Despite the use of safer tubes with high-volume, low-pressure cuffs, post-intubation injury is still the leading cause of benign, acquired, tracheoesophageal fistula (TEF). Cuff pressure, which is their primary pathogenetic driver, is not routinely monitored as a quality metric. To highlight the devastating consequences, we report this case of a fatal, iatrogenic fistula in a 64year-old Asian male. He had undergone tracheostomy due to amyotrophic lateral sclerosis (ALS) and had a series of hospitalizations due to recurrent episodes of pneumonia. A TEF was eventually diagnosed to be the underlying cause. Esophageal stenting was ineffective. We intend to present teaching points aimed at reducing the risk of TEF in ventilator-dependent patients.

INTRODUCTION: All that looks like cancer is not always cancer. Esophageal Actinomycosis is a fine example that frequently mimics malignancy. Actinomyces is a bacteria acting like fungi which extremely rarely infects the esophagus in immunocompetent hosts. Risk factors are unknown due to paucity of data. CASE DESCRIPTION/METHODS: A 79-year-old African American woman was admitted with mild hematemesis. She had progressive, painless dysphagia for solids for 6 weeks and had lost 12 lb. She had curative lobectomy for lung cancer and quit smoking 10 years ago. She had COPD and GERD. Medications included Budesonide-Formoterol and Albuterol inhalers. She had no history of chemo/radiotherapy, tuberculosis, HIV, or diabetes. Physical exam was normal. CBC, renal function and LFTs were normal. CT chest with contrast showed air-fluid levels within the esophagus and wall thickening. EGD revealed a 1 cm friable mass in distal esophagus. Biopsy confirmed actinomycosis and candida esophagitis. She was discharged on Ceftriaxone 2 g/day for 4 weeks and oral Fluconazole 200 mg/day for 3 weeks. At 1-month follow up, dysphagia had improved and she was switched to oral Amoxicillin for 6 months. DISCUSSION: Actinomyces is an anaerobic, gram-positive, filamentous, branching rod. It grows as normal flora in the mouth and GI tract. Esophageal Actinomycosis is exceedingly rare in immunocompetent people with only 28 cases indexed in PubMed in English. 13 cases were reported in the US. 2/3 of patients were immunocompromised. It invades the esophagus following mucosal breach, and presents as a mass, esophagitis, ulcer, abscess, fistula, or stricture causing dysphagia/odynophagia. It is a great imitator, often misleading physicians, thereby triggering malignancy work-up. Diagnosis involves imaging and biopsy. Microscopy reveals yellow sulfur granules in 50% of cases. Actinomyces is difficult to isolate with culture yield as low as 24%. RNA sequencing can provide a quick, accurate diagnosis in future. Patient education and counseling is the cornerstone of successful prolonged antibiotic therapy. An initial course of IV penicillin G or Ceftriaxone for 4-6 weeks is followed by oral penicillin V or amoxicillin for 6-12 months. Necrotic ulcer, fistula, or abscess is managed surgically. We believe that inhaled corticosteroids may have created the milieu for the growth of Actinomyces and Candida in the esophagus by impairing local defenses. 43% of inhaled corticosteroid is deposited in the esophagus according to Gamma scintigraphic studies.

55case series AbstractIntroduction: Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention. Methods: A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined. Results: During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically. Conclusion: Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication. IntroductionAppendicectomy is the most common emergency surgical procedure performed worldwide.1 Laparoscopy plays a valuable role in the management of patients with acute lower abdominal pain. A Cochrane review has recommended laparoscopy and laparoscopic appendicectomy (LA) in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible.2 Minimally-invasive approaches have revolutionized surgery.3 Laparoscopic surgery has well-documented benefits with associated shorter length of stay, quicker return of bowel function, decreased analgesic requirements, lower rates of wound complications, and improved cosmesis.4,5 Furthermore LA is seen as an excellent training opportunity and evidence shows an attainable learning curve.6 LA is a safe procedure for junior trainees to perform; 7-9 however resident involvement in LA has resulted in increased operative time and complications. 10,11The overall rate of major complications following a laparoscopic procedure is about 1.4 per 1000 procedures. 12However, the incidence of port site complications following laparoscopic surgery is around 21 per 100 000 cases.13 Port site complications can be grouped into access-related complications (vascular or visceral injuries) 14 and postoperative complications (wound infection or port site herniation). 15,16Currently, there is little data regarding iatrogenic secondary trocar induced injuries in LA. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention. MethodsWe performed a retrospective analysis of LA over a 2-year period (2012)(2013) at a tertiary referral university teaching hospital. Data were obtained from the hospital in-patient enquiry (HIPE) system. The outcomes measured included the incidence of iatrogenic bladder injuries at the time of LA, mode and time of clinical presentation, type of port used, le...

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