Auris Nasus Larynx 42 (2015) 254–257
Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Negative pressure wound therapy for cervical esophageal perforation with abscess Byung-Woo Yoon a, