Background Stenting of Boerhaave syndrome is accepted as a modality of therapy but may not be successful at all times. We report a case of failed stenting, restenting and TEF due to stent. Methods This patient was managed at a different center and has undergone multiple procedures before. We have listed the procedures in chronological order. 24 FEB 2017: Endoscopy for acute retrosternal pain 28 FEB 2017: Left ICD for pyothorax 4 MARCH 2017: 15cm PTFE covered stent for large oesophageal rent at 28 cm 3 APRIL 2017: Stent removal 4 APRIL 2017: Check CT scan oesophago pleural fistula with 3mm rent on lelft lateral wall 8 APRIL 2017: Fistula closure with APC and fibrin sealant. 12 APRIL 2017: Fistula closure done with Thermal coagulation glue and covered SEMS. 27 MAY 2017: Stent removal and check ct showed supracarinal TEF admitting the scope. REFERED TO OUR UNIT AT THIS STAGE. Results Procedure done at our center: Right thoracotomy, layered fistula closure and vascularised intercostal muscle flap, subtotal esophagectomy, retrosternal gastric pullup, oesophago gastric anastamosis with feeding enteral access. Conclusion Post operative period was uneventful. Tracheostomy was done on 4th POD as there was drop in oxygen saturation. He improved gradually. Oral fuid started on day 7. Discharged on day 16. He is on regular followup.Tracheostomy and jejunostomy tubes removed. He was eating and speaking normally. This case is presented to high light the pertinent issues and limitations of SEMS placement for oeosphageal perforation. Diligent approach is to be followed in cases presenting with large diameter perforations. Caution should be exercised in SEMS exchange procedures when primary stenting has not produced optimal results. Surgery in select situations can be an optimal solution in these patients. Disclosure All authors have declared no conflicts of interest.

Background Stomach is the best conduit available after esophageal resection for both benign and malignant esophageal disorders. Malignancy in the gastric conduit after esophageal resection is a rare occurrence with worst outcome. Methods 13 cases of gastric conduit malignancy admitted in our institution from 2006 to 2016 were analysed. Malignancy in the conduit may be a second primary or a recurrence of the tumor bed or at anastamotic site. Indication for surgery, Demographic profile, Interval between occurrence and primary disease, site, type, stage and grade of malignancy, route of the conduit (retro sternal/posterior mediastinum), presence of pyloroplasty, post operative therapy and complications were analysed. Results The mean interval between primary esophageal malignancy and conduit cancer was 4.3 years. 6 cases represented the second primary, 4 represented anastamotic recurrence and 3 cases of bed recurrence. All cases were adenocarcinoma. Out of 13 patients 8 were advanced malignancy. Out this 8, one patient had conduit pulmonary fistula. Only feeding/stenting procedure and chemo/RT were done. In the remaining 5 patients wedge resection in 1patient and total conduit gastrectomy in 4 patients with colonic replacement were done. Comparing 2 cases of substernal with 2 cases of posterior mediastinal colonic conduit placement the post operative pulmonary complications are less and no need for delay in RT in substernal route. Median overall survival in non surgical patients was 6.2 months (range 4–11 months) and 1.9 months (range 6months -5.6 years) in surgical patients.(P = 0.003) Conclusion Colonic reconstruction and even partial resection is possible in the management of conduit malignancy after esophagectomy and even yields survival closer to primary gastric maligmancy. Placement of the conduit in the substernal route offers some advantage in treating the tumour bed with radiotherapy. Continuous postoperative monitoring after esophagectomy with the monotored surveillance program is needed to select appropriate cases for better results. Disclosure All authors have declared no conflicts of interest.

Background Scleroderma esophagus is a rare entity. Only few case reports of esophagectomy were done and reported for this condition. We are presenting this rare case of failed fundoplication and mesh repair with a diagnosis of GERD and hiatus hernia, which was found later on due to Scleroderma with Esophageal involvement. Methods 58 year old female admitted with dysphagia following laproscopic fundoplication with mesh repair of crura with a diagnosis of GERD and hiatus hernia.She presented with persistent vomiting and loss of weight.On evaluation, her Upper GI scopy revealed dilated esophagus with sluggish peristalisis. Since the patient had tightness of skin over the distal extremities, face and fish mouth appearance with thinning of nail, Skin biopsy was taken. The skin biopsy was reported to be scleroderma.The esophageal manometry demonstrated failed esophageal peristalisis with high normal LES pressure due to tight fundal wrap.The patient was treated with mesh remova, Transhiatal esophagectomy with gastric pull-up and cervical Anastomosis.Post operatively the patient was treated with hydrocholoroquine and predinisolone. Results The patient is free of dysphagia and is on regular follow up. Conclusion In case of failure, detailed evaluation including High resolution manometry (MII HRM) has to be done before doing laparoscopic fundoplication for GERD has to rule out uncommon and rare disorders of esophagus. Detailed clinical examination in GERD patients has to be done to rule out systemic disease like scleroderma.In case of failed fundoplication for GERD, patients have to investigated for the failure.So patients with incapacitating esophageal neuromotor disease, a more radical approach in the form of esophagectomy may be safer and more reliable than attempting another procedure and risk another failure. Disclosure All authors have declared no conflicts of interest.

