Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report.

BACKGROUND Achalasia is a rare primary esophageal motility disorder of unknown etiology, with significant negative impact on patient quality of life. Esophageal perforation is the most serious complication after pneumatic dilatation for achalasia, with a high mortality rate of up to 20%. Double-tract reconstruction is used mainly after proximal gastrectomy for gastric cancer, with the advantage of functional preservation of the stomach. We report a case of iatrogenic esophageal perforation after endoscopic pneumatic dilatation for achalasia that was successfully managed by laparoscopic proximal gastrectomy with double-tract reconstruction. CASE REPORT An elderly man started to manifest desaturation during endoscopic dilatation for achalasia, and multiple esophageal perforations were confirmed just above the gastroesophageal junction. During diagnostic laparoscopy, multiple perforations were found 2 cm proximal to the gastroesophageal junction extending 5 cm proximally with multiple linear mucosal tears. A trial of primary repair was difficult and double-tract reconstruction was performed by transection of the distal esophagus above the perforations and proximal gastrectomy. Then, 3 anastomoses were performed: end-to-end esophago-jejunostomy, end-to-side jejuno-jejunostomy, and side-to-side gastro-jejunostomy 15 cm distal to the esophago-jejunostomy site. After a smooth postoperative course, he was discharged home and was followed up regularly. CONCLUSIONS Esophageal perforation is the most serious complication after endoscopic pneumatic dilatation for achalasia. Double-tract reconstruction is a feasible and effective reconstruction modality following esophageal resection that avoids complications of esophago-gastrostomy. This technique deserves to be considered a valid treatment modality for advanced and complicated cases of achalasia, but further research is needed.

Intrathoracic Gossypiboma: An Overlooked Entity.

BACKGROUND During any surgical procedure, there are several factors that may lead to morbidity and mortality. One of those factors is a retained cotton or gauze surgical sponge inadvertently left in the body during an operation, known as gossypiboma. This clinical oversight may cause serious postoperative complications and increase the risk of mortality, particularly if left undiscovered. Furthermore, this issue adds to the economic burden on healthcare systems by increasing the rate of reoperation and rehospitalization. The length of postoperative gossypiboma diagnosis varies greatly, as patients may either present acutely with symptoms such as a palpable mass, pain, nausea, and vomiting, or remain asymptomatic for several years. CASE REPORT We report the case of a 48-year-old man who underwent a thoracotomy after a road traffic accident. The resulting empyema led to the intraoperative discovery of an intrathoracic gossypiboma, which was initially interpreted radiologically as a part of the previous surgical staple line. The causative agent was discovered by the team's nurses during the postsurgical count of instruments and sponges, and who were alerted to a recovered sponge differing in appearance from the sponges used for that procedure. CONCLUSIONS In general, proper counting and adherence to the World Health Organization 'Surgical Safety Checklist' can greatly improve the outcome of any surgery. The diagnosis of gossypiboma is often late or missed entirely and leads to additional interventions that can be avoided or detected early when the material contains a radiopaque marker. In cases under suspicion of any mistakenly left object, the use of intraoperative radiology before skin closure is highly recommended to prevent postoperative complications for the patient and organization.