received mechanical ventilation; of them, 24 infants (2.8%) had tracheostomy. Mortality associated with esophageal perforation was 25.8%. Regression analysis did not show an association between esophageal perforation and increased mortality in preterm infants (aOR = 1.0, CI: 0.83-1.20, p = 0.991). Procedures encountered in these infants include thoracentesis (10.8%), laparotomy (4.1%), percutaneous abdominal drainage (4.1%), and gastrostomy tube insertion (6.2%), whereas the rest of the infants were managed conservatively. There was a significant trend for increasing prevalence of esophageal perforation over the years.Conclusion: Esophageal perforation does not independently increase the risk for mortality in very low birth weight infants. The increasing prevalence is possibly related to increased care offered to infants at limits of viability in recent years. What is Known: • Knowledge about esophageal perforation is derived from anecdotal single-center case reports. • Esophageal perforation in neonates is mostly iatrogenic. • It is considered a critical complication that is associated with high mortality. What is New: • This is the first and largest national study on prevalence of esophageal perforation in preterm infants. • Esophageal perforation does not independently increase the risk for mortality. • Septicemia and pneumothorax are frequent complications to esophageal perforation.

Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers.

BACKGROUND: To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers. METHODS: Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed. RESULTS: The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person. CONCLUSIONS: Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.

National Database Outcomes of Esophageal Dilations.

OBJECTIVES/HYPOTHESIS: To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes. STUDY DESIGN: Observational, retrospective cohort study. METHODS: We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged. RESULTS: We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%. CONCLUSIONS: Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2436-2440, 2021.

Foreign body-related oesophageal perforation: a case series at a community-based hospital in Nepal.

Oesophageal perforation is rare, associated with diagnostic dilemma, delayed presentation and high mortality rate (36%). Early diagnosis and treatment are crucial for a good outcome. Treatment is by non-operative methods (antibiotics, drainage of collections, oesophageal stenting and nutritional support) or by surgery, depending on the condition of the patient, timing of presentation and expertise. During a five-year period (2015-2019), we managed seven cases of oesophageal perforation due to a foreign body. Of them, 4 (57%) received operative intervention, while 3 (43%) were managed non-operatively. One postoperative mortality ensued; there was a mean hospital stay of 20 days.

Complications of esophageal strictures dilatation in children. A tertiary-center experience.

OBJECTIVES: To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology. METHODS: The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia. RESULTS: The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21. CONCLUSION: Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.

Transesophageal echocardiography complications associated with interventional cardiology procedures.

BACKGROUND: Although there have been several reports documenting complications related with transesophageal echocardiography (TEE) manipulation following cardiac surgery, there is a paucity of data regarding the safety of TEE used to guide catheter-based interventions. The aim of this study was to determine the prevalence, types and risk factors of complications associated with procedures requiring active TEE guidance. METHODS: This study included 1249 consecutive patients undergoing either transcatheter aortic valve implantation (TAVI), Mitraclip, left atrial appendage occlusion (LAAO) or paravalvular leak closure (PVLC). Patients were divided into 2 cohorts based on the degree of probe manipulation required to guide the procedure and the risk of developing a TEE-related complication: low-risk (TAVI, n = 1037) and high-risk (Mitraclip, LAAO and PVLC, n = 212). Patients were further analyzed according to the occurrence of major and minor TEE-related complications. RESULTS: The overall incidence of TEE-related complications was 0.9% in the TAVI group and 6.1% in the rest of the cohort (P < .001). Patients in the high-risk cohort had also a higher incidence of major-complications (2.8% vs 0.6%, P = .008), and factors associated with an increased risk were being underweight, having a prior history of gastrointestinal bleeding and the use of chronic steroids/immunosuppressive medications. Procedural time under TEE-manipulation was longer in patients exhibiting complications and was an independent predictor of major complications (OR = 1.13, 95% CI 1.01-1.25, for each 10 minutes increments in imaging time). Patients with major complications undergoing Mitraclip had the longest median time under TEE-manipulation (297 minutes) and a risk of developing a major-complication that was 10.64 times higher than the rest of the cohort (95% CI 3.30-34.29, P < .001). CONCLUSION: The prevalence of TEE-related complications associated with interventional procedures is higher than previously reported. Undergoing a prolonged procedure, particularly in the setting of Mitraclip, was the main factor linked to TEE-related complications.

