Characteristics of Atrial Fibrillation Patients Suffering Esophageal Injury Caused by Ablation for Atrial Fibrillation.

The close proximity of esophagus to the left atrial posterior wall predisposes esophagus to thermal injury during catheter ablation for atrial fibrillation (AF). In this retrospective study, we aimed to investigate risk factors of esophageal injury (EI) caused by catheter ablation for AF. Patients who underwent first-time AF ablation from July 2013 to June 2018 were included. The esophagus was visualized by oral soluble contrast during ablation for all patients and a subset of patients were selected to undergo endoscopic ultrasonography (EUS) to estimate EI post ablation. Degree of EI was categorized as Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial ulcers; 2b: deep ulcers); type 3: perforation (3a: perforation without communication with the atria; 3b: atrioesophageal fistula [AEF]). Of 3,852 patients, 236 patients (61.5 ± 9.7 years; male, 69%) received EUS (EUS group) and 3616 (63.2 ± 10.9 years; male, 61.1%) without EUS (No-EUS group). In EUS group, EI occurred in 63 patients (type 1 EI in 35 and type 2 EI in 28), and no type 3 EI was observed during follow up. In a multivariable logistic regression analysis, an overlap between the ablation lesion and esophagus was an independent predictor of EI (odds ratio, 21.2; 95% CI: 6.23-72.0; P < 0.001). In No-EUS group, esophagopericardial fistula (EPF; n = 3,0.08%) or AEF (n = 2,0.06%) was diagnosed 4-37 days after ablation. In 3 EPF patients, 2 completely recovered with conservative management and 1 died. Two AEF patients died. Ablation at the vicinity of the esophagus predicts risk of EI. EUS post ablation may prevent the progression of EI and should be considered in management of EI. It remains challenging to identify patients with high risk of EI.

Surgical Management of Non-Malignant Esophageal Perforations: A Single-Center Analysis Over a 15-Year Period.

PURPOSE: Esophageal perforations are associated with high morbidity and mortality. Different nonoperative and operative treatment options have been proposed. This study focuses on the impact of different surgical treatments in nonmalignant esophageal perforations and tries to identify predictors of mortality in a single tertiary center over a 15-year period. METHODS: From 2002 to 2017, patients with surgically managed esophageal perforation were identified from our database. Patients with esophageal malignancies were excluded. Etiology, clinical data, treatment, and outcome were analyzed. A multivariate logistic regression analysis was performed to investigate the impact on mortality. RESULTS: A total of 72 patients were identified. The majority of perforations were iatrogenic (54.2%) followed by Boerhaave's syndrome (23.6%). Most ruptures were found in the distal third of the esophagus (59.7%) measuring <3 cm (61.1%). Patients were treated with exploration and drainage (8.3%), primary suture and patch reinforcement (36.1%), resection and restoration of continuity (25.0%), or resection without restoration of continuity (30.6%). Delayed therapy significantly correlated with sepsis (p < 0.0001) and mortality (p = 0.032). A correlation between an increasing perforation length with sepsis (p = 0.012) was observed. A higher Perforation Severity Score (PSS; OR 4.430; 95% CI 1.143-17.174; p = 0.031) and a higher American Society of Anesthesiologists (ASA) score (OR 2.923; 95% CI 1.011-8.448; p = 0.048) were associated with mortality in multivariate analysis. CONCLUSION: Esophageal perforations are associated with high mortality, and larger ruptures are associated with worse outcome. Rapid diagnosis and treatment are crucial for patient survival. Hence, PSS and ASA score help to identify high-risk patients. The advantage of surgical management lies in the rapid control of the septic focus in an already critically ill patient. Though, the kind of surgical technique needs to be adjusted to the individual situation.

Poorly Differentiated Biliary Adenocarcinoma Leading to Boerhaave syndrome: A Case Report and Review of the Literature.

