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Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options\' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT\'s duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

BACKGROUND: Transmural defects in the upper gastrointestinal (GI) tract, such as anastomotic leakage and oesophageal perforations, are associated with significant morbidity and mortality risks. Endoscopic vacuum therapy (EVT) is an efficient and safe treatment option for these patients. With the growing use of EVT in the upper GI tract, it is important to share expertise on the topic.
OBJECTIVE: This review explores the emerging role of endoscopic vacuum therapy (EVT) as treatment for transmural defects in the upper GI tract. An overview of the mechanism and procedures, outcomes in current literature and challenges of implementation and application are discussed.
CONCLUSIONS: EVT exhibits great efficacy and safety for the treatment of transmural defects in the upper GI tract. Current use of EVT is mostly experience-based, emphasizing the importance of sharing expertise and performing research to unlock its full potential.

BACKGROUND: Gastrointestinal schwannomas are most commonly found in the stomach. Owing to their nonspecific clinical and endoscopic presentations, distinguishing gastric schwannomas (GS) from other gastric submucosal tumors based on typical symptoms and endoscopic features is challenging. Endoscopic full-thickness resection (EFTR) is safe and effective for GS management; however, no standard method exists for the extraction of large gastric specimens after endoscopic treatment.
METHODS: We report the case of a 72-year-old Chinese woman who presented with abdominal distension.
METHODS: Gastroscopy revealed a submucosal bulge on the anterior wall of the lower stomach near the greater curvature. Endoscopic ultrasonography and computed tomography suggested a stromal tumor. The patient underwent EFTR of the stomach, and the tumor was successfully removed. The surgical specimen, with a long-axis diameter of approximately 5.5 cm in vitro, was extracted using a snare. Subsequent endoscopic examination revealed longitudinal, full-thickness perforations > 2 cm at the esophageal entrance. Over 10 metal clips were used to seal the mucosa, and a gastrointestinal decompression tube was placed. Follow-up radiography performed at 1 week postoperatively revealed an esophageal mediastinal fistula, which required subsequent endoscopic intervention to close the fistula using metal clips. The patient showed improvement and was discharged at 3 weeks postoperatively. Follow-up esophageal radiography revealed no abnormalities. Postoperative immunohistochemical analysis indicated CD34 (-), CD117 (-), DOG-1 (-), Ki67 (1%), S-100 (+), SDHB (+), SOX-10 (+), and Desmin (-), confirming the diagnosis of GS. Three months postoperatively, gastroscopy showed that the esophageal perforation healed well, a white ulcer scar had formed locally, metal clips were found in the stomach body, and no recurrence was found.
CONCLUSIONS: EFTR is effective for removing giant schwannomas, although the extraction of large specimens may result in iatrogenic cervical esophageal perforations. Perforations > 2 cm can be managed using endoscopic metal clip closure.

Blunt esophageal injury is an unusual organ injury that has unclear clinical symptoms due to the overlap of thoracoabdominal trauma in the setting of multiple traumas. The treatment options vary depending on the patient\'s clinical symptoms, the extent of esophageal damage, and the time from the onset of damage to diagnosis. This article presents a case of a young male patient receiving emergency treatment after a traffic accident. Esophageal perforation was diagnosed through chest computed tomography with contrast injection and oral contrast. The article focuses on imaging characteristics and suggestive signs of blunt esophageal injury in the setting of multitrauma.

Dual antiplatelet therapy (DAPT) is a vital part of the pharmacological management in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). While early discontinuation of DAPT increases ischemic risk, some patients on DAPT may require urgent surgery, necessitating its interruption. Cangrelor, an intravenous P2Y12 antagonist, provides strong platelet inhibition within minutes and platelet activity normalizes within one hour after the cessation of the drug. Bridging antiplatelet therapy with cangrelor has been increasingly studied as an alternative option to ensure the continuation of platelet inhibition in CAD patients who require discontinuation of DAPT. The present patient, with a recent history of PCI for acute coronary syndrome, experienced a significant esophageal perforation following transesophageal echocardiography (TEE). This severe complication was effectively managed endoscopically, and as part of the recent PCI treatment, prolonged cangrelor infusion was successfully utilized with no thrombotic or bleeding events throughout the management of the complication.

