Thyroidectomy is associated with low morbidity and mortality. Esophageal perforation following thyroidectomy has been reported only three times previously, with subsequent fistulization occurring in two of these cases. The authors present the first such case report in the English-speaking literature

Lee, Cortney Y.

Lee, James T.

Sloan, David A.

Ward, Nicholas D.

Journal of Surgical Case Reports

English

PubMed

N. D. Ward

C. Y. Lee

J. T. Lee

D. A. Sloan

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Esophageal fistula complicating thyroid lobectomy

University of Kentucky

University of KentuckyUKnowledgeSurgery Faculty Publications Surgery1-7-2015Esophageal Fistula Complicating ThyroidLobectomyNicholas D. WardUniversity of KentuckyCortney Y. LeeUniversity of Kentucky, cortney.lee@uky.eduJames T. LeeUniversity of Kentucky, james.lee@uky.eduDavid A. SloanUniversity of Kentucky, davidsloan@uky.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/surgery_facpubPart of the Surgery CommonsThis Article is brought to you for free and open access by the Surgery at UKnowledge. It has been accepted for inclusion in Surgery Faculty Publicationsby an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu.Repository CitationWard, Nicholas D.; Lee, Cortney Y.; Lee, James T.; and Sloan, David A., "Esophageal Fistula Complicating Thyroid Lobectomy"(2015). Surgery Faculty Publications. 19.https://uknowledge.uky.edu/surgery_facpub/19Esophageal Fistula Complicating Thyroid LobectomyNotes/Citation InformationPublished in The Journal of Surgical Case Reports, v. 2015, no. 1, p. 1-3.Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. Thisis an Open Access article distributed under the terms of the Creative Commons Attribution Non-CommercialLicense (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 commercialre-use, please contact journals.permissions@oup.comDigital Object Identifier (DOI)http://dx.doi.org/10.1093/jscr/rju136This article is available at UKnowledge: https://uknowledge.uky.edu/surgery_facpub/19CAS E R E PORTEsophageal fistula complicating thyroid lobectomyNicholas D. Ward1, Cortney Y. Lee2, James T. Lee3, and David A. Sloan2,*1Graduate Medical Education, General Surgery Residency Program, University of Kentucky, Lexington, KY, USA,2Department of Surgery, Section of Endocrine Surgery, University of Kentucky, Lexington, KY, USA, and3Department of Radiology, University of Kentucky, Lexington, KY, USA*Correspondence address. Division of General Surgery, Section of Endocrine Surgery, University of Kentucky College of Medicine, UK Good SamaritanHospital, 125 East Maxwell Street, Suite 302, Lexington, KY 40508, USA. Tel: +1-859-218-2782; Fax: +1-859-257-0511; E-mail: dasloa0@uky.eduAbstractThyroidectomy is associated with low morbidity and mortality. Esophageal perforation following thyroidectomy has beenreported only three times previously, with subsequent fistulization occurring in two of these cases. The authors present the firstsuch case report in the English-speaking literature.INTRODUCTIONEsophageal perforation is associated with high morbidity andmortality, varying from 5 to 31% [1]. Perforation of the cervicalesophagus is most commonly a complication of endoesophagealprocedures or intubation [2, 3], but can also result from injuryduring operations directly involving or in close proximity to theesophagus. The development of esophago-cutaneous fistulahas been reported secondary to esophageal perforation [4], fol-lowing penetrating trauma and esophagectomy and as a conse-quence of anastomotic leak. Esophageal perforation duringthyroid surgery has only been reported three times in the litera-ture, with subsequent fistulization occurring only twice [5–7].CASE REPORTA 56-year-old femalewas noted to have a solitary left thyroid nod-ule, discovered incidentally on CT scan following neck trauma.The patient’s past medical history was significant for hyperten-sion, hyperlipidemia, gastroesophageal reflux and depression.The patient reported no symptoms of dysphagia, history of neckirradiation or symptoms of thyroid dysfunction and denied familyhistory of thyroid disease, including thyroid cancer. Neck ultra-sound demonstrated a dominant, heterogeneous, 2.9-cm solidnodule with microcalcifications. Ultrasound-guided, fine-needleaspiration cytology revealed a follicular lesion of undeterminedsignificance. The patient was referred to a local general surgeonand underwent left thyroid lobectomy. According to the opera-tive report, the recurrent laryngeal nerve was identified and pre-served throughout its course. The