Treatment of Esophago-Airway Fistula after Esophageal Resection.

(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.

Surgical treatment of thoracic esophageal diverticula.

Introduction: Thoracic esophageal diverticulum (TED) is a rare benign disease associated with motility disorders of the esophagus. Surgical management is usually the definitive treatment, with traditional excision of the diverticulum via thoracotomy and minimally invasive techniques being comparable and associated with a mortality rate of between 0 and 10%. Aim: To present the results of surgical treatment of patients with thoracic diverticula of the esophagus in a 20-year period. Material and methods: The study presents a retrospective analysis of the results of surgical management of patients with the thoracic esophageal diverticulum. All patients underwent open transthoracic diverticulum resection with myotomy. Patients were evaluated for the degree of dysphagia before and after surgery, associated complications and overall comfort after surgical treatment. Results: Twenty-six patients due to diverticula of the thoracic part of the esophagus underwent surgical treatment. Resection of the diverticulum with esophagomyotomy was performed in 23 (88.5%) patients, anti-reflux surgery was performed in 7 (26.9%) and in 3 (11.5%) patients with achalasia, the diverticulum was left unresected. Among the patients operated on, 2 (7.7%) patients developed a fistula, and both required mechanical ventilation. In 1 patient the fistula closed spontaneously, and the other patient required esophageal resection and colon reconstruction. Two patients required emergency treatment due to mediastinitis. There was no mortality in the perioperative period of hospital stay. Conclusions: Treatment of thoracic diverticula is a difficult clinical problem. Postoperative complications pose a direct threat to the patient's life. Esophageal diverticula is characterized by good long-term functional results.

Various clinical scenarios of primary melanoma of the esophagus: A retrospective 20-year analysis from two university thoracic surgery centers.

BACKGROUND: Primary melanoma of the esophagus (PME) represents a rare type of gastrointestinal malignancy with an exceptionally poor diagnosis. So far, only few descriptions of PME which satisfactorily summarize their clinical characteristics and prognosis have been published. OBJECTIVES: The aim of our study was to summarize our experience with PME patients. MATERIAL AND METHODS: In a group of 1387 patients who underwent esophagectomy due to neoplastic process in the years 2000-2020 in 2 high-volume university thoracic surgery centers, we identified those with confirmed PME diagnosis. Subsequently, their clinical characteristics, imaging and histopathological results were compared. The data regarding the long-term survival were obtained from the Polish National Death Registry. RESULTS: The PME was identified in 4 (0.29%) patients. Three of them (75%) were males. The mean age on admission was 64.3 ±17.5 years. The main symptom in all patients was dysphagia. In 1 patient with the most advanced PME, the clinically relevant weight loss was noted. In 3 patients, Ivor Lewis esophagectomy was performed, and 1 patient underwent McKeown resection. Histopathologic examination revealed a metastasis of lymph nodes only in 1 patient. The average maximum size of tumor was 6.9 ±4.7 cm and all tumors were located in distal part of the esophagus. Two out of those 4 patients are still alive and the longest survival time is 17 years. One patient died due to postoperative massive gastrointestinal bleeding complicated with cardiac arrest and the other one due to progression of PME systemic dissemination 6 months after surgical treatment. CONCLUSION: The PME is an extremely rare diagnosis. A long-term survival can be achieved with the complete resection. Clinical scenarios of surgically treated PME patients may significantly differ.

Less invasive transoral resection of esophageal fibrovascular polyps: case reports.

We report five patients treated for esophageal fibrovascular polyps using a minimally invasive technique. Esophageal fibrovascular polyps are benign pedunculated submucosal tumors of considerable size. The treated polyps size ranged from 1.5 to 13 cm. The polyps were removed by relocation to the oral cavity under endoscopic control. No perioperative complications occurred after the treatment. The follow-up of patients after surgery was 9-89 months, with no evidence of polyp recurrence. Thus, the described treatment is safe but requires experience with endoscopy as well as esophageal surgery.

Endosonography­guided fine­needle aspiration in the diagnosis of sarcoidosis: a randomized study.