Conservative treatment of iatrogenic perforations caused by gastric tubes in extremely low birth weight infants.

BACKGROUND: Iatrogenic gastrointestinal perforations are rare, but life-threatening events in preterm infants. AIM: Aim of the study was to report on incidence, management, morbidity, and mortality. STUDY DESIGN: This was a retrospective analysis performed at a tertiary neonatal intensive care unit in Vienna, Austria. SUBJECTS: Extremely low birth weight infants (ELBW, birth weight < 1000 g) with perforations of the upper gastrointestinal tract (GIT) caused by gastric tubes were included. OUTCOME MEASURES: All ELBW infants born within the 6-year study period were identified and their discharge summaries or notes were screened for esophageal and gastric perforations. Data on incidence, management of GIT perforations, morbidity, and mortality were obtained. RESULTS: During a 6-year study period 646 ELBW infants were analyzed. Incidence of perforations was 1.1% (n = 7/646). Median gestational age was 23 + 3 (range: 23 + 0-24 + 5). Perforations occurred on the third day of life (=median, range: day 2-14) and were primarily managed conservatively. Enteral feeding was stopped for 6 days (range: 4-13 days), antibiotic therapy administered for 16 days (range: 8-22 days). In one infant, gastrorrhaphy was performed. CONCLUSIONS: Conservative treatment of upper GIT perforations led to spontaneous recovery without major complications in 85.7%.

Thoracic Complications of Bariatric Surgeries: Overlooked Entities.

INTRODUCTION: Bariatric surgeries are increasingly performed to treat obesity worldwide. The currently available literature on these surgeries mainly focuses on their abdominal complications, giving less attention to their thoracic ones. Hence, the present work aimed to highlight the thoracic complications associated with bariatric surgeries. METHODS: A retrospective descriptive study was performed and involved the review of the medical charts of 390 patients who underwent different bariatric surgeries between January 2014 and January 2017 in our hospital or who were referred to us from other centers after their specific operations. The data of patients who developed thoracic complications and who required further intervention were identified and categorized by the modality of diagnosis, outcome, duration of hospital and ICU stays, and management. Patients with a history of a preexisting pulmonary disease were excluded. RESULTS: Twenty-six patients were observed to have thoracic complications secondary to their bariatric surgeries. Twenty-two patients (84.6%) received post-laparoscopic sleeve gastrectomy (LASG). Nine patients (34.6%) required ICU stays. Twenty patients (76.9) had incidences of pleural effusion in the postoperative period. The mean duration of hospital and ICU stays were 4.4 ± 11.67 days and 15 ± 19.36 days, respectively. Other reported thoracic complications included esophageal perforations, thoracic empyema, septic pericardial effusion, and pancreaticopleural fistula. CONCLUSION: Bariatric surgeries are safe procedures in selected patients. There is a significant amount of literature describing abdominal, nutritional, neurological, and even ophthalmic complications after bariatric surgeries. Being that they are relatively rare, thoracic complications are underreported in the literature. The management of thoracic complications after bariatric surgery requires awareness and a high index of suspicion to prevent further morbidities and mortalities.

Anterior cervical spine surgical site infection and pharyngoesophageal perforation. Ten-year incidence in 1475 patients.

BACKGROUND: Surgical site infection is reputed to be infrequent in anterior cervical spine surgery. Data on pathophysiological mechanism and risk factors are sparse. The relationship between local site infection and pharyngoesophageal perforation is unclear. The present study aimed: (1) to estimate the incidence of surgical site infection in anterior cervical spine surgery, (2) estimate the incidence of associated pharyngoesophageal perforation, and (3) suggest a decision-tree for early management of this two-fold issue. HYPOTHESIS: Although with very low incidence, anterior cervical spine surgical site infection and pharyngoesophageal perforation are frequently associated. MATERIAL AND METHODS: A 2-center retrospective study included all anterior cervical spine surgeries between January 1, 2007 and December 31, 2016. Data were provided by the two medical information departments. Patients undergoing anterior revision surgery on the cervical spine were included. Files were analyzed to determine whether the revision surgery was secondary to surgical site infection. RESULTS: In total, 1475 patients with anterior cervical spine surgery were identified: 1180 in center A (80%) and 295 in center B (20%). The rate of revision surgery for surgical site infection was 0.34% (5/1475). There were 3 cases of pharyngoesophageal perforation (0.2%). DISCUSSION: The incidence of revision surgery for anterior cervical spine surgical site infection was comparable to rates in the international literature (0.07-1.6%). An association between surgical site infection and pharyngoesophageal perforation was frequent, but not statistically significant. This complication is extremely serious, requiring urgent multidisciplinary management. LEVEL OF EVIDENCE: IV, retrospective study.

