P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair

Abstract

Abstract Background Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management. Methods A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube. Results The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation. Conclusions Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract. Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.