Background Boerhaave syndrome produces an extremely severe clinical profile due to extravasation of digestive secretions and food into the mediastinum and pleural space. Diagnosis is often delayed, since it is a rare disease and is usually confused with other equally serious pathologies. These factors contribute to its high mortality rate. We present a case which was previously treated in three different institutions and finally referred to our department. Methods 81 year old gentleman was diagnosed as Boerhaave syndrome on 23rd Jan 2017. He had treatment in three different institutions: right ICD in first center: feeding jejunostomy and venting gastrostomy in second center: over the scope clipping and hemoclip in third center. As he continued to have persistent leak of enteral contents and purulent discharge in ICD, he was referred to our department for further management, two months after the intial insult. Results Patient was optimised for surgery and transhiatal esophagectomy with esophago gastric anastomosis was done in our department. Operative findings: Abdomen entered through midline incision, hiatal peritoneum incised, gastro esophageal junction encircled and esophagus mobilised. It revealed purulent discharge from right hemithorax and a 4cm esophageal perforation along right lateral aspect of esophagus above GE junction.About 120ml of foul smelling pus drained. Considering unhealthy esophageal tissue, long rent and failed endotherapy it was decided to do transhiatal esophagectomy. Previous gastrostomy site closed in 2 layers with 3–0 PDS. Through left anterior sternomastoid incision cervical esophagus mobilised and transected at low neck level and the specimen was removed through the hiatus. A gastric tube was made with linear staples and brought into neck through posterior mediastenum by camera sheath technique. Esophago-gastric anastamosis completed with posterior stapled and anterior hand sewn technique. Post op period was uneventful. Conclusion Early diagnosis and appropriate therapeutic strategies can reduce the mortality rate of Boerhaave's syndrome. Early intervention reduces the morbidity and mortality. The mortality increases with increasing time post insult. our patient who had undergone multiple theraputic modalities in three different centers was succesfully managed with trans hiatal esophagectomy in our department. Disclosure All authors have declared no conflicts of interest.

Background Malignancy developing in a corrosive injured esophagus has been described in the literature. Though the possibility of malignancy developing in a corrosive esophagus is expected to be around 1000 fold no team has managed large numbers. The aim of this study is to analyse the pattern of presentation and problems encountered in managing these difficult patients. Methods 13 patients with corrosive malignancy encountered between 1991 and 2016 were included in this study. Patients basic demographic profile, incidence, time interval between ingestion of corrosive and occurrence of malignancy, site of malignancy, symptoms at presentation, stage, management and survival were analysed. Results There were 10 males and 3 females. The age at presentation was between 35 and 52 years. The time taken between ingestion to presentation with cancer was between 13 and 29 years. The commonest presentation was dysphagia in 11, TEF in 1, UGI bleed in 1 patient. Most common site of malignancy is upper cervical esophagus (53.8%) either at the anastamotic site after coloplasty or at post cricoid region followed by middle (30.7%) and lower esophagus (7.75%) and OG junction (7.75%). 6 of them underwent definitive chemo RT, 3 were unwilling for any sort of management, 1 died within 24 hours due to aorto enteric fistula, 3 underwent THE and gastric pull up. Of these 9 patients only seven were under regular follow up. The survival in 3 patients who underwent THE respectively were 3.8, 5.5,7 years. The survival in patients who underwent Chemo RT was between 3 months and 15 months. Conclusion There were 10 males and 3 females. The age at presentation was between 35 and 52 years. The time taken between ingestion to presentation with cancer was between 13 and 29 years. The commonest presentation was dysphagia in 11, TEF in 1, UGI bleed in 1 patient.. Most common site of malignancy is upper cervical esophagus (53.8%) either at the anastamotic site after coloplasty or at post cricoid region followed by middle (30.7%) and lower esophagus (7.75%) and OG junction (7.75%). 6 of them underwent definitive chemo RT, 3 were unwilling for any sort of management, 1 died within 24 hours due to aorto enteric fistula, 3 underwent THE and gastric pull up. Of these 9 patients only seven were under regular follow up. The survival in 3 patients who underwent THE respectively were 3.8, 5.5,7 years. The survival in patients who underwent Chemo RT was between 3 months and 15 months. Disclosure All authors have declared no conflicts of interest.