LAUSR

Laparoscopic transhiatal omental patch repair(OPR) of esophageal perforation after pneumatic balloon dilatation(PBD) for achalasia. In August 2018 a 72yrs woman with a history of dysphagia for solids and liquids, nocturnal regurgitation and chest pain had a diagnosis of achalasia. After inhalation during a barium swallow the patient developed fever, respiratory insufficiency and worsening of vital signs leading to ICU and intubation. She developed a right-pleural empyema, massive pneumothorax and right-upper lobe abscess, requiring thoracotomy and right-superior lobectomy. She had been scheduled for a Per Oral Endoscopic Myotomy in November. After the submucosal tunnel, the procedure had been suspended due to presence of fibrosis. In December the patient underwent a first PBD up to 30mm with symptoms resolution and 2kg weight regain. In February, few hours after a second PBD up to 35mm, she complained mild pain at the left hemithorax and fever. 24hrs later a CTscan with water-soluble-contrast revealed a 3cm long esophageal perforation 5cm above the diaphragm and left paraesophageal mediastinal abscess without pleural involvement. Endoscopic treatment was excluded for significant dilatation of the esophagus and the fragile esophageal wall. Because of the frailty status of the patient, the delayed diagnosis, the high risk of a direct suture of the esophageal wall through a left thoracotomy, the even higher risk of an emergency esophagectomy, we performed a laparoscopic approach. Limited dissection of the esophagogastric-junction and of the left diaphragmatic crura allowed access to the abscess cavity, no attempt to direct suture was done, a drain was placed, a pedicled omental flap was realized filling the cavity and repairing the esophageal defect. A jejunostomy was placed. The post-op period was uneventful; a CTscan with per-os contrast on POD3 and POD9 didn’t show any collection. The patient started an oral semisolid-diet on POD11. An EGDS on POD19 confirmed the presence of the OPR in the esophageal lumen and after 2-months showed a completely re-epithelialized esophagus. Laparoscopic trans hiatal OPR of esophageal perforation in achalasia proved to be a minimally invasive and effective procedure in this patient due to its immunogenic and angiogenetic properties.