Introduction

Esophageal perforation is a rare condition with a high mortality rate. Often it has an iatrogenic origin, being caused by transesophageal echocardiography, different endoscopic and surgical procedures. Furthermore, there are other causes such as foreign body ingestion, tumor associated perforation and Boerhaave’s syndrome. Esophageal perforation can be difficult to diagnose since the clinical presentation is often unspecific. This can lead to a delay in appropriate treatment. Optimal management of this condition challenges clinicians in daily practice. Therefore, we present a monocentric retrospective study, evaluating our experience in treating esophageal perforations over more than a decade as a tertiary referral University Medical Center in Germany.

Aims & Methods

This study comprises the retrospective analysis of data from all patients treated for esophageal perforation in our clinic in the departments of general and visceral surgery and gastroenterology between 2012 and 2024. Only patients with confirmed esophageal perforation were included. Data was collected by means of a retrospective analysis of digital and analogous data archives as well as information from the physicians providing further treatment.

Results

A total of 78 cases (47 male, 31 female) of esophageal perforation were included. The leading cause was iatrogenic (n=45), consisting of endoscopic procedures (n=22), operative complications (n=11), TEE (n=6), diagnostic EGD (n=5) and one case of endotracheal intubation. The second most common cause of perforation was Boerhaave’s syndrome (n=23), followed by perforations associated with foreign body ingestion (n=5) or tumors of the esophagus (n=4). Traumatic perforations were rare (n=1). Most perforations occurred in the lower third of the esophagus (58 cases), 11 perforations were located in the mid esophagus and 9 in the upper third. Primary treatment consisted of direct surgical management in 26 cases (suture of the esophagus, gastrectomy, esophagectomy, definitive cervical esophagostomy, thoracic drainage, lavage), endoscopic therapy in 38 cases (Endo-VAC, stenting and application of OTSC or TTSC clips) and a conservative approach in 14 cases. Eventually a total of 48 patients underwent surgical treatment. Survival was poorest in spontaneous and tumor associated perforations (mean survival 22 and 23 months). Iatrogenic perforations showed an intermediate outcome. The best outcome was observed in perforations associated with foreign body ingestion (mean survival 50 months). In correlation with perforation location, the survival was best for perforations in the upper esophagus, followed by those in the lower esophagus, while lesions in the mid esophagus showed the worst outcome. Perforation associated death was recorded in 17 cases.

Conclusion

Esophageal perforations are a life-threatening event that require immediate and adequate treatment. Our analysis identified risk groups resulting in poorer survival: perforations in the mid esophagus, primary surgical treatment, advanced age. Within the last years, endoscopic techniques have reduced the need for surgical interventions. Nevertheless, surgical treatment remains the therapy of choice for patients not eligible for endoscopic treatment or after failure of endoscopic therapy. Our analysis emphasizes the importance of multidisciplinarity, close monitoring and continuous reassement of treatment strategy. Further investigation will help to improve the outcome via prospective studies or the establishment of a local or interregional database seem promising to underline suggestions derived from our analysis.

Introduction

In the treatment of esophageal carcinoma, abdomino-thoracic esophagectomy is the curative therapeutic option, often combined with perioperative (radio-)chemotherapy. This procedure is associated with high complication rates and significant mortality. Anastomotic leakage, with a pooled incidence of 11% (ranging from 0% to 49%)¹, constitutes a major postoperative complication. New therapeutic options, such as the EndoVac (Stent) system, offer promising approaches for its management. The aim of this study was to identify risk factors for the occurrence of anastomotic leaks and to evaluate the effectiveness of various treatment methods.

Aims & Methods

We present data from 2022–2024 collected at the University Medical Center Göttingen, a high-volume center for esophageal surgery. A total of 242 patients who underwent abdomino-thoracic esophagectomy, either as primary treatment or after neoadjuvant therapy, were included. Structured data collection and analysis were carried out using Excel and GraphPad Prism.

