Oesophageal perforation following cervical spinal surgery with instrumentation: A case report on primary repair with pedicled sternocleidomastoid muscle flap reinforcement and review of the literature

Anterior cervical spine fusion and stabilisation is an entrenched procedure for managing traumatic spinal fracture. Oesophageal perforation by spinal hardware after cervical spinal fusion surgery is a rare complication that can be life-threatening. We present a case with a complication of oesophageal perforation following anterior and posterior spinal fusion with instrumentation performed 7 years ago with a review of literature.     

Laparoscopic approach to esophageal perforation secondary to pneumatic dilation for achalasia

Background  Perforation of the esophagus after pneumatic dilation for achalasia is a severe complication which should be treated accurately in order to obtain a successful immediate outcome and a satisfactory result for the underlying condition. Methods  Five consecutive patients presenting with distal esophageal perforation after pneumatic dilation for achalasia were included in this study. All patients had gastrografin swallow performed to confirm the perforation, and one patient was also submitted to flexible esophagoscopy. Laparoscopic approach was performed in all patients with five portals. The phrenoesophageal membrane was opened on its anterior aspect. The distal esophagus was dissected free, and perforations were identified with the help of methylene blue or milk administration through the esophageal tube. All perforations were sutured with interrupted absorbable sutures. Contralateral myotomy and partial anterior Dor fundoplication completed the operation. Endoscopic control of length of myotomy and watertightness of mucosal closure was performed in all cases. Results  There were no intraoperative complications. After surgery all patients were maintained with nil per os until a barium swallow showed no leakage. One patient had a radiologic leakage sustained for 1 week. All patients were dismissed uneventfully. At 6 months after surgery, esophageal manometry was performed. Mean lower esophageal sphincter resting pressure had fallen from 30 to 8.7 mmHg. Conclusions  Laparoscopy offers an excellent approach to treat distal esophageal instrumental perforations, perhaps even better than open surgery. Suture of the perforation, contralateral myotomy and partial anterior fundoplication is a good option in the treatment of perforated achalasia after pneumatic dilation. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Traumatic rupture of the oesophagus and stomach

Thirty-nine cases of traumatic perforation of the oesophagus or stomach have been studied. Thirty-two of the perforations followed oesphagoscopy, five were `spontaneous,' and two were due to damage by a foreign body. Eight of the perforations occurred in the cervical oesophagus, 22 in the thoracic portion, and nine were in either the abdominal oesophagus or the stomach. Treatment was of two types—either operative closure of the perforation or a conservative routine of intravenous fluids, parenteral antibiotics, and cessation of oral feeding. In some patients treated conservatively, drainage procedures were also carried out. Five patients with terminal carcinoma, in whom oesophageal intubation after prolonged dysphagia caused perforation, had no treatment apart from analgesics and sedatives. Several of the patients treated by surgical closure had a concurrent definitive operation (resection of carcinoma in four cases and myotomy for achalasia in two cases). Fourteen of the 21 patients treated by repair or resection of the perforation survived. Ten of the 13 treated conservatively also survived. The good results of conservative treatment for cervical perforations appear to make it the treatment of choice. Only an occasional case of thoracic perforation is suitable for conservative treatment, and as a general rule perforations in this area and in the peritoneal cavity should be treated surgically.     

Use of a free jejunal graft for oesophageal reconstruction following perforation after cervical spine surgery: case report and review of the literature

STUDY DESIGN:: Single-subject (male, 16 years of age) case. OBJECTIVES: To demonstrate a suitable method for oesophageal repair after perforation as a complication of anterior spinal fusion in an individual with quadriplegia, and to review the literature on oesophageal perforation and repair. SETTING: University hospital, large trauma centre with departments for spinal injuries and reconstructive surgery in Germany. METHODS: A free jejunal graft used for oesophageal reconstruction in a post-traumatic situation after a complicated treatment course in a C6 quadriplegic patient. RESULTS: A protuberant loose screw of the titanium plate after anterior spinal fusion perforated the oesophagus. Imbricating sutures and a fascia lata patch were insufficient to repair the oesophageal leakage. An 8 cm long segment of the cervical oesophagus including a fistula had to be excised, and a free microsurgical jejunal flap was used for restitution of continuity. The jejunal vessels were connected to the superior thyroid artery and external jugular vein. At 1 week after the oesophageal repair, an enteral contrast study showed a small amount of contrast medium leaking at the oesophago-pharyngeal anastomosis. A percutaneous gastric tube was inserted, and oral feeding was limited to tea and still water for 4 weeks. The further course was uneventful. CONCLUSIONS: Oesophageal perforation is a rare but recognized complication after cervical spine surgery, which can mostly be managed using secondary suture techniques. The free jejunal flap is a reliable and innovative tool in the particularly complex situation of a segmental oesophageal loss. It should be considered in similar cases to reconstruct oesophageal continuity or to treat stricture and fistula formations.     

