Esophageal ﬁstulas in the cervical region are usually difﬁcult to manage and carry a high morbidity. We report a case of an esophago-colonic ﬁstula after colonic interposition, successfully managed with vacuum-assisted closure ‘V.A.C. system’, (Kinetic Concepts Inc., San Antonio, TX, USA). The patient initially presented with purulent ﬂuid from the cervical wound 13 days after surgery. Esophagogram conﬁrmed a leak. Since the patient had a history of anastomotic leaks, a surgical interven- tion was not the treatment of choice. In light of this, conservative treatment with V.A.C. system was initiated. She under- went full recovery. INTRODUCTION CASE REPORT Colon interposition is a reliable esophageal replacement; colon Patient is a 51-year-old woman with past medical history of hypo- provides an extended conduit length, reliable blood supply and thyroidism. She was complaining of dyspepsia so an upper endos- low incidence of reﬂux . Anastomotic leak presents in copy was done, revealing a mass in the greater curvature of the 10–25% in the cervical region but mortality rate in this region is stomach, andabiopsywas taken. Pathologyshowedapoorly dif- low 4% . Leakage of cervical anastomosis defeats the primary ferentiated inﬁltrating adenocarcinoma with signet ring cells. A objective of esophageal reconstruction since the patient cannot total radical gastrectomy reconstructed with esophagojejunal eat. The etiology of anastomotic leaks is multifactorial includ- Roux-en-Y anastomosis was done. On the sixth postoperative ing systemic diseases, esophagus anatomy and operative fac- day, purulent drainage was seen on the abdominal drain. And, an tors . Management of cervical leaks may be treated with abscess was discovered at the level of the esophagojejunal anasto- drainage, daily bedside dressing, antibiotics, total parental mosis, surgery was required, the abscess was drained and a new nutrition  and surgical procedures. esophagojejunal anastomosis was done high in the chest with We present a case of an esophagocoloplasty anastomotic autosutures. The patient persisted with poor medical condition; leak successfully treated with V.A.C. system. so an esophagogram identiﬁed a leak at the level of esophageal Received: October 19, 2017. Accepted: December 16, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx256/4788812 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S.A. Endara et al. Figure 1: (A) Metal stent seen during thoracotomy. (B) Cervical ﬁstula seen during esophagogram. (C) Cervical ﬁstula seen during upper endoscopy. Figure 2: (A) Functional V.A.C. system in-patient. (B) Granulation tissue in the cervical wound. (C) Wound after therapy. anastomosis, and after failed endoscopic placement of two metal wound and placed over it. The adhesive drape was ﬁxed to the stents to solve the leak, patient persisted with sepsis. Redo oper- neck skin and continuous suction between 100 and 125 mmHg ation was performed and at thoracotomy an anastomotic leak, was installed (Fig. 2A). In the ﬁrst week, V.A.C. system drained with free purulent ﬂuid in the pleural cavity was found (Fig. 1A). about 50cc of saliva-like ﬂuid daily and was changed every 2 days, An exhaustive washing of the pleural cavity was performed, once granulation tissue had begun to form over the wound, the stents were removed, thoracic esophagectomy was done, a feed- system was changed every 5 days and no parafﬁngauze was used ing jejunostomy was made and a cervical esophagostomy was (Fig. 2B). All V.A.C. changes were done in the operating room and performed. Patient improved considerably after this, with during the ﬁrst week of V.A.C. treatment, patient received total adequate nutritional management through jejunostomy. She was parental nutrition, on the 10th day patient was able to ingest discharged, and 6 months later she was hospitalized again for liquids. Twelve days after initial use, the leak closed, since no ﬂuid intestinal transit restitution with an esophagocoloplasty with came out of the V.A.C. system, and after the patient resumed full interposition of the right colon via substernal route. normal diet, she was discharged home. On follow-up controls, the Esophagocoloplasty was done, and hand-sewn anastomoses patient was in good condition (Fig. 2C). were made between the esophagus and the colon, drains were left in the abdomen and neck. On the 10th postoperative day, an esophagogram was done DISCUSSION to assess the neck anastomosis, which did not show any leak- The etiology of esophageal anastomotic leaks is multifactorial age or stenosis, which is why sips of liquids were initiated, . Our patient had hypothyroidism and gastric cancer that attaining good oral tolerance, antibiotics were withdrawn, may have contributed to the development of anastomotic abdominal and cervical drains were removed and soft diet was leaks. The initial