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To evaluate clinical features and manifestations of Eales disease and the efficacy of different interventions.The databases PubMed, EMBASE, and Ovid from inception until February 2021 were searched. Pooled analyses included 1) presenting features, 2) symptoms and signs, and 3) postoperative vision outcomes and complications. Statistical analyses were conducted with R software version 3.6.3.Forty-seven studies involving 3,557 patients and 4,959 eyes were included. The pooling results showed that Eales disease was male dominated (94%), bilateral involvement (64%), and mainly occurred in adolescents. Approximately 83% of patients were positive in Mantoux test, and 31% of patients have vitreous tap polymerase chain reaction positive for tuberculosis genome. More than half of the patients had decreased vision at the first clinic visit. The common signs of Eales disease included sclerotic vessels (83%), neovascularization of retina elsewhere (64%) and periphlebitis (51%). Macular changes could be detected in 24% of patients. The most common complication was vitreous hemorrhage, followed by cataracts and retinal detachment. Photocoagulation was directed at nonperfusion or neovascularization areas, with a decrease in the incidence of later pars plana vitrectomy (19%). Anti-vascular endothelial growth factor treatment was suggested for vitreous hemorrhage, which could achieve high visual acuity improvement rate (82%) while increasing the possibility of retinal detachment (18%). Pars plana vitrectomy was indicated in cases with persistent vitreous hemorrhage or retinal detachment, with 56% of patients obtaining visual improvement. Still, 17% of patients needed a second pars plana vitrectomy, mainly because of recurrent vitreous hemorrhage or retinal detachment.Eales disease most commonly affects young men. It has diverse clinical features, and management should be based on the progression of the disease.

Minimally invasive esophagectomy (MIE) has the advantages of reduced post-op cardiopulmonary complications, faster recovery and better quality of life. MIE has been the standard approach for esophageal cancer in our center since year 2020. A systematic approach with prehabilitation and enhanced recovery after surgery is key in improving outcomes after MIE. We herein report our protocol for MIE in esophageal cancer. A stepwise diagnostic, staging and multidisciplinary management pathway was adopted. All patients with histologically confirmed esophageal cancer were staged according to the 8th edition AJCC cancer staging with PET-CT scan. Patient assessment, comorbidity optimization and 3-axis prehabilitation were initiated on the first consultation. All cases were discussed in the multidisciplinary tumour board meeting and multimodality treatment approach was advocated. MIE was the standard surgical approach with selective ERAS pathway especially on goal directed fluid therapy, multimodality analgesia, timely extubation, early ambulation and enteral feeding. A total of 10 patients underwent MIE between June 2020 to June 2021 with the MIE protocol. The mean age was 56.7. Adenocarcinoma was the commonest histology. All patients had neoadjuvant therapy due to locally advanced disease. 6 patients had McKeown MIE with either 3-field or total 2-field lymphadenectomy. The mean length of stay post-op was 8.3 days. The average post-op pain score was 2.3 and the mean time to ambulation post-op was 1.6 days. Post-operative complications were noted in 4 patients with only one being Clavien Dindo grade 3. There was no 90-day mortality post-op. The early result of this systematic protocol with multidisciplinary approach, prehabilitation, MIE and selective ERAS pathway was promising. Evidence based practice with regular clinical audit are important in improving the quality of care and clinical outcomes.

Esophageal perforation or fistula is a devastating condition with diagnostic and therapeutic challenges. It is associated with high morbidity and mortality due to its rapid progression to mediastinitis or peritonitis, septic shock and multiorgan failure. Iatrogenic perforation is the commonest in this era. We hereby report a case of esophagopulmonary fistula following a right lower lobectomy which was successfully treated with endoscopic clipping. A 52-year-old man presented with productive cough and weigh loss for 2 weeks. Initial workup in another center revealed right lung lower lobe lesion and a right lower lobectomy was done. Saliva and food particle were noted in chest drain on post-operative day 2 due to esophageal perforation. Re-thoracotomy, washout and esophageal repair was done. An open window thoracostomy was created for further drainage and parenteral nutrition was initiated. Histology of the lobectomy specimen revealed actinomycosis of right lung. However, there was persistent leak from the esophagus with suspicion of esophagopulmonary fistula. He was then transferred to our center for further treatment. OGDS revealed a 5mm defect at right lateral wall mid thoracic esophagus, about 28cm from incisor, with healthy and supple surrounding mucosa. Contrast study revealed esophagopulmonary fistula. Esophageal defect was successfully closed with over-the-scope padlock clip (Steris). Repeat contrast study 1 week later revealed resolution of fistula. Sepsis and source control, nutritional support with restoration of gastrointestinal tract intergrity are key steps in the management of esophageal perforation. Endoscopic treatment is efficacious, less invasive, and with the advantage of organ preservation. Endoscopic clipping is safe and effective in selected group of patients with esophageal perforation or fistula.

Esophagectomy is a complex procedure that is traditionally associated with high morbidities. Minimally invasive esophagectomy (MIE) has the benefits of reduced post-op complications and improved quality of life in comparison to open esophagectomy (OE). This study aimed to compare the outcomes of MIE vs OE since the advocation of MIE as the standard approach in an upper gastrointestinal center. A retrospective review of prospectively collected data from the institutional online databank. OE was the main approach for esophageal cancer between year 2015 to 2017, while MIE was the standard approach in 2020 to 2021. Patient’s demography, tumour’s characteristics, operative approach, perioperative outcomes such as operation time, blood loss, post-op length of hospital stay, number of lymph node yield, post-op morbidities and mortality were compared between the OE (Jan 2015 – Dec 2017) and the MIE (Jan 2020 – Dec 2021) group. 28 patients were included in this study, 15 in the OE group while 13 in the MIE group. Mean age was similar in both groups (60.4vs59.4). 46.7% were of squamous cell carcinoma in the OE group vs 76.9% of adenocarcinoma in the MIE group. Ivor-Lewis approach was more common in the OE group (53.3%vs38.5%). MIE was associated with shorter mean operative time (489.38minutes vs 526minutes), less blood loss (110ml vs 250ml), shorter length of stay post-op (10.38days vs 24.67days) and higher number of lymph node yield (44vs31.67). Post-op morbidity was lower in MIE (30.7%vs73.3%) with Clavien-dindo grade-III and above complication rate of 7.69% vs 26.67%. 90-day mortality was 0 in the MIE vs 1 in the OE group. MIE was associated with shorter operative time, higher number of lymph node yield, reduced post-op morbidity, mortality and shorter post-operative hospital stay in patients with esophageal cancer. The encouraging results marked the paradigm shift from OE to MIE in our center.