patient tolerated the procedurewell and was noted to have normal speech following theoperation.The original thyroid lobectomy operation was performed by ageneral surgeon who typically performs half-dozen thyroidec-tomies a year at a rural hospital. The surgeon described the ori-ginal operation as ‘uneventful’ in a letter accompanying thepatient, and a detailed review of the operative report by theauthors reveals no mention of any inflammatory reaction or fi-brosis surrounding the tumor. The original pathology report de-scribes a well-differentiated papillary thyroid carcinoma3.0 × 2.5 × 1.5 cm (Staging classification T2 N0 M0). There was nolymphatic or vascular invasion (V0). There was no extra capsularextension and margins were negative (R0). A normal parathyroidgland was identified, but no lymph nodes were seen.On the third postoperative day, however, the patient returnedto the surgeon’s officewith complaints of neck pain and swelling.A CT scan of the neck performed at that time revealed a 7.7 × 3.7cm fluid collection in the left neck (Fig. 1). The patient was takenemergently to the operating room, where upon opening the inci-sion a large amount of purulent fluid was evacuated. Therewas aReceived: October 10, 2014. Revised: November 19, 2014. Accepted: November 22, 2014Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.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 journals.permissions@oup.comJournal of Surgical Case Reports, 2015 , 1–3doi: 10.1093/jscr/rju136Case Report1;1 thick, yellowish exudate adherent to the involved surfaces, andthe strapmuscleswere noted to be thickened, stiff and friable. In-spection of the esophagus revealed no obvious injury, but sur-rounding tissues were noted to be discolored and inflamed,making visualization of the esophagus difficult. The recurrent la-ryngeal nerve, which had been identified during the initial oper-ation, was not seen.To better characterize the nature of the injury, thewoundwasfilled with sterile water, and air was instilled into the esophagusvia placement of an orogastric tube. Air was then seen bubblinginto the wound. Indigo carmine diluted in water was instilledinto the esophagus, whereupon blue-tinged fluid was seen leak-ing into the wound from an upper esophageal defect. A 3.0 silksuture was placed in the area of the defect, and the repair but-tressed with omohyoid muscle. The strap muscles were closedin the midline, and two Jackson–Pratt drains were placed forwide drainage.The patient soon demonstrated a recurrent esophageal leak(Fig. 2), which was managed by maintaining the patient nil peros, providing nutrition via a feeding tube, and applying negativepressure to the wound. The esophageal leak gradually resolved,as evidenced by multiple contrast esophagrams, permitting re-moval of the patient’s drains. Prior to discharge from the hos-pital, barium esophagram showed no evidence of contrastextravasation.Pathology demonstrated a 3-cm, well-differentiated papillarythyroid carcinomawithnegativemargins andno lymphatic or vas-cular invasion (T2, N0, M0, R0 and V0). The patient was referred toan experienced endocrine surgeon at a tertiary care institution forcompletion thyroidectomy; that surgeonperforms∼250 thyroidec-tomies per year. Upon evaluation, the patient complained ofhoarseness and dysphagia, most pronounced with liquids, andflexible laryngoscopy revealed a fixed and paramedian left truevocal cord. Thyroid ultrasound showed multiple sub-centimeternodules of the remaining thyroid, diffuse heterogeneity and noevidence of suspicious cervical lymphadenopathy.Uncomplicated completion thyroidectomy was performed∼11 months after the patient’s initial operation. Prior to comple-tion thyroidectomy, the patient’s voice quality had improvedconsiderably, but nasolaryngoscopy again showed a fixed para-median left vocal cord. Final pathology revealed no evidence ofmalignancy, and the patient was subsequently referred for adju-vant radioactive iodine therapy.DISCUSSIONIn experienced hands, thyroidectomy is a safe procedure asso-ciatedwith low complication rates. Themost common complica-tions include recurrent laryngeal nerve injury, neck hematomaand hypoparathyroidism. Numerous large retrospective studieshave examined the incidence of postoperative complications fol-lowing thyroidectomy, with definitive morbidity rates rangingfrom 2.8 to 16.4% [8–10]. Thyroid cancer operations are consist-ently associated with higher complication rates than operationsperformed for benign disease.While esophageal perforationmayoccur spontaneously,most studies implicate iatrogenic