Asymptomatic esophageal perforation discovered after elective cardiac surgery: the importance of clinical awareness.

Transesophageal echocardiography (TEE) has become an indispensable part of cardiothoracic surgery at present and is considered to be a safe procedure, rarely associated with complications. However, TEE may cause serious and life threatening complications, as presented in this case report. We describe a patient who developed an empyema after elective cardiac surgery due to an esophageal perforation caused by TEE, without any clinical symptoms. Risk factors for TEE-related complications, identified in recent literature, will be discussed as well as the remarkable absence of clinical symptoms in this particular patient.

Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population.

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male (n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology.

Aortoesophageal fistula as a fatal complication of esophageal perforation.

Aortoesophageal fistula is a very rare cause of upper gastrointestinal bleeding, however its interest lies in the high mortality rate associated with it. Due to this, early diagnosis and treatment of this entity is essential to increase survival. The typical symptoms known as the Chiari´s triad are only present in 45% of reported cases. We present the case of a patient with upper gastrointestinal bleeding due to an aortoesophageal fistula as well as the importance of endoscopic use for its differential diagnosis.

Non-operative management of iatrogenic esophageal perforation in a 6-year-old child.

BACKGROUND: Esophageal perforations are rare, the most common encountered esophageal perforation is iatrogenic in origin. It can be life-threatening if not diagnosed and treated early. Medical treatment has been recommended primarily in hemodynamically stable children. Drainage of intrathoracic or periesophageal fluid formation should be reserved to patients with hemodynamic instability. Surgical intervention may seldomly be required, depending on the localization and size of the defect. CASE REPORT: A 6-year-old male patient was referred to our clinic due to an esophageal perforation whilst removing the foreign body from upper esophagus under direct vision of a rigid esophagoscope. A radiologic appearance similar to esophageal duplication was detected along the esophagus in the esophagogram. A secondary esophagoscopy was carried out by our clinic, laceration at the esophagopharyngeal junction and dissection along the esophagus were observed and the foreign body was propelled into the stomach. The patient, whose clinical condition was stable, was managed medically without the need for a surgical intervention. CONCLUSIONS: Esophageal perforation is rare, yet perilous if not handled properly. We do not encounter this clinical entity frequently. Despite its rarity it can arise either iatrogenically or while managing a previous complication such as a simple nasogastric tube insertion in an infant or during an endoscopy for an esophageal foreign body. Its management is challenging, and we believe that non-operative treatment is still an important option in childhood esophageal perforations.

Herpes simplex oesophagitis leading to perforation and mediastinal collection: a case report and review of literature.

Herpes simplex oesophagitis is rare, especially in immunocompetent patients. A 78-year-old man presented with sepsis on the background of several months of retrosternal chest pain and fatigue. Computed tomography of the chest abdomen and pelvis revealed a large mediastinal collection and an oesophago-gastro-duodenoscopy demonstrated a healed mucosal scar from a spontaneously healed perforation. The collection was successfully drained with an ultrasound-guided drain and the patient made a full recovery. Spontaneous oesophageal perforation from herpes simplex oesophagitis has been reported five times in the literature, with only two occurrences in immunocompetent individuals.

Endoscopic stent placement after spontaneous esophageal perforation associated with chemoradiotherapy for esophageal cancer.

A 38-year-old male with established diagnosis of stage IV squamous cell carcinoma of the esophagus treated with chemoradiotherapy (25 sessions of 50 Gy), presented with acute aphagia, thoracic pain, productive cough, and mild hemoptysis. Upon physical examination the right hemithorax presented with crepitations. An initial CT scan showed an esophageal perforation. An upper endoscopy was performed, visualizing the esophageal perforation in the mid third of the esophagus at 26 cm of the dental arcade. It was possible to bypass and intubate the stomach, enabling the placement of a guide wire under endoscopic visualization. Afterwards, a partially covered, self-expandable, metal stent (Wallflex esophageal stent 10 cm/18/23; Boston Scientific) was placed in the esophagus restoring continuity, visualized by fluoroscopy.

[Idiopathic and Iatrogenic Esophageal Rupture].

