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Impacted Esophageal Denture with Esophageal Perforation





















            Figs 1A and B: (A) Non-contrast CT image showing the impacted denture in the esophagus (line arrow), extraluminal air (block arrow) and extensive
            subcutaneous emphysema (arrowhead) are also noted. There is minimal infiltration seen in the left pleural cavity; (B) Contrast-enhanced CT sagittal
            image showing the denture and the extraluminal air

                                                               •  Cervical esophagus was looped through a left hockey
                                                                  stick cervical incision along the anterior border of the left
                                                                  sternocleidomastoid muscle. Blunt digital mobilization of the
                                                                  upper esophagus was done keeping close to the esophagus up
                                                                  to the level of carina.
                                                               •  Specimen was delivered out in the neck and an end
                                                                  esophagostomy fashioned on the left side (Fig. 4).
                                                               •  Feeding jejunostomy was constructed and tube drains were
                                                                  inserted transhiatally into the mediastinum
                                                               Postoperative recovery was uneventful. She was discharged on
                                                               postoperative day 7 on jejunostomy feeds.
                                                                  Elective reconstruction was performed after 6 weeks. A
                                                               laparoscopic retrosternal gastric pull-up with cervical esophago-
                                                               gastric anastomosis was performed in the following steps:
                                                               •  Standard foregut ports as illustrated earlier (Fig. 2)
            Fig. 2: Laparoscopic port positions. C, camera port; R, right mid-clavicular   •  Laparoscopic adhesiolysis and gastric conduit preparation based
            line which serves as the left-hand working port; LS, left mid-clavicular   on the right gastroepiploic arcade.
            line which serves as the right-hand working and stapler port; E, epigastric   •  Creation of retrosternal tunnel.
            port; L, assistant retraction port                 •  Cervical exploration, take down of the cervical esophagostomy
                                                                  and completion of the upper part of retrosternal tunnel.
            •  At laparoscopy, she had a hugely dilated stomach necessitating   •  Nasogastric tube passed from the neck via the retrosternal
              gastrotomy and decompression as pre-operative placement of   tunnel into the abdomen. Tip of the NG hitched to the fundus
              a nasogastric (NG) tube was not feasible            of the gastric conduit. Rail roading of the gastric conduit into
            •  The gastroesophageal junction (GEJ) and lower esophagus were   the neck by steady traction on the NG tube.
              defined and short gastric vessels divided. A ribbon tape loop   •  Cervical esophagogastric anastomosis was performed using an
              placed around the GEJ facilitated traction for further dissection.  Endo GIA  universal 60-mm stapler (United States Surg Corp.
                                                                         TM
            •  An impacted denture was visualized perforating the esophagus   Norwalk, Conn.). Neck wound was closed in layers after placing
              in the lower one-third at two sites (measuring 2 cm at 3 o’clock   a corrugated drain.
              and 4 cm at 9 o’clock positions) (Fig. 3).
            •  Transhiatal mobilization of the esophagus was carried up to the   Postoperative recovery was uneventful except for left pleural
              carina. This step was performed using 5-mm harmonic shears   effusion which settled with a single-time image guided aspiration.
              (Ethicon Endosurgery, Cincinnati, USA).          Contrast study on day 5 did not show any evidence of anastomotic
            •  The denture causing perforation was retrieved through the   leak (Fig. 5) and she was discharged on day 7. She is doing well at
              esophageal perforation site and extracted through an endobag   8 years follow-up.
              (Fig. 3).
            •  As there were two large perforations with adjacent mediastinal   dIscussIon
              contamination not amenable to primary closure a decision to   Foreign body ingestion with resulting impaction proximal to the
              proceed with esophagectomy was taken.            site of narrowing in the esophagus is a rare but serious surgical
                                                                               2
            •  Esophagus just proximal to the GEJ was divided with Endo   emergency in adults.  Multidetector contrast enhanced computed
                 TM
              GIA  Universal 60-mm linear stapler (United States Surg Corp.   tomography is preferred over conventional radiography for the
              Norwalk, Conn.)                                  diagnosis, recognition of resulting complications, and planning the
                                                        World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)  175
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