causes inthe majority of cases [2, 4]. Other causes include blunt and pene-trating trauma, Boerhaave syndrome, malignancy and inadvert-ent injury during surgery [4]. Esophageal perforations havebeen reported in association with pneumonectomy, vagotomy,hiatal hernia repair, cervical spine operations and atrial surgery.The clinical spectrum of esophageal perforation is broad.Commonly presenting signs and symptoms include chest pain,dysphagia, dyspnea, subcutaneous emphysema and epigastricpain [3]. In the setting of recent endoscopy or surgery, these clin-ical manifestations should raise suspicion for esophageal perfor-ation. Because of variability in clinical presentation, however,early diagnosis is often difficult, whichmay lead to treatment de-lays. Chest and neck radiographs should be obtained immediate-ly, and in thosepatientswhoseclinical presentationand radiographyare suggestive of esophageal perforation, CT or water-soluble con-trast esophagram should be performed for definitive diagnosis [3].Traditionally, esophageal perforations have been managedoperatively [1], depending on the location and nature of the in-jury. Conservative management, which includes bowel rest,Figure 1: Axial CT image of the neck without oral or intravenous contrastdemonstrates an air fluid collection in the left thyroid lobectomy bed (whitearrows). Subcutaneous emphysema and a large anterior neck air fluid collection(asterisks) are also present. T, residual right lobe of the thyroid.Figure 2: Axial CT image of the neck after fluoroscopy barium swallowdemonstrates contrast pooling in the lobectomy bed with a fistulous connectionto the esophagus (white arrow; image shown using a ‘bone window’ to clearlyoutline the barium contrast).2 | Esophageal fistula complicating thyroid lobectomynasogastric tube placement and broad-spectrum antibiotics, hasbeen described for select patients with well-contained perfora-tions,minimal contamination andnounderlyingmalignancy, ob-struction or sepsis. The role of conservativemanagement is limited,however, sincemost esophageal perforations are not self-containedand therefore require operative intervention [2]. Traditional teachingemphasizes the importance of intervention within 24 h of perfor-ation, and a recent review found a near doubling of mortalitywhen treatment is delayed by more than 24 h [3]. Prompt diagnosisand intervention continue to be of critical importance.Esophageal perforation is a life-threatening complicationwith a high mortality rate, and must be promptly diagnosedand appropriately managed to prevent further complicationsand death.CONFLICT OF INTEREST STATEMENTNone declared.REFERENCES1. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P,Hopt UT. Nonoperative treatment of 15 benign esophagealperforations with self-expandable covered metal stents.Ann Thorac Surg 2006;81:467–72.2. Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation:emphasis on management. Ann Thorac Surg 1996;61:1447–51.3. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR,Kucharczuk JC. Evolving options in the management ofesophageal perforation. Ann Thorac Surg 2004;77:1475–83.4. Hardy JD, Tompkins WC, Ching EC, Chavez CM.Esophageal perforations and fistulas: review of 36 caseswith operative closure of four chronic fistulas. Ann Surg1973;177:788–97.5. Ozer MT, Demirbas S, Harlak A, Ersoz N, Eryilmaz M,Cetiner S. A rare complication after thyroidectomy: perfor-ation of the oesophagus: a case report.Acta Chir Belg 2009;109:527–30.6. Conzo G, Stanzione F, Della Pietra C, Palazzo A, Candilio G,Fiorelli A, et al. Tracheal necrosis, oesophageal fistula: un-usual complications of thyroidectomy. Report of two casesand literature review. Ann Ital Chir 2012;83:259–64.7. Akbulut G, Gunay S, Arena A, Bilge O. A rare complicationafter thyroidectomy: oesophageal perforation. Ulusal TravmaDergisi 2002;8:250–52.8. Rosato L, AveniaN, Bernante P, De PalmaM,GulinoG,Nasi PG,et al. Complications of thyroid surgery: analysis of a multi-centric study on 14,934 patients operated on in Italy over 5years. World J Surg 2004;28:271–6.9. Kandil E, Noureldine SI, Abbas A, Tufano RP. The impact ofsurgical volume on patient outcomes following thyroid sur-gery. Surgery 2013;154:1346–52.10. Hauch A, Al-Qurayshi Z, Randolph G, Kandil E. Total thyroi-dectomy is associated with increased risk of complicationsfor low- and high-volume surgeons. Ann Surg Oncol 2014;21:3844–52.N.D. Ward et al. | 3

Esophageal Fistula Complicating Thyroid Lobectomy

Esophageal Fistula Complicating Thyroid Lobectomy

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