Treatment of postoperative esophageal leak by active drainage procedure (case report).

Postoperative esophageal leak is still a very serious and complex problem, which is associated with poor results, because of considerable morbidity and mortality rate. We described the case of successful treatment of suture line leak of 53 year old patient after resection of a big size epiphrenic diverticulum. Traditional right-sided transthoracic approach in 7th intercostal space with dissection, exposure and resection of diverticulum by stapler with 40F bougie within the esophagus was performed with reinforcement of suture line. On 6th postoperative day the control water-soluble contrast X-ray examination was done and pleural effusion and suture line disruption was found. Immediately under X-ray control the large diameter chest tube (Ch24) was inserted and periesophageal mediastinum as well as pleural cavity was drained and active aspiration with simultaneously irrigation/lavage procedures was started. Parallel fasting, systemic antibiotic therapy was started and feeding balloon catheter gastrostomy by Stamm was created. The healing process of the leak was controlled every week by water-soluble contrast swallow and the chest drain tubes were twice changed (Ch20 and Ch14) during the treatment. The complete healing and closure of the leak was achieved after 2,5 month of starting the treatment by using this method. Our case have demonstrated, that aggressive conservative treatment approach with combination of: active and adequate drainage of the leak site, systemic antibiotic therapy, nutritional support by feeding gastrostomy with frequent radiologic examinations for monitoring of healing process is the effective and safe treatment of esophageal leaks.

[Case of successful repair of penetrating cardiac injury].

The penetrating cardiac injury after the chest stab wound in 33 year old patient is described. The following clinical signs indicated suspected cardiac injury: localization of injury to the region of the heart, the signs of acute bleeding and cardiac tamponade, which was also confirmed by echocardiography. During urgent thoracotomy with additional sternotomy the right ventricle injury of 1,5 cm of length was found, which required 5 stitches for repair of defect and complete hemostasis. The temporary cardiac arrest (40-50 sec) has occurred during cardiography and internal cardiac massage was performed to restore the normal cardiac rhythm. Postoperative course was uneventful and patient on the 10th day after admission was discharged from the hospital. The successful outcome of treatment of this severe group of patients could be achieved by maintenance of the following fundamental principles: rapid transport of patients to the nearest hospital, maximum rapidity in establishment of diagnosis and highly qualified urgent surgical intervention. Echocardiography is the most informative and quick method of noninvasive diagnostics of penetrating cardiac injury.