Results

In this patient cohort, 79.3% were male (n=192) and 20.7% female (n=50), with a mean age of 65.4 years and a mean BMI of 26.1 kg/m² at the time of surgery. The most common pre-existing conditions were 56.6% arterial hypertension (n=137), 7,9% COPD (n=19), 21% diabetes mellitus (n=51), as well as coronary artery disease (CAD) and peripheral arterial disease (PAD), each 8.2% (n=20). Histologically, 80.1% (n=194) adenocarcinomas and 19.4% (n=47) squamous cell carcinomas. 88.8% of patients received neoadjuvant therapy (n=215): 35.5% radiochemotherapy (n=86) and 53% chemotherapy (n=129). Of all patients, 24.8% (n=60) underwent primary open surgery and 75,3% (n=182) had minimally invasive hybrid procedures. By 2024, minimally invasive approaches had increased to 83.3% (n=86).
Anastomotic leakage occurred in 25 patients (10.3%), with clinical manifestation appearing on average 8 days postoperatively (range: 1–29 days). An association with the occurrence of anastomotic leakage was observed for nicotine abuse (OR 1.35; 95% CI: 0.60–3.11), alcohol consumption (OR 1.69; 95% CI: 0.66–4.24), coronary artery disease (CAD), and peripheral arterial disease (PAD) (each OR 2.37; 95% CI: 0.80–7.81); however, none reached statistical significance in Fisher’s exact test (all p > 0.05). Complete remission (24.4%, n=59) was significantly associated with an increased risk of leakage (OR 3.51; 95% CI: 1.53–7.86; p = 0.005).
All 25 anastomotic leaks were initially treated with EndoVac, healing successfully in 21 cases (96%). Four patients (16%) required revision surgery. An EndoVacStent was implanted in 52% of cases (n=13), with 20% receiving only an EndoVacStent (n=5) and 32% treated with a combination of sponge and stent (n=8). The average duration of EndoVac therapy was 15 days (range: 1–42 days), with the system being exchanged three times on average. In-hospital mortality was 1.6% (n=4).

Conclusion

In summary, the EndoVac and EndoVacStent systems have proven to be safe and effective treatment options for anastomotic leakage. Patients with complete remission showed an increased susceptibility to anastomotic leakage. Our data supports the importance of studies like ESORES (DRKS00022050)² and PRESTO (NCT05713838)³, investigating non-operative treatment approaches for clinical complete remission cases followed by a watch-and-wait strategy.

References

1. Sivesh K Kamarajah, Aaron Lin, Thahesh Tharmaraja, Yashvi Bharwada, James R Bundred, Dmitri Nepogodiev, Richard P T Evans, Pritam Singh, Ewen A Griffiths, Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis, Diseases of the Esophagus, Volume 33, Issue 3, March 2020, doz089, https://doi.org/10.1093/dote/doz089
2. ESORES – A prospective registry study for patients with esophageal cancer and clinical complete response after neoadjuvant therapy. German Clinical Trials Register (DRKS00022050). https://www.drks.de/DRKS00022050
3. PRESTO – Prospective evaluation of watch-and-wait strategies in complete responders to neoadjuvant therapy for esophageal cancer. ClinicalTrials.gov (NCT05713838).
https://clinicaltrials.gov/ct2/show/NCT05713838

Introduction

Esophageal or gastric perforation is associated with systemic inflammatory response syndrome (SIRS), which can lead to multi-organ dysfunction and mortality in up to 50% of cases. Endoscopic vacuum therapy involves the use of a catheter with a sponge attached to its distal end, connected to a machine that applies negative pressure, allowing for continuous drainage of the perforation site and potentially promoting healing of the transmural defect. Previous series have reported promising results, indicating the potential effectiveness of this therapy in managing esophageal perforations. To evaluate the efficacy of endoscopic vacuum treatment in patients with primary or secondary gastroesophageal perforations.

Aims & Methods

Single-center retrospective cohort study on patients treated for gastroesophageal perforation between March 2019 and September 2022. The inclusion criteria for the study were patients with gastroesophageal perforation resulting from spontaneous rupture or iatrogenic damage (post-surgical or post-endoscopic treatment). The primary outcomes of the study were the success rate of endoscopic therapy, the length of hospital stay, and the specific survival at 30 and 90 days. The success rate of endoscopic therapy was assessed by considering the treatment successful if it led to the resolution of the fistula following vacuum endoscopic therapy. Secondary endpoints included the need for intensive care unit (ICU) stay between the start of vacuum endoscopic therapy and the patient's discharge.