Complications following removal of oesophageal foreign bodies: a retrospective review of 349 cases.

AIM: To determine the incidence and types of complications associated with oesophageal foreign body (FB) removal in dogs, as well as to evaluate potential risk factors for the development of complications. METHODS: Clinical records were searched within Animal Emergency Service and Veterinary Specialist Services databases between July 2001 and March 2017. Data were collected regarding signalment, FB type, method of removal, medical management and complications. Follow-up records from the referring veterinarian were then obtained by either phone call or email. RESULTS: A total of 349 FB cases were reviewed. The majority of FBs were bones (77.4%), with Staffordshire Bull Terriers (12.3%) and West Highland White Terriers (9.8%) the most common breeds seen. Complications at the time of FB removal occurred in 20 cases (5.9%), with 14 cases of perforation. Persistent gastrointestinal signs were reported in 4.7% of cases within the initial 72-h period following FB removal and 11.9% cases outside this time period. Respiratory signs such as dyspnoea and coughing were also reported in 8 cases (2.3%), all of which occurred within 72 h after FB removal. Follow-up of at least 1 month was available in 151 cases. Delayed complications occurred in 11 cases (7.3%), with stricture occurring in 4 cases (2.6%); 16 animals were either euthanased (n = 14) or died (n = 2) post-FB removal, resulting in a case fatality rate of 4.6%. CONCLUSION: Use of antacid medications and FB type did not have a statistically significant relationship with complications following FB removal.

A 4-year single-center experience in the management of esophageal perforation.

BACKGROUND: Esophageal perforation (EP) is a lethal surgical emergency that needs to be diagnosed and treated immediately. Diagnosis and treatment options for EP are limited due to its lower incidence. There are scoring systems proposed for this purpose; however, they cannot be applied to every patient. The recent trend in the treatment of EP is toward the non-operative approach over the surgical treatment methods. The purpose of the present study was to evaluate our treatment methods and outcomes in patients with EP. METHODS: Thirteen patients with EP treated in our clinic between 2013 and 2017 were retrospectively reviewed. The Pittsburgh Perforation Severity Score (PSS), systemic condition status, and Clavien-Dindo Classification (CDC) score were assessed, and treatment methods were reviewed. Their effects on morbidity and mortality were examined using Fisher's exact test and biserial correlation test. RESULTS: A total of 13 patients (six males and seven females; median age 64 years) were included in the study. Ten patients were managed non-operative, and three were treated surgically. Of the 10 patients, two had additional surgery after non-operative management. The PSS, systemic condition status, CDC score, duration of stay in the hospital, time to diagnosis, presence of hypotension, and being in shock were strongly correlated with mortality (p<0.05). The PSS, CDC score, and stay in the intensive care unit were strongly correlated with morbidity (p<0.05). The comparison between the non-operative and operative groups did not yield a statistically significant difference in mortality and morbidity. CONCLUSION: Even if the scoring systems help to understand the severity of the condition, they are inadequate to determine the treatment option. Early diagnosis and treatment are the most important steps in management. Operative and non-operative treatment options are not superior to each other, but their complementary use will be more beneficial for the patients.

To Pull or to Scope: A Prospective Safety and Cost-effectiveness of Percutaneous Endoscopic Gastrostomy Tube Replacement Methods.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common. GOALS: We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval. STUDY: A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs. RESULTS: Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively). CONCLUSION: Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.

Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy.

BACKGROUND AND AIMS: Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS: A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS: POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS: MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.