Boerhaave syndrome (BS) is a rare clinical diagnosis associated with a high morbidity and mortality rate. Diagnosis of this condition is usually delayed which can lead to a very poor outcome. The timing of presentation and time to management plays a very important role in the prognosis and selection of the management method. With the advances seen in therapeutic endoscopy, many authors have been exploring the possibility of shifting the focus of management from surgery to interventional endoscopy. We present a case report of a patient presenting with BS that was successfully managed endoscopically. We also reviewed the literature on how surgical management compares to endoscopic management and attempted to establish general recommendations from available literature on management of BS.

OBJECTIVE: Esophageal perforations are a complex clinical scenario that have been poorly studied. To date, there is no grading of esophageal perforations, the reason being that the outcome is very heterogeneous, because the perforation is very heterogeneous. A grading of the severity of the perforation may guide treatment, and could ultimately affect morbidity and mortality.
METHODS: The observation period of the study was four years. All patients with a perforation of the esophagus aged 18 to 90 years were included. All anastomotic insufficiencies or fistulas after surgery of the esophagus were excluded. The cause of the injury and the time interval between the event and the start of therapy were analyzed. The severity of each perforation was classified based on the results of a diagnostic CT scan, gastroscopy as well as clinical and laboratory findings. Therapy and signs of infection were evaluated. Endpoints of the study were patient recovery or death. The study was conducted as a retrospective single-center study at a university hospital of Düsseldorf. The study has been approved by the review board. Patients gave their informed consent before data collection. All data were analyzed using SPSS 29 (IBM SPSS Statistics software).
RESULTS: Age, gender and cause of the esophageal perforation did not impact significantly on overall survival. The duration of injury > 24 h (p = 0.01), presence of mediastinitis (p = 0.01) and necrosis of the esophagus (p = 0.02) were associated with an unfavorable outcome. The correlation of the clinical grading of the severity of the perforation based on the endoscopic, radiological and clinical findings with the overall survival of patients was significant. Patients categorized into the four grades of severity (I-IV) had an overall survival of 100%, 100%, 70% and 50%, respectively.
CONCLUSIONS: The severity of esophageal perforations can be systematically rated grades I to IV based on the radiological, endoscopic and clinical findings at diagnosis. Due to the grading and its correlation to the overall survival, a comparison of patients, their treatment and outcome becomes possible. In future, the grade of a perforation may guide treatment, and therefore affect morbidity and mortality.

BACKGROUND: An aortoesophageal fistula can prove to be fatal. Salvage thoracic endovascular aortic repair as a bridging therapy and radical surgery with thoracotomy should be considered while treating aortoesophageal fistula without spontaneous closure. Moreover, it is essential to select a technique that reduces the risk of reinfection. Here we report a rare case of a ruptured thoracic aortic aneurysm related to esophageal perforation by a fish bone that led to massive hematemesis and shock, and the surgical treatment of an aortoesophageal fistula that developed after salvage thoracic endovascular aortic repair.
METHODS: A 70-year-old Japanese female patient was admitted with hematemesis, thoracic pain, and shock related to esophageal perforation of a ruptured descending aortic aneurysm caused by fish bone aspiration and esophageal perforation 1 month previously. An emergency thoracic endovascular aortic repair was performed. Postoperatively, an aortoesophageal fistula that remained open and a food intake-related increase in the inflammatory response was noted. Radical blood-vessel prosthesis implantation and fistula closure were performed. The patient\'s postoperative course was favorable and the patient was discharged 22 days after the blood vessel prosthesis implantation.
CONCLUSIONS: Such a case of rupture of a descending aortic aneurysm related to perforation by a fish bone and an aortoesophageal fistula is considerably rare. Thus, we report the therapeutic strategy of this particular case and review the relevant literature.