Spontaneous Healing Of A Shredded Esophagus After Acdf Without Direct Repair
Shah, S. S., Burks, S. S., Nguyen, D. M., Sargi, Z. B., Stephens-McDonnough, J., & Wang, M. Y. (2018). Spontaneous healing of a shredded esophagus after ACDF without direct repair. Acta neurochirurgica, 160(2), 413–417. https://doi.org/10.1007/s00701-017-3414-7
View Original Source →Abstract
Esophageal perforation is a catastrophic complication of anterior cervical discectomy and fusion (ACDF). While direct surgical repair has been reported as optimal for restoration of upper gut function, we present the case of a 58-year-old woman who achieved complete resolution when treated only with debridement and drainage. We find that a supportive approach, surgical management without direct repair, may play a vital role in select patient populations in order to avoid potentially long-term consequences or radical treatments, like esophageal diversion. Decisions regarding direct repair versus debridement and inspection only should be made on a case-by-case basis through a multidisciplinary approach.
Case Details
Disease Location
Esophagus
Personal Characteristics
58-year-old woman. Cervical spondylosis and radiculopathy
Clinical Characteristics
Underwent adjacent level anterior cervical discectomy and fusion (acdf) extension (c3/4 and c6/7) for previous c4-c6 fusion. Along with dysphagia and dysphonia, her postoperative course was complicated by rapidly progressing subcutaneous emphysema and neck and chest pain on the 2nd day after surgery. A barium esophagram had been ordered at the outside facility, demonstrating extensive extravasation of contrast into the prevertebral cervical and superior mediastinal spaces. The patient was taken to the operating room for a trans-cervical mediastinotomy (tcm). There was significant tissue edema as well as purulent fluid in the cervical and superior mediastinal spaces. Two gaping holes were seen in the esophagus large enough to allow visualization through the anterior wall, into the mucosal surfaces, then through the posterior wall. Direct repair of the injury was not attempted. Extensive irrigation and debridement was performed. Drains were placed in the mediastinal space, which was then aggressively irrigated with antibiotic impregnated saline. A penrose drain was then placed in the neck. A feeding gastrostomy was placed, and she remained on broad-spectrum antibiotics. Drainage via her surgical drains progressively decreased and they were all removed by pod 20.
Remission Characteristics
Gastrograffin followed by thin barium esophagram per- formed on pod 30 showed complete closure of the esopha- geal perforation.
Treatment & Mechanisms
Clinical Treatment
Antibiotics, drainage, gastrostomy, irrigation and debridement
Non-Clinical Treatment
Soft diet