Perforation of the cervical esophagus and hypopharynx complicating surgery by an anterior approach to the cervical spine

Difficult diagnostic and therapeutic problems are raised by perforations of the cervical oesophagus or hypopharynx in patients undergoing surgery to the cervical spine via an anterior approach. Based on their experience of three recent cases, the authors review the diagnostic approach, based on clinical examination and diatrizoate sodium oesophageal series, and propose conservative treatment consisting of surgical drainage with or without suture of the perforation and without removal of the osteosynthesis material, appropriate antibiotic therapy and hypercaloric enteral nutrition via nasogastric tube. The prevention of this complication is based on correct use of surgical retractors.     

Traumatic oesophageal perforation due to haematoma

INTRODUCTION

Traumatic oesophageal perforation is a rare, life-threatening emergency that requires early recognition and prompt surgical management.

PRESENTATION OF CASE

We present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.

DISCUSSION

In treatment of oesophageal haematoma in patients on vitamin-K antagonists, strict control of the International Normalized Ratio (INR) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes. Three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma, azygos vein and the lower part of thoracic trachea; or could be an immediate rupture walled-off until the patient became symptomatic; or the intramural hematoma gradually lysed and causing late perforation.

CONCLUSION

Although extremely rare, an oesophageal haematoma and late complications must be considered in patients on anti-coagulant therapy following blunt thoracic trauma and complaining only of chest pain.     

Screw migration and oesophageal perforation after surgery for osteosarcoma of the cervical spine

Background

Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.

Case presentation

We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.

Conclusions

Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.

     

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.     

Late esophageal perforation complicating anterior cervical plate fixation in ankylosing spondylitis: a case report and review of the literature

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5–7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.     

Instrumental perforations of the oesophagus and their management.

The records of 39 patients who had developed a perforation of the oesophagus after instrumentation were reviewed. Ten (group A) had cervical and 29 (group B) thoracic oesophageal perforation. Twenty three perforations occurred during dilatation of an oesophageal stricture, 10 during oesophagoscopic removal of a foreign body, and six during diagnostic oesophagoscopy. Of the 21 patients treated within 36 hours (early treatment group), four (19%) died; of the 18 treated more than 36 hours after the perforation (late treatment group), nine (50%) died. None of the 10 patients in group A had strictures and only two presented late. After drainage of the neck and mediastinum the outcome was successful in all patients. Thirteen of the 29 in group B were treated early and four of these died; nine of the 16 treated late died, the total mortality for thoracic perforation being 48%. An oesophageal stricture was present in 23 patients. Twelve of these underwent various forms of conservative surgery and there were 10 deaths. This contrasts with the 11 who received radical treatment with resection and reconstruction, only two of whom died. The six patients with no pre-existing stricture were treated with conservative forms of surgery, with one death.     

Role of transoral irrigation in mediastinitis due to hypopharyngeal perforation

Mediastinitis resulting from perforations of the hypopharynx is a life-threatening complication associated with a high morbidity and mortality. In cases of perforation, which are not amenable to primary closure, transoral irrigation has been found to be an effective means of therapy. This technique rapidly controls sepsis, favoring the closure of perforations of the hypopharynx and cervical esophagus. Using this technique we have had no mortality attributed to mediastinitis in patients with mediastinitis due to perforation of the hypopharynx, cervical and thoracic esophagus.     

SURGICAL MANAGEMENT OF BENIGN OESOPHAGO-PLEURAL FISTULA

Three cases of oesophago-pleural fistula are presented. Two resulted from foreign body perforation of the oesophagus and one followed left lower lobectomy for bronchiectasis. All three presented late; the time lapse ranged from 6 days to 2 months. An initial course of conservative treatment was given to all three patients. Alimentation via nasogastric tube feeding, gastrostomy or total parenteral nutrition was carried out. The pleural fluid grew the anaerobe, Baaeriodies melaninogenicus, in all three cases. Gram-negative aerobes, Escherichia coli and Proteus mirabilis, were also cultured. Closed intercostal drainage and a course of appropriate antibiotics were instituted. The patients were subjected to surgery after the infection had been brought under control. Simple repair was performed in two patients. Exclusion of the oesophageal leak with drainage and later reconstruction was carried out in the third patient. Although all three patients recovered, the morbidity was considerable. The duration of hospital stay ranged from 2 to 4 months.     

Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers

BackgroundTo evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers.MethodsFifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed.ResultsThe mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person.ConclusionsLaparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.     

Tracheal perforation following double-lumen intubation: a case report

Tracheal perforation following endotracheal intubation is an underestimated complication that seriously compromises prognosis. Treatment can be either conservative or surgical, depending on the lesion and the patient's clinical condition. In this case report, we describe a patient in whom tracheal perforation occurred during double-lumen tube placement for elective surgery on a pulmonary nodule. As the perforation was accessible to the surgeon, a running suture could be made from the oesophageal wall.     