Boerhaave syndrome is a transmural disruption of the esophagus, due to an increase in esophageal pressure and is associated with high morbidity and mortality. There are cases reported secondary to bowel obstructions such as incarcerated hernias and gallstone ileus. Here, we describe an unusual autopsy case of Boerhaave syndrome, due to bowel obstruction secondary to biliary adenocarcinoma, which has never been reported in the literature. The patient was an 87-year old male presenting with severe chest and epigastric pain. Computed tomography showed fluid-filled esophagus, gastric distention and an ill-defined mass within the liver. Patient underwent esophagogastroduodenoscopy, which revealed esophageal rupture. Patient expired within 20 hours of admission. On autopsy, the decedent was found to have an esophageal perforation and an inferior hepatic mass, which morphologically and immunohistochemically was consistent with a biliary adenocarcinoma.

Sudden Unexpected Death Due to Left Subclavian Artery-esophageal Fistula Caused by Fish Bone.

A 53-year-old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery-esophageal fistula induced by a fish bone can be used as a reference in forensic practice.

Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data: A case report.

RATIONALE: Spontaneous esophageal rupture (Boerhaave syndrome) is a rare, though frequently fatal, event. It is generally caused by a sudden increase in pressure inside the esophagus. In some cases, full-thickness perforations of the esophagus may develop from previous lesions that initially involve only the esophageal mucosa (Mallory-Weiss syndrome) and which, following further triggering events, give rise to a transmural lesion. PATIENT CONCERNS: Here, we present the case of a 45-year-old subject who suddenly died of acute cardio-respiratory failure, an autopsy was performed to identify the cause of death. DIAGNOSIS, INTERVENTIONS, AND OUTCOMES: The autopsy examination revealed a full-thickness rupture of the esophageal wall. Through the integration of necroscopy findings, anamnestic data, and histopathological examination, it has been possible to establish that complete esophageal rupture resulted from the evolution of a previous partial lesion of the esophageal wall, and that an untreated Mallory-Weiss syndrome evolved into a rapidly fatal Boerhaave syndrome. LESSONS: This case shows that distal esophageal tears, rather than constituting a distinct entity, may be part of a spectrum of diseases and that a partial lesion of the esophageal wall caused by barogenic injury may evolve into a full-thickness rupture following further barotraumas.

An autopsy case of spontaneous esophageal perforation (Boerhaave syndrome).

A 45-year-old male, an alcohol addict with asthma, was found dead in his home, after several days of continued drinking. A forensic autopsy was performed 3days after the discovery of his death in order to specify the cause of death. A longitudinal perforation penetrating all layers of the esophagus measuring 1.8cm was present on the left wall approximately 2.0cm from the gastroesophageal junction. There were 1900mL of greenish to brownish turbid liquid in the left pleural cavity and 150mL of greenish viscous liquid in the stomach. Histopathologically, an infiltration of numerous neutrophils was evident in the submucosa layer, proper muscular layer, and serous membrane of the esophagus, corresponding to the esophageal laceration. The serum C-reactive protein (CRP) concentration was determined to be 3.1mg/dL. The alcohol concentrations were determined to be 1.49mg/g in the right cardiac blood, 1.31mg/g in the left cardiac blood, and 2.48mg/g in urine. Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation. This was the first report of a spontaneous esophageal perforation eventually causing respiratory failure.

The surgical management of spontaneous esophageal perforation (Boerhaave's syndrome) ‒ 20 years of experience.

Spontaneous esophageal perforation (Boerhaave's syndrome) is an uncommon and challenging condition with significant morbidity and mortality. Surgical treatment is indicated in the large majority of cases and different procedures have been described in this respect. We present the results of a mono-institutional evaluation of the management of spontaneous esophageal perforation over a 20-year period. The charts of 25 patients with spontaneous esophageal perforation treated at the Surgical Department of the University Hospital of Lausanne were retrospectively studied. In the 25 patients, 24 patients were surgically treated and one was managed with conservative treatment. Primary buttressed esophageal repair was performed in 23 cases. Nine postoperative complications were recorded, and the overall mortality was 32%. Despite prompt treatment postoperative morbidity and mortality are still relevant. Early diagnosis and definitive surgical management are the keys for successful outcome in the management of spontaneous esophageal perforation. Primary suture with buttressing should be considered as the procedure of choice. Conservative approach may be applied in very selected cases.

Left atrio-esophageal fistula of a possibly iatrogenic aetiology.

