An Atypical Case of Melena Caused by Esophageal Perforation

Abstract

Introduction: Anterior cervical spine surgery (ACSS) is a widely accepted surgical approach by both orthopedic and neurosurgeons for many common conditions like degenerative disk disease, spondylosis, trauma, vertebral body collapse secondary to metastatic disease, osteomyelitis, discitis, or disc herniation. One rare complication of ACCS is esophageal damage or perforation. We present a case of esophageal perforation years after ACCS that presented as melena. A 54-year-old female with past medical history significant for motor vehicle accident causing small bowel perforation requiring small bowel transplantation 1 year ago, ACCS at the C6-C7 level 1.5 years ago who was admitted with concerns of three days of black, tarry stools and found to be anemic with Hgb of 6.0. On admission, patient denied hematochezia, dysphagia, regurgitation, odynophagia, chest pain, shortness of breath, pleuritic pain, shoulder or arm pain. Patient underwent an EGD that showed erosions around a fixed, metal foreign body at 20cm from incisors determined to be cervical plate from her cervical hardware. No other site of bleeding was identified during endoscopy. Patient was evaluated immediately by ENT, plastic surgery, neurosurgery and orthopedic teams. After consultation, evaluation and discussion between all the surgical and primary teams, patient first underwent repair and reconstruction of the esophageal wall (pharyngoplasty and cricopharyngeal myotomy and flap reconstruction of the pharynx) followed by removal of anterior cervical plate, screws and DePuy Skyline system. Patient had a complicated postop course with multiple wound infections and required a 2 month hospitalization stay. The incidence of esophageal injuries after ACSS is noted to be between 0 and 3.4%, mostly with injury noted intraopeartively in 77% of cases, known as early injuries. Early injuries are usually iatrogenic. Delayed cases typically manifest years after surgery and are due to chronic compression, dislocation, or migration of the bone graft. As in our patient’s case, the typical area susceptible for esophageal perforation is at the level of C5-6, known as the Killian triangle. Late presentations of esophageal perforation may present as odynophagia, hoarseness, aspiration, wound infection, neck swelling after drinking water, unexplained tachycardia and blood in the nasogastric. We present an unusual presentation of melena caused by esophageal perforation. It is important to keep this rare complication in differential when managing a patient with history of ACCS as imaging to evaluate for pneumomediastinum should be obtained first if there is high clinical suspicion.