Results

27 patients, with a mean age of 69.8 years (95% CI 65.4-74.3), including 9 (33.3%) women, underwent endoscopic treatment with vacuum therapy for esophageal perforation. The causes of perforation were as follows: 6 (22.2%) cases were primary (Boerhaave syndrome), 15 (55.5%) cases were post-surgical (post-surgical anastomosis), and 6 (22.2%) cases were post-endoscopic treatment (endoscopic dilatation). Among the patients, 13 (48.1%) had previously undergone surgery for cancer, with 69.2% of them receiving intrathoracic stomach interposition reconstruction and the remaining patients undergoing reconstruction according to Roux-en-Y procedure. The treatment was successful in 21 (77.7%) patients, with a 14 days (9.0-24.4, 95% CI) median duration of treatment, and 4 (3-7, 95% CI) median number of endoscopic devices used per patient. One patient (3.7%) died within 30 days, and another one (3.7%) within 90 days. A total of 10 (38.4%) patients required an ICU stay, and there were no readmissions within 30 days. No procedure-related complication was reported.

Conclusion

In the current pilot study, the findings support the feasibility and safety of endoscopic vacuum therapy as a treatment modality for both primary and secondary gastro-esophageal perforations.

References

• Kuehn F, Schiffmann L, Rau BM, Klar E. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg 2012
• Pattynama LMD, Eshuis WJ, van Berge Henegouwen MI, Bergman J, Pouw RE. Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects. Front Surg 2023
• Luttikhold J, Pattynama LMD, Seewald S, et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023

Disclosure

Dr Valente and Dr Arnelo are consultant to Boston Scientific. Dr Arnelo is Consultant to Ambu

Introduction

Upper dysphagia is a swallowing disorder associated with underlying pathology in the mouth, throat, or esophagus. Cricopharyngeal achalasia (CA) may cause upper dysphagia and its diagnosis is not well established. In case of CA, endoscopic myotomy of upper esophageal sphincter (C-POEM) may be offered to relieve symptoms.

Aims & Methods

We present our experience in diagnosing and managing upper dysphagia with suspicion on CA in patients referred to our center between May 2022 and April 2024. The patients with Zenker diverticulum or organic stricture were not enrolled. All patients underwent X-ray examination, high-resolution manometry and endoscopy. In patients with suspected CA, botulinum toxin injection (100 IU) was administered into the upper esophageal sphincter. After botulinum toxin injection, the follow up visits were scheduled 1, 5 and 12 months after the procedure. In case of a positive effect of the injection, C-POEM (endoscopic myotomy of cricopharyngeal muscle) was considered after the effect of botulinum toxin had vaned. FOSS Function Outcome Swallowing Score and Dakkak and Bennett score of dysphagia were used to assess the severity of the symptoms. The score systems are listed in the table.

Results

Ten patients (4 males, 6 female) were referred to our center with long term upper esophageal dysphagia and considered eligible for botulinum toxin injection. The mean age was 69.7 years (ranges 30, 85), mean duration of symptoms was 8.6 years (SD ± 11) Three patients were unable to swallow safely and PEG tube had to be placed for nutritional support. Aetiologies of dysphagia were cervical injury (n=2), radiotherapy (n=2) and previous neurosurgery (n=1) or idiopathic dysphagia.
All patients underwent botulinum toxin injection. One patient developed vocal cord paresis one week after the injection and her condition improved after corticoid administration. No other adverse events of botulinum toxin were observed.
Improvement of dysphagia occurred in 7 patients after botulinum toxin injection while no change in symptoms was present in 3 patients. One month after the procedure mean
FOSS Function Outcome Swallowing Score improved from 3.3 to 1.56 (p = 0.015) and Dakkak and Bennett score of dysphagia from 2.7 to 1.33 (p=0.012). Two patients received successful C-POEM, the remaining patients will be offered C-POEM once a recurrence of symptoms will occur.
Three patients without effect of botulinum toxin injection were considered endoscopically incurable and referred back to neurology or otorhinolaryngology departments.

Conclusion

Botulinum toxin injection may be effective in treating upper dysphagia caused by a spasm of cricopharyngeal muscle and may serve as a useful selection tool for endoscopic myotomy.

Introduction

Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF.

Aims & Methods

This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES ≥ 4), gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis > B grade at esophagogastroduodenoscopy (EGD) and acid exposure time (AET) > 6% at pH-impedance monitoring. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure. A 1:1 PSM without replacement was performed, and weighted regression analyses were used to evaluate outcomes.