The study presents an exceptionally rare case of an esophago-left atrial fistula, which was diagnosed during a forensic post-mortem examination. Due to complex nature of the disease and many attempts to cure the patient, the authors did not manage to identify the aetiology of the fistula. It was only implied that the fistula might have been a distant complication of intraoperative endocardial ablation or it might have appeared as a consequence of perforation of the esophageal wall or left atrial wall of the enlarged heart with the end of an intubation tube or nasogastric tube.

Temporary insertion of a covered self-expandable metal stent to treat esophageal perforation due to endoscopic submucosal dissection.

There are no previous reports of esophageal perforation due to endoscopic submucosal dissection developing into pyothorax. We herein describe a case of esophageal healing following perforation in a 60-year-old woman undergoing esophageal endoscopic submucosal dissection. Post-procedural computed tomography revealed pyothorax in the right thoracic cavity, compressing the right lung. The pyothorax did not improve despite treatment with thoracic drainage because the esophageal lumen was connected to the right thoracic cavity. In order to close the site of esophageal perforation, we inserted a covered self-expandable metal stent. The affected site subsequently healed without complications, allowing the drainage tube and stent to be removed.

Multiple magnetic gastrointestinal foreign bodies in a dog.

CASE DESCRIPTION: A 3-year-old castrated male Yorkshire Terrier was referred because of a 3-day history of vomiting, hyporexia, and lethargy after suspected ingestion of magnetic desk toys. Multiple metallic gastric foreign bodies were visible on radiographic views obtained 24 hours previously by the referring veterinarian. CLINICAL FINDINGS: On physical examination of the dog, findings included moderate dyspnea, signs of pain in the cranial portion of the abdomen, hypothermia, and tachycardia. Repeated radiography revealed moderate pleural effusion and the presence of several round metallic foreign bodies in a linear ring formation in the distal aspect of the esophagus and gastric cardia. TREATMENT AND OUTCOME: Endoscopy was performed, at which time the dog became increasingly dyspneic, tachycardic, and hypotensive. Thoracocentesis was performed, and a large volume of septic exudate was removed from the left hemithorax. Exploratory surgery of the thoracic and abdominal cavities was performed, during which the magnetic foreign bodies were removed and esophageal and gastric perforations were debrided and closed. The dog died following acute cardiac arrest 48 hours after surgery. CLINICAL RELEVANCE: Ingestion of multiple magnetic foreign bodies carries a high risk of gastrointestinal tract perforation, volvulus, and obstruction. Immediate surgical intervention is recommended in such cases and would have likely improved the outcome for the dog of this report.

Aorto-oesophageal fistula and aortic pseudoaneurysm caused by a swallowed fish bone.

We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.

Esophageal perforation related to anterior cervical spinal surgery.

Esophageal perforation is an uncommon but potentially fatal complication of anterior cervical spinal surgery. This study aimed to investigate the diagnosis and treatment of cervical esophageal perforation related to spinal surgery. Among 1097 consecutive cases of anterior cervical spinal surgery that were managed at our institution over a 20 year period, five patients with esophageal perforation were identified. We performed a retrospective review of the diagnoses and treatment of esophageal perforation in these five patients as well as another patient who was transferred from another hospital. The esophageal perforations in all six patients were recognized during the early postoperative period. All patients presented with neck pain, dysphagia, odynophagia, coughing, fever and incision swelling and drainage. Diagnosis was confirmed by one or several of the following methods: contrast swallow study; endoscopy; cervical radiographs; or oral methylene blue. Nasogastric tube, intravenous antibiotics, enteral and parenteral nutrition, and open drainage were conducted in all patients. The wound was debrided in three patients, while two had implant removal and primary suture of the perforation. Five patients had a good recovery with healing of the esophagus, while one patient died due to severe pneumonia. The early diagnosis of esophageal perforation related to cervical spinal surgery relies on clinical suspicion and efficient investigation. The selection of appropriate treatment options, which include esophageal rest, antibiotic administration, nutrition support, wound debridement, open drainage, and surgical repair, largely depends on when the perforation is recognized. Early diagnosis and prompt management of this complication are likely to result in a good clinical outcome.