One of the most common indications for emergency surgery is full-layer rupture of the esophagus. Iatrogenic injury to the esophagus is the most frequent cause of esophageal rupture, followed by spontaneous rupture. If the patient is not treated promptly, mediastinitis can develop into a serious and life-threatening condition. Diagnosis and treatment must be initiated as soon as possible. Spontaneous esophageal rupture often requires emergency surgical intervention. Various surgical techniques for esophageal rupture have been reported, including transabdominal or transthoracic, open or thoracoscopic surgery, drain placement, and surgical position. There have been reports of thoracoscopic primary closure of esophageal tear and thoracic drainage in the prone or lateral decubitus position. On the other hand, iatrogenic esophageal rupture is often treated conservatively, those patients require fasting, administration of antibiotics and proton pump inhibitors, suctioning and decompression using nasogastric tube, and chest drainage if necessary. In addition, close follow-up should be maintained so that the opportunity for surgery is not missed when necessary. Although esophageal rupture is relatively rare and is not an everyday occurrence, it is an urgent condition that requires prompt diagnosis and treatment, so it is necessary to have prior knowledge and to respond promptly.

[Esophageal Perforation on Transesophageal Echocardiography in Open-heart Surgery:Report of a Case].

A 70-year-old woman, who was taking prednisolone to treat Takayasu arteritis, underwent surgery for aortic regurgitation and aneurysm of the ascending aorta. The probe of the transesophageal echocardiography (TEE) could not be inserted due to resistance during anesthesia induction and was inserted after starting cardiopulmonary bypass. The right pneumothorax was observed during surgery. After surgery, fever and a high C-reactive protein level continued, and a computed tomography (CT) examination revealed right thoracic empyema together with free air around the esophagus. The esophageal perforation diagnosis was confirmed by upper endoscopy. Esophageal leakage continued despite emergency esophageal repair and enterostomy. Although esophagectomy was performed 2 months later, the patient died 6 months after cardiac surgery due to sepsis. Thus, esophageal perforation related to TEE in open-heart surgery was considered to be associated with a poor prognosis.

Endoscopic Mucosal Incision to Remove a Fish Bone Completely Embedded Under the Esophageal Mucosa: A Case Report and Literature Review.

BACKGROUND Esophageal foreign bodies are known to cause esophageal perforation, penetration, and mediastinitis if left untreated. Therefore, it is desirable to remove them immediately upon being diagnosed. While endoscopic removal is the first choice for removing esophageal foreign bodies, surgical procedures are required when endoscopic removal is not possible due to the shape of the foreign bodies, or if they are completely embedded within or outside the esophageal wall. CASE REPORT An 83-year-old woman experienced pain in her throat after eating grilled fish. She visited our hospital the following day. Computed tomography (CT) confirmed a linear foreign body had likely become completely embedded inside the cervical esophageal wall. Upper gastrointestinal endoscopy was performed under general anesthesia, but the foreign body was not visible. Thereafter, endoscopic mucosal incision was performed and the malpositioned fish bone was finally found. We were able to remove it with gripping forceps. The procedure was completed with the mucosal incision site left open, as there was no obvious damage to the muscle layer. Postoperative CT also confirmed the full removal of the fish bone as well as the lack of any perforation. Following surgery, she underwent 2 days of fasting before re-starting meals. She was discharged uneventfully from the hospital on the seventh hospital day. CONCLUSIONS Even when the foreign body is not visible via endoscopy, it can still be removed by endoscopic mucosal incision based on the CT and endoscopic findings. We summarized 10 similar cases and discussed the efficacy of endoscopic removal of foreign bodies buried under the esophageal mucosa.

Successful Management of Esophageal Perforation by Intraoperative Microscopy and Esophagoscopic Assistance: A Case Report.

Surgical repair of esophageal perforation is a challenging procedure with a high risk of secondary complications, such as early esophageal leakage and late esophageal stricture, which can significantly reduce the patient's quality of life. A 34-year-old man underwent anterior cervical corpectomy decompression and fusion. On the ninth day post-operation, the patient developed fever and neck swelling. A computed tomography scan of the neck showed multiple subcutaneous pneumatosis. An esophageal perforation of approximately 1.5 cm in diameter was identified by esophagoscopy. During the operation, the fistula was first located using an esophagoscope. The distal end of the esophagoscope was then placed into the stomach to support the damaged segment of the esophagus. The esophageal mucosa was sutured under the microscope, and the perforation was successfully repaired. Postoperatively, the patient's body temperature decreased, and the infection indexes gradually returned to normal. Three months after the operation, the esophagoscopic review showed complete healing of the perforation. Esophagoscopy plays an important role in diagnosing and repairing esophageal perforations. The esophagoscope provides direct visualization of the perforation during diagnosis and detects smaller and not yet fully penetrated esophageal injuries. During the repair process, the esophagoscope immobilizes the esophagus, prevents its movement and facilitates suturing, maintains proper dilatation of the esophagus, provides space for suturing, and prevents esophageal stricture.