Laparoscopic Heller’s cardiomyotomy is the surgical procedure of choice in the management of oesophageal achalasia. It is critical to confirm the completeness of the myotomy and mucosal integrity at the conclusion of the procedure. This is conventionally achieved by intraoperative endoscopy and dynamic air leak test. Other modalities that can be used to confirm the myotomy and the integrity of the mucosa at the myotomy site are oesophageal manometry and a methylene blue dye study, respectively. Indocyanine green (ICG) has been in clinical use for more than six decades. The real-time integration of ICG fluorescence with laparoscopy is a relatively new breakthrough. Here, we present a novel method of using real-time near-infrared ICG fluorescence for confirming the completeness of the myotomy and mucosal integrity at the myotomy site post laparoscopic Heller’s myotomy. This is the first report on the use of ICG in laparoscopic Heller’s cardiomyotomy that we are aware of.

Spontaneous esophageal perforation (SEP) (Boerhaave syndrome) carries high morbidity and mortality. Delay in diagnosis, because of the non-specific complaints and the rarity of the condition, further increases the mortality. While patients diagnosed early can be managed by primary closure of esophageal perforation, those presenting beyond 24 hours often require an esophagectomy with salivary diversion and feeding access with a plan for the reconstruction of the alimentary tract at a later date. In a minority of patients with a controlled esophageal fistula and feeding access, source control could be achieved by endotherapy. Patients with mediastinitis and associated systemic sepsis would be better served by surgical intervention. We present a case of an SEP with a delayed diagnosis, who underwent three unsuccessful endotherapy attempts and decortication before referral for surgical repair. The patient had an established esophageal fistula. He underwent a laparoscopic repair of the fistula. Postoperative recovery was uneventful. At the one-year follow-up, the patient was asymptomatic and had gained weight. Though surgery is the treatment of choice, the optimal management of SEP with delayed diagnosis is not clearly defined. In the current era of advanced endotherapy, more cases are being managed endoscopically. However, they carry a high failure rate, resulting in increased morbidity among the patients. Early involvement of a surgical team in the decisionmaking is crucial for optimal outcomes of the disease.

An intestinal stoma is an opening of the intestinal tract onto the anterior abdominal wall. It is a commonly performed surgical procedure done for various benign and malignant pathologies. The construction of the stoma is temporary or permanent. Loop stoma is usually performed to divert the faecal stream for protection of the downstream anastomosis. They are usually reverted once the purpose of their creation is served. Spontaneous closure is a rare event that could result from a gradual stomal retraction. However, a normal bowel with no distal obstruction would be a prerequisite for it to be asymptomatic. Here, we report a case of spontaneous closure of a diversion loop sigmoid colostomy which had a delayed presentation. This is the second case of spontaneous closure of a sigmoid loop colostomy and the first report on the management of ventral hernias following spontaneously closed stoma in the English literature to the best of our knowledge.

A congenital tracheo-esophageal fistula of the H-type is a rare variant. The diagnosis is usually missed because of mild symptoms. A long history of coughing during liquid intake and nocturnal cough may aid in the diagnosis. A delay in the diagnosis may have a deleterious effect on the lung because of recurrent infections. Surgery is the cornerstone of management. Self-expandable metallic stents (SEMS) do not have a role in the management of these fistulae. We report a case of a missed diagnosis of a congenital H-type fistula managed as an acquired tracheo-esophageal fistula with two attempts at conservative management with a tracheal self-expandable metallic stent. The difficulties and disadvantages of using self-expandable metallic stents for the management of benign tracheo-esophageal fistulae are also discussed.

Malignancies developing in two organs or more in the same patient are called multiple primary malignancies. They can be synchronous or metachronous based on the time of diagnosis of second cancer from the first. We encountered a synchronous stage IV sigmoid colon cancer (resectable liver metastasis) and breast cancer in a lady. The clinical dilemmas that arose with multiple primary malignancies and how they were tackled in our case have been discussed. A second malignancy should not deter the management or alter the clinical decision-making. Multidisciplinary teams are crucial to the management of these rare occurrences. We could successfully manage a synchronous breast and colon cancer with resectable liver metastasis at presentation.