Diagnosis and treatment of pharyngostoma and esophagostoma after anterior cervical spine surgery

Abstract

Objective To investigate the diagnosis, treatment and prevention strategies of pharyngostoma and esophagostoma caused by anterior cervical spine surgery. Methods A retrospective analysis were performed in 17 cases of anterior cervical operation complicated with pharyngeal and esophageal fistula from 1999 March to 2010 June, including 11 male cases and 6 female cases, aged from 7 to 67 years with the mean age of 44.23 years. 16 cases (94%) got inflammation of anterior cervical surgery incision and throat pain. 2 cases (11%) accompanied by high fever, whose body temperature was as high as 39.2° and incision particles or liquid flew after eating. 17 cases underwent upper gastrointestinal radiography, and regular oral methylene blue. Barium overflew from fistula in 2 cases (11%) after upper gastrointestinal tract barium meal angiography, while methylene blue overflew from incision in 7 cases (41%) after oral methylene blue. Through X-ray examination, gas fistula before vertebral was visible in 14 cases (82%). A diagnosis can be made by outflow through fistula after barium esophagography or oral administration of methylene blue. For unknown but highly suspected pharyngeal and esophageal injury, operation can be confirmed if no improvement of symptoms was found after fasting, nasogastric or parenteral nutrition, and ant-infection treatment for 1 week. Results All of 17 patients underwent surgical treatment. During operation, fistula dot or small irregular shape can be seen in 8 cases; long stripe in 3 cases; boundary not clear or irregular in 2 cases; adhesion around the fistula of anterior cervical fascia, similar to tear in 1 case; two fistula in 1 case; fistula located in pharynx posterior wall or esophageal which was not clear or fistula of unknown reason in 2 cases (fascia might be not at the same side of incision or fascia was small and already closed). Pharynx posterior wall and esophageal fistula was found in 3 cases during surgical exploration, which was immediate sutured and placed with drainage tube. After 7 to 14 days, if flow was less than 30 ml, and no bacterial growth was found in 3 consecutive drainage fluids, we pull out the tube. Patients who underwent nasal feeding for 2 to 3 weeks, and then took liquid diets complained nothing, and cured after 1 month. 12 cases underwent debridement, stitching fistula, irrigation and drainage tube placement instantly. The wash pipe was removed after 12 to 21 days and 3 consecutive drainage fluids showed no bacterial growth. Then 2 to 3 days later the drainage pipe was pull out. Two to three months later these patients healed. 2 cases firstly underwent debridement and suture or part suture, and then the incision was opened and filled with nitrofurazonium gauze tamponade. Gradually pull out the filling gauze and change the dressing of wound. If the residual cavity was large or the drainage was pus, flush the wound with physiological saline once a day, then three times a week, and finally once a week. These patients healed after 6 to 12 months. Pharyngostoma or esophagostoma of all patients was found timely, and active surgical treatment was performed, so no obvious complications was found postoperatively. All 17 patients recovered and resumed diet after 1 to 12 months postoperatively. Conclusion Pharyngeal and esophageal fistula is a rare but severe complication after anterior cervical surgery, which seriously affect the effect of operation and even lead to death. Early diagnosis and active intervention can obtain satisfactory curative effect. Key words: Cervical vertebrae; Decompression, surgical; Spinal fusion; Postoperative complications; Esophageal fistula