INTRODUCTION    There are no widely accepted standards for the diagnosis of sarcoidosis. OBJECTIVES    The aim of this study was to assess the relative diagnostic yield of endobronchial ultrasound fine-needle aspiration (EBUS -FNA) and endoscopic ultrasound fine needle aspiration (EUS -FNA), and to compare them with standard diagnostic techniques such as endobronchial biopsy (EBB), transbronchial lung biopsy (TBLB), transbronchial needle aspiration (TBNA), and mediastinoscopy. PATIENTS AND METHODS    This was a prospective randomized study including consecutive patients with clinical diagnosis of stage I or II sarcoidosis. EBB, TBLB, and TBNA were performed at baseline in all patients. Subsequently, patients were randomized to group A (EBUS -FNA) or group B (EUS -FNA). Next, a crossover control test was performed: all patients with negative results in group A underwent EUS -FNA and all patients with negative results in group B underwent EBUS -FNA. If sarcoidosis was not confirmed, mediastinoscopy was performed. RESULTS    We enrolled 106 patients, of whom 100 were available for the final analysis. The overall sensitivity and accuracy of standard endoscopic methods were 64% each. When analyzing each of the standard endoscopic methods separately, the diagnosis was confirmed with EBB in 12 patients (12%), with TBLB in 42 patients (42%), and with TBNA in 44 patients (44%). The sensitivity and accuracy of each endosonographic technique were significantly higher than those of EBB+TBLB+TBNA (P = 0.0112 vs P = 0.0134). CONCLUSIONS    The sensitivity and accuracy of EBUS -FNA and EUS -FNA are significantly higher than those of standard endoscopic methods. Moreover, the sensitivity and accuracy of EUS -FNA tend to be higher than those of EBUS -FNA.

Surgical Treatment Results of Burn-Related Oesophageal Strictures.

BACKGROUND: Post-burn oesophageal stricture is a late complication, which may require surgical intervention. The aim of the study was to compare gastric and colonic conduits and to evaluate the safety, efficacy and complications of these techniques. METHODS: Retrospective analysis of all patients treated for burn-related oesophageal strictures between 1989 and 2013. Oesophagectomy was performed via laparotomy and right thoracotomy, and/or cervical incision. RESULTS: Forty-six patients, including 29 men, aged 17-67 years (mean: 41 years), had burn-related oesophageal strictures. The post-operative follow-up period ranged between 3 months and 30 years. Colonic transposition was used in 23 patients. In 21 patients, the oesophageal substitute was introduced through the posterior mediastinum, and in two patients the retrosternal route was used. Gastric conduit in was used in 21 patients and jejunal interposition in one patient. One patient underwent segmental oesophageal resection with end-to-end anastomosis. One patient had necrosis of the colonic conduit with anastomotic leakage, two patients had oesophago-colonic anastomosis leakage, five developed anastomotic stenosis, and two had respiratory insufficiency. Among patients with a gastric conduit, anastomotic leakage occurred in four, cervical anastomotic stenosis occurred in two, and respiratory insufficiency occurred in three, and one patient had impaired gastric emptying that required surgical re-intervention. Operative mortality was three patients (6.5%). CONCLUSIONS: The use of colonic and gastric conduit is an effective and safe method for restoring the continuity of the gastrointestinal tract, with an acceptable rate of post-operative complications. Patients who undergo oesophageal resection for post-burn stricture require post-operative systematic endoscopic control.

Minimally invasive strategy for mediastinal staging of patients with lung cancer.

INTRODUCTION: The exclusion of mediastinal involvement in patients with non-small cell lung cancer is essential for choosing an appropriate therapy. OBJECTIVES: The aim of the study was to analyze the ability of a new minimally invasive strategy combining positron emission tomography (PET), endobronchial ultrasound needle aspiration (EBUS-NA), and endoscopic ultrasound needle aspiration (EUS-NA) to exclude mediastinal nodal metastases of non-small cell lung cancer. PATIENTS AND METHODS: In a group of consecutive patients with primary non-small cell lung cancer, the preoperative assessment of medisastinal lymph nodes using PET, EBUS-NA, and EUS-NA. Patients in whom this minimally invasive staging protocol did not confirm mediastinal nodal metastases underwent pulmonary resection with systematic lymph node dissection. The negative predictive values of the combined EBUS-NA/EUS-NA as well as PET/EBUS -NA/EUS-NA were calculated. RESULTS: We analyzed data of 532 patients (367 men and 165 women; mean age, 65 years [range, 30-84 years]). Squamous carcinoma were diagnosed in 276 patients; adenocarcinoma, in 150; large cell carcinoma, in 22; adenosquamous carcinoma, in 40; small cell carcinoma, in 4; carcinoids, in 21; and other histological types, in 19. We performed 421 lobectomies, 55 pneumonectomies, 51 bilobectomies, and 5 sublobar resections. In all patients, systematic lymph node dissection was performed. The mean number of removed lymph nodes was 22. The negative predictive value of EBUS-NA/EUS-NA was 89.8% and of PET/EBUS-NA/EUS-NA-93.2%. CONCLUSIONS: Patients with lung cancer with negative results of PET, EBUS-NA, and EUS-NA are at low risk of mediastinal nodal metastasis. In these patients, invasive mediastinal staging may not be necessary.