Jörg Hutter

Summary: Background: Boerhaave’s syndrome (BS) is a rare but often fatal condition with high mortality rates despite intensive treatment. Data are scarce. We herein report a single-center experience with BS. The aim of this study was to investigate and point out the role of endoluminal vacuum therapy (EVT) in BS. Methods: Between June 2011 and April 2024, all patients with BS in our tertiary referral center with a unit specialized in surgical endoscopy were analyzed regarding age, gender, delay of diagnosis, treatment technique, and outcome. Results: During the study period, 12 consecutive patients (9 male) were treated for BS. The median age was 64.8 years. Five patients were treated with EVT only, four with surgery and simultaneous EVT, and three by surgery only. After implementation of EVT, all patients were treated with either EVT only or surgery with simultaneous EVT. Intensive care unit stay was significantly shorter in patients treated with EVT only. The 30-day mortality was 25% (3 patients). No long-term complications occurred. Conclusion: This investigation led to our current strategy of applying only EVT in patients in a stable condition and no CT signs of vast pleural content. Otherwise, surgery plus EVT is performed.

Background: Secondary resection rates in first-line chemotherapy trials for metastatic colorectal cancer (mCRC) remain below 15%, representing a clear contrast to reports by specialised surgical centres, where progressive liver, peritoneal-surface, and pulmonary surgery increased access to curative-intent treatment. We present a long-term evaluation of oncosurgical management in a single-centre, analysing the aggregate effect of gradual implementation of surgical subspecialties and systemic treatments on mCRC patients’ resection rates and prognosis. Methods: Patients with newly diagnosed mCRC from 2003 to 2014 were retrospectively categorised into palliative treatment (PAT) and curative intent surgery (CIS) and three time periods were analysed for treatment changes and factors associated with survival. Results: Four hundred-twenty patients were treated (PAT:250/CIS:170). Over time periods, the number of presenting patients remained consistent, whereas curative resection rates increased from 29% to 55%, facilitated by an increment of patients undergoing hepatectomy (21 to 35%), pulmonary surgery (6 to 17%), and peritonectomy/intraoperative chemotherapy (0 to 8%). Also, recently, significantly more multi-line systemic treatments were applied. The median survival markedly improved from 21.9 months (2003–2006; 95% confidence interval (CI) 17.3–26.5) to 36.5 months (2011–2014; 95% CI 26.6–46.4; p = 0.018). PAT was a significant factor of poor survival and diagnosis of mCRC in the latest time period was independently associated with a distinctly lower risk for palliative treatment (odds ratio 0.15). Conclusions: In modern eras of medical oncology, achieving appropriate resection rates through utilization of state-of-the-art oncological surgery by dedicated experts represents a cornerstone for long-term survival in mCRC.

Objectives Gastrointestinal stromal tumours (GIST) of the oesophagus are rare. In a series of 1160 cases, only 1.1% originated from the oesophagus. Most stromal tumours of the oesophagus are leiomyomas. Resection can be done endoscopically by submucosal dissection (ESD), open thoracotomy or video-assisted thoracoscopy (VATS). Methods We present the video of a patient with a stromal tumour of the oesophagus, 40 x 17 mm in the aortopulmonary window. Due to the size and the location the resection by ESD was withdrawn. Despite being located on the left side and because of the close relationship the large vessels the operation was done by VATS from the right side. After transsection of the vena azygos and generous mobilization of the oesophagus, the enucleation of the tumour could be accomplished from the right side. Results After an uneventful intra- and postoperative course the patient was discharged on day 2. The histology revealed a GIST of the oesophagus, with clear resection margins, low mitotic activity (1/50 HPF), UICC Stage I (pT2). Conclusions GISTs are rare malignant tumours of the oesophagus. Enucleation of the tumour without resection of the oesophagus is justified in tumours up to 4 cm and low malignant potential. Even left-sided tumours can be operated from the right side by VATS. Disclosure All authors have declared no conflicts of interest.

Video-assisted thoracic surgery (VATS) is recognized to be as effective as open thoracic surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. Chronic postoperative pain (CPP) is defined as persisting more than 2 months after the procedure. CPP and other neurological sensations like dysesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. In 1999 we retrospectively investigated a group of 46 (31.9%) out of 144 patients who were identified with sequels at a mean of 32 months after a VATS procedure. Now at 123 months postoperation we reinvestigated those patients for ongoing sequels. Out of 46 patients, 36 were still alive and could be reached for an interview. Eighteen patients (50%) were now free from symptoms while 18 patients (50%) still suffered from sequels. From the group of 144 patients operated on, sequels were now present in 18 patients (12.5% at 123 months vs 31.4% at 32 months, p=0.0002). Pain was present in 17 patients (11.8% vs 20.1%, p=0.11), in 3 patients (2.1% vs 18.1%, p<0.000001) even at rest, and in 4 patients (2.7% vs 12.5%, p=0.0002) only at exercise. Ten patients (6.9% vs 28.5%, p=0.096) suffered from pain occasionally, e.g. because of changing weather. Painkillers were taken only by one patient (0.7% vs 16.6%, p<0.0001) occasionally, and the sequels impacted the life of one female patient (0.7% vs 13.2%, p<0.0001) badly. Numbness was present in 16.9% versus 1.3% (p=0.0013) of patients. Early postoperative sequels are frequently found in VATS procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. In addition, numbness and dysesthesia seem to disappear almost completely several years after the procedure.

The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially. We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7–97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit. Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with “conversion” and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001). A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the “first line” approach to FBs, although RE has its place as the “second line” therapy.