Results

595 patients underwent POEM during the study period. A total of 564 patients (median age 57 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.1%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of median procedural time (70 minutes (IQR 55;85) vs 71 minutes (IQR 56;86)) and adverse events (4.6% vs 1.8%) between primary POEM patients and those with PTF (P = ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. After matching, 130 patients (65 per group) were analyzed for clinical failure. In the matched cohort, clinical failure occurred more frequently in PTF patients compared to controls (24.6% vs 10.8%). In a weighted Cox regression model, PTF was associated with a significantly higher risk of clinical failure (HR 2.20; 95% CI 1.05–5.36; p = 0.04). Regarding reflux-related outcomes, no statistically significant differences were observed between groups after matching: clinical reflux (38.2% vs 30.3%, p = 0.41), severe esophagitis (34.2% vs 24.7%, p = 0.29), and pathological AET >6% (45.9% vs 45.9%, p = 1.00).

Conclusion

POEM remains a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients.

Introduction

Thoracic surgeries have been the traditional therapeutic approach for esophageal giant subepithelial lesions (g-SELs). Due to the rapid development of endoscopic techniques, increased reports on endoscopic resection (ER) of g-SELs have emerged in recent years.

Aims & Methods

We aimed to summarize the experience of our center on ER of esophageal g-SELs, and also develop a nomogram model to predict the procedural difficulty. 75 patients with g-SELs treated with ER at Zhongshan Hospital were included in the training set. Clinicopathological features, procedure-related characteristics, postprocedural outcomes and follow-up data were gathered and analyzed. A predictive nomogram model for procedural difficulty was proposed based on the risk factors identified by multivariable logistic regression analysis. Internal and external validation were conducted to verify the model performance.

Results

Of the 75 cases, the en bloc resection rate was 93.3%. Intraoperative and postoperative adverse events occurred in 7(9.3%) and 13(17.3%) patients, respectively. No recurrence or metastasis was observed. 32(42.7%) patients underwent a difficult procedure. A younger age, maximal tumor diameter ≥ 8 cm, irregular shape and extraluminal growth pattern were independent risk factors of a difficult procedure, while adopting submucosal tunneling endoscopic resection (STER) as the ER method was inversely correlated with procedural difficulty. The nomogram model showed good discrimination, with the area under the receiver-operating characteristics curve (AUC) of 0.858 and 0.827 of the training and validation set. Calibration curves and Hosmer-Lemeshow tests (P =0.524 of the training set and 0.413 of the validation set) also achieved favorable results.

Conclusion

ER serves as a promising therapeutic option for esophageal g-SELs. A younger age, large tumor size, irregular shape and extraluminal growth may indicate increased ER difficulty, while a STER procedure tends to be of lower difficulty. Our nomogram model performs well to predict ER difficulty for esophageal g-SELs.

Introduction

Thyroidectomy is one of the most common surgical procedures worldwide, yet its potential effects on esophageal function remain inadequately characterized. While post-thyroidectomy issues such as voice changes have been well-documented, alterations in esophageal motility following this procedure have received limited attention in scientific literature.

Aims & Methods

This study aims to evaluate the impact of thyroidectomy on esophageal motility parameters using High-resolution manometry (HRM), with particular attention to upper esophageal sphincter (UES) function. Seventeen patients (11 females), who were to undergo total thyroidectomy or hemithyroidectomy, were prospectively recruited between the months of February and May 2023. Ten of them had goiters, while seven had thyroid nodules. Exclusion criteria were having an age under 30 or over 70 years old, having to also undergo a parathyroid surgery and taking medications that could alter the esophageal sphincter. All of them underwent a pre-operative HRM and a second one thirty days after surgery. HRM were performed according to the Chicago Classification 4.0 and the data were analyzed using the online analysis platform “Swallow Gateway”. Gastrointestinal (GI) symptoms were assessed using a standardized questionnaire, before the first and the second HRM. No after procedural complication was reported.

Results

UES function significatively changed after thyroidectomy, as it is shown by HRM metrics such as Pharyngeal Contractile Integral (CI), Velopharyngeal CI, Hypopharyngeal CI, UES-CI, UES Integrated Relaxation Pressure (UES-IRP), Post-Deglutitive UES CI, Proximal Contractile Integral (PCI), which all significatively decreased (p < 0.05) at the HRM performed after surgery. Compared to Swallow Gateway normal values, there was an important increase of pathological HRM metrics after thyroidectomy. No significant HRM difference was found between the two categories of patients (goiter and thyroid nodules) and no significant correlation was registered between GI symptoms pre- and post-surgery and between GI symptoms and HRM metrics.

Conclusion

Thyroidectomy may significantly affect esophageal motility, especially the function of the upper esophageal sphincter. This finding could be useful in the diagnostic and therapeutic pathway of these patients, although further and larger studies are required to confirm this result.