Foreign body perforation of the normal oesophagus.

Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (> 48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesophagoscopy. A third of the perforations were cervical, the remainder intrathoracic. All patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment.     

Esophagus perforation complicating anterior cervical spine surgery

Purpose  

To study the diagnosis and treatment strategy of esophagus perforation complicating anterior cervical spine surgery.     

VIDEOTHORACOSCOPIC PRIMARY REPAIR OF EARLY DISTAL OESOPHAGEAL PERFORATION

Distal oesophageal perforation following dilation of oesophageal strictures or achalasia is usually recognized soon after the event. Treatment of two patients with perforation resulting from vigorous achalasia, diagnosed within hours of the procedure, was approached by videothoracoscopic exposure and successful primary repair was achieved in both instances. Details relating to patient preparation and operative technique are presented. Both patients recovered, with normal diet being tolerated by the seventh day after surgery, were discharged on day eight and 10 and returned to normal activities within 3 weeks of surgery. The technique presented is apparently well suited to distal oesophageal perforations diagnosed early, when primary closure can be achieved safely, and significantly improves patient recovery after this often iatrogenic injury.     

Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique

Anterior procedures in the cervical spine are feasible in cases having anterior aetiologies such as anterior neural compression and/or severe kyphosis. Halo vests or anterior plates are used concurrently for cases with long segmental fixation. Halo vests are bothersome and anterior plate fixation is not adequately durable. We developed a new anterior pedicle screw (APS) and plate fixation procedure that can be used with fluoroscope-assisted pedicle axis view imaging. Six patients (3 men and 3 women; mean age, 54 years) with anterior multisegmental aetiology were included in this study. Their original diagnoses comprised cervical myelopathy and/or radiculopathy (n = 4), posterior longitudinal ligament ossification (n = 1) and post-traumatic kyphosis (n = 1). All patients underwent anterior decompression and strut grafting with APS and plate fixation. Mean operative time was 192 min and average blood loss was 73 ml. Patients were permitted to ambulate the next day with a cervical collar. Local sagittal alignment was characterised by 3.5° of kyphosis preoperatively, which improved to 6.8° of lordosis postoperatively and 5.2° of lordosis at final follow-up. Postoperative improvement and early bony union were observed in all cases. There was no serious complication except for two cases of dysphagia. Postoperative imaging demonstrated screw exposure in one screw, but no pedicle perforation. APS and plate fixation is useful in selected cases of multisegmental anterior reconstruction of cervical spine. However, the adequate familiarity and experience with both cervical pedicle screw fixation and the imaging technique used for visualising the pedicle during surgery are crucial for this procedure.     

Surgical management of huge tracheo-oesophageal fistula with oesophagus segment in situ as replacement of the posterior membranous wall of the trachea

Tracheo-oesophageal fistula (TEF) is an uncommon and potentially life-threatening complication of blunt chest trauma. We describe our surgical experience in a patient with huge TEF (5.6 cm in diameter) and evaluate the short-term results of surgical management by oesophageal exclusion (cervical gastro-oesophagostomy) and show that the use of oesophagus segment in situ as replacement of the posterior membranous wall of the trachea is feasible. Improving the nutrition status and controlling the lung infection were critical in the perioperation period.     

颈椎前路手术并发食管瘘的原因及处理

 目的 探讨颈椎前路手术并发食管瘘的原因及处理对策。方法 回顾性分析2004年1月至2011年12月采用颈椎前路手术治疗2348例颈椎疾患患者资料,其中5例发生食管瘘,男3例,女2例;年龄14~48岁,平均34岁;颈椎外伤3例,颈椎病1例,颈椎结核1例。1例患者术中发现食管瘘,给予修补;另4例均为术后发现,行清创探查引流术,其中1例探查时发现食管瘘口遂给予修补,1例仅行清创探查术,1例清创探查术后二期行内固定取出术,1例清创探查术后二期行内固定取出及肌瓣填塞术。给予禁食、营养支持、伤口引流及抗生素治疗;定期吞服亚甲蓝,观察漏口情况。结果 经过9～61周治疗,所有患者食管瘘口愈合,恢复进食。随访6～48个月,无一例发生食管瘘复发、颈椎失稳及迟发感染;吞咽功能均良好;患者原有颈部疾患治疗效果均满意,颈椎外伤患者Frankel分级平均提高1级,颈椎病患者JOA评分由术前9分提高至术后15分。结论 采用食管瘘口修补、肌瓣填塞以及引流手术,并严格禁食禁水、营养支持,必要时取出内固定物,多数颈椎前路手术并发食管瘘的患者能获得满意的疗效。术中仔细轻柔操作是预防食管瘘发生的关键。