PS01.110: ACUTE NECROTIZING ESOPHAGITIS WITH ESOPHAGUS PERFORATION, TREATED BY THORACOSCOPIC ESOPHAGECTOMY

Background Acute necrotizing esophagus is defined as the diffuse black pigmentation of the esophagus due to the necrosis of the esophageal mucosa, and so called ‘black esophagus’ from its endoscopic findings. The prevalence is only 0.001∼0.2%, although the mortality rate is up to 32%. Methods 67 years old female with medical history of diabetes mellitus, transported to the emergency room with hematemesis and conscious disorder. She had suffered from nausea and epigastralgia for two days. Her general status was in shock vitals and didn’t respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa and diagnosed as acute necrotizing esophagitis. Antibiotics and blood absorption therapy had been started and the patient gradually stabilized. 1 week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy was performed and found that the esophagus was edematous and adventitia was colored into black. The esophagectomy with esophagostomy and enterostomy was performed. Results On resected specimen, mucosal necrosis was found only on squamous epithelium with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation nor ischemia was found on the gastric mucosa of the esophagogastric junction. After the operation, patient recovered generally well, except the severe stenosis of the cervical esophagus had developed. Although endoscopic dilation had been constantly performed, the reconstruction remains unsolved issue. Conclusion In acute necrotizing esophagitis, stabilization of the patient's condition by treating comorbid diseases is extremely important. Improving the nutritional status in addition to the administration of antacids and antibiotics is also required. Surgical intervention should be performed when perforating mediastinitis or abscess formation occurs. Primary closure shouldn’t be attempted, and esophageal resection with delayed reconstruction should be considered in addition to drainage. In this case, we could successfully rescued the patient with necrotic esophagitis by performing surgical intervention promptly. It is important to detect the esophagus perforation and mediastinitis early, not to miss the chance of surgical intervention for curative treatment. Disclosure All authors have declared no conflicts of interest.

PS01.115: ESOPHAGECTOMY FOR ACHALASIA CARDIA: A SINGLE TEAM EXPERIENCE

Background In the era of per oral endoscopic myotomy, advancement in manometry and laparoscopy the treatment for achalasia cardia is well defined. Oesophagectomy has only a limited role in rare patients with sigmoid esophagus, perforation during nonsurgical treatment and malignancy. This study is about the indications of esophagectomy for achalasia cardia from one of the high volume centers for upper gastrointestinal disorders in India Methods This study includes 10 patients (7 male, 3 female) between august 2010 to august 2016.They had symptoms like dyspnea, dysphagia, regurgitation, chest discomfort, weight loss and cough. The duration of symptoms range from 2–120 months. Seven patients underwent previous pneumatic dilatation, four underwent Laproscopic Hellers cardiomyotomy with fundoplication (dor 3, toupet 1) and one patient had both pneumatic dilatation and cardiomyotomy. Results The indications for esophagectomy were sigmoid esophagus, failed pneumatic dilatation and laproscopic hellers cardiomyotomy, perforation after pneumatic dilatation and malignancy. The procedures done were transhiatal esophagectomy with stomach pull-up in 8 patients, Transthoracic esophagectomy in one, Esophagogastrectomy with transabdominal intrathoracic esophagojejunal anastomosis in one patient. The follow-up range between 14–84 months. During follow-up one patient developed hepatocellular carcinoma right lobe and died. Conclusion In the era where nonresection treatment play a major role in the management of achalasia cardia, esophagectomy still has a role in select patients. The indications for esophagectomy in our series included failed endotherapy, failed Hellers cadiomyotomy, sigmoid esophagus and malignancy. Disclosure All authors have declared no conflicts of interest.

A rare case of combining foreign body of the esophagus with the Zenker’s diverticulum and primary spontaneous pneumothorax

Actuality: A rare combination of a foreign body of the esophagus with Zenker's diverticulum and spontaneous pneumothorax can be mistakenly regarded as clinical and radiologic manifestations of perforation of the cervical esophagus, a dangerous condition requiring emergency surgery. Objective: On the clinical example, to show the importance of an integrated approach in the examination of patients with foreign bodies of the esophagus to exclude the perforation of the esophagus. Materials and methods: A rare clinical case of a combination of a foreign body of the esophagus with Zenker's diverticulum and spontaneous pneumothorax on the background of bullous emphysema in a 62-year-old patient is presented. Conclusions: In a comprehensive examination of patients with both foreign bodies of the esophagus with suspicion of perforation of the latter and spontaneous pneumothorax, an important role is played by performing spiral computed tomography, which allows excluding or confirming the esophagus perforation and determining the primary or secondary nature of pneumothorax, thereby providing an accurate and timely diagnosis and choose the optimal surgical tactics.

A case of esophageal perforation: Clinical and diagnostic management in emergency medicine

Esophageal perforation is a welldefined and severe clinical condition. The associated mortality rates range between 5% and 40% and are worsened by delayed diagnosis. Rapid diagnosis and therapy provide the best chance for survival; however, a delay in diagnosis is common, resulting in substantial morbidity and mortality. There are several aetiologies of esophagus perforation. Most esophageal ruptures are secondary to medical instrumentation. Other causes are Boerhaave syndrome, toxic ingestions and radiation, foreign body ingestion, penetrating trauma, and, rarely, blunt chest trauma. We reported the clinical management and the diagnostic work-up case of esophagus perforation due to the foreign body ingestion.