Postoperative pharyngocutaneous fistula: treated by sternocleidomastoid flap repair and cricopharyngeus myotomy

Abstract

Introduction: Pharyngoesophagocutaneous fistula (PEF) is one of the rare but serious complications of antero-lateral approach to cervical spine surgery. Because of its rarity, the true incidence of PEF is not clear. But, retrospective analysis of large series of cervical spine surgery reports 0-1.62 % incidence (Cloward in Surg 69:175-182, 1971; Elerkay et al. in J Neurosurg Spine 90(Suppl 1):35-41, 1999). Proximity to the vertebral column and thin walls makes the upper digestive tract vulnerable to injury in cervical trauma, surgical or nonsurgical. Presentation in early postoperative period is not rare and carries high morbidity and mortality (Jones and Ginsberg in Ann Thorac Surg 53(3):534-543, 1992). Various procedures for these fistulae such as simple closure, muscle flap interposition, esophageal diversion and jejunal interposition are reported. Some authors also advise removal of prosthetic plates and posterior stabilization, besides the repair of fistulae in a staged manner (Orlando et al. in Spine 28(15):E290-E295, 2003).

Methods: Two similar cases of pharyngeal fistulae with similar etiology and clinical scenario are presented here, which were managed successfully with initial control of sepsis followed by delayed definitive repair with sternocleidomastoid muscle flap interposition and cricopharyngeus myotomy without removal of prosthetic plates.

Results: Postoperatively, both patients showed no evidence of any wound complications or collections until the seventh day. A contrast swallow study on seventh day showed no leak following which soft diet was started. Both patients were not having any difficulty in swallowing or aspiration. On 1-year follow-up, both patients were having no difficulty in swallowing, no episodes of aspiration and no recurrence of fistula.

Conclusion: This case series highlights the importance of cricopharyngeus myotomy for treating PEF and the improved results with the prosthesis kept undisturbed.

Fig. 1

a MRI image shows fracture of C3–C4 vertebra. b Plain X-ray lateral view of neck showing the prosthetic plates at C3–C4 level. c Cervical fistula opening through the previous surgical scar

Fig. 2

Barium swallow showing contrast filling the esophagus but no contrast leak in the neck

Fig. 3

a Intra-operative picture showing pharyngeal wall defect near the prosthetic plate fixation (case 1). b Intra-operative picture showing pharyngeal wall defect (case 2)

Fig. 4

a Intra-operative picture showing closed defect, exposed prosthesis and posterior wall of laryngo-pharynx. b Intra-operative picture showing completed cricopharyngeus myotomy

Fig. 5

a Intra-operative picture showing mobilized sternocleidomastoid muscle flap. b Intra-operative picture showing sternocleidomastoid muscle flap covering the prosthetic plates