presence of ﬁstula was based on the clinical initiated. ﬁndings and veriﬁed with an esophagogram. On the 13th postoperative day, serous ﬂuid drained through The use of negative pressure wound therapy healing consists the neck and became purulent a day after. A new esophago- of a hydrophobic sponge, connected to a device that produces a gram was done and an esophago-colonic anastomosis leak was negative pressure over the wound . V.A.C. therapy is a unique discovered (Fig. 1B). An upper endoscopy was performed, local- wound management system speciﬁcally designed for wounds izing the ﬁstula of 12 × 6 mm (Supplementary Video & Fig. 1C). through the application of negative pressure . Since, it was Plastic surgery consultation was requested; management of ﬁrst described by Argenta in 1997 and introduced in USA, (V.A. the ﬁstula with V.A.C. was decided. C., KCI, San Antonio, TX) as a commercial product the number Partial opening of the cervical wound was done, and necrotic of indications for the V.A.C. system has steadily increased . tissue debridement with extensive irrigation of the wound with Applications of V.A.C. on a wound provide better infection saline and iodine over the cervical esophagus was performed. control, faster wound healing, improved comfort of patients, After this to protect the esophago-colonic anastomosis from dir- decreased workload for the medical team and less need for an ect contact with the V.A.C. a small parafﬁn gauze dressing advanced reconstruction. V.A.C. therapy is a useful modality to (Lomatuell H, Parafﬁn Gauze Dressing) was placed over the cer- manage wounds in the head and neck . For these reasons, vical esophagus. The V.A.C. sponge was fashioned to ﬁt the Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx256/4788812 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Esophagocoloplasty ﬁstula successfully treated with vacuum-assisted closure 3 we attempted to treat an esophago-colonic ﬁstula in a patient Eur J Cardiothorac Surg 2008;34:432–7. doi:10.1016/j.ejcts.2008. with a past medical history of leaks. 04.008. discussion 437. The major advantages of the V.A.C. system are the no need 2. DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, of a nasogastric tube for decompression, no need of a nasoen- Mcgill JE, et al. Indications, surgical technique, and long- teric tube for feeding, the possibility to maintain oral diet and term functional results of colon interposition or bypass. Ann no need of frequent daily dressing changes . In our patient, Surg 1988;208460–474. therapy lasted 12 days; in other publications, the duration of 3. Turkyilmaz A, Eroglu A, Aydin Y, Tekinbas C, Muharrem Erol this treatment was similar, with a minimum of 6 days to a M, Karaoglanoglu N. The management of esophagogastric maximum of 18 days . anastomotic leak after esophagectomy for esophageal car- There are reports of V.A.C. in cervical leaks after gastric pull cinoma. Dis Esophagus 2009;22:119–26. up , however, after an extensive search we have not found 4. Lorentz T, Fok M, Wong J. Anastomotic leakage after resec- the use of V.A.C. in this kind of ﬁstula. tion and bypass for esophageal cancer: lessons learned from Complications following colon interposition may be difﬁcult to the past. World J Surg 1989;13:472–7. treat. Creative strategies are needed to salvage or help in wound 5. Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative healing when the anastomosis is compromised, we strongly sug- pressure wound therapy on wound healing. Curr Probl Surg gest applying V.A.C. therapy in esophago-colonic ﬁstulae. 2014;51:301–31. 6. Reiter M, Harreus U. Vacuum assisted closure in the man- agement of wound healing disorders in the head and neck: a SUPPLEMENTARY MATERIAL retrospective analysis of 23 cases. Am J Otolaryngol 2013;34: Supplementary material is available at the Journal of Surgical 411–5. Case Reports online. 7. Lambert KV, Hayes P, McCarthy M. Vacuum assisted closure: a review of development and current applications. Eur J Vasc Endovasc Surg 2005;29:219–26. CONFLICT OF INTEREST STATEMENT 8. Payne C, Edwards D. Application of the single use negative None declared. pressure wound therapy device (pico) on a heterogeneous group of surgical and traumatic wounds. Eplasty 2014;14:e20. 9. Schintler M, Maier A, Matzi V, Smolle-Jüttner FM. Vacuum REFERENCES assisted closure system in the management of cervical anas- 1. De Delva PE, Morse CR, Austen WG Jr, Gaissert HA, Lanuti M, tomotic leakage after gastric pull-up. Interact Cardiovasc Wain JC, et al. Surgical management of failed colon interposition. Thorac Surg 2004;3:92–4. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx256/4788812 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Journal of Surgical Case Reports – Oxford University Press
Published: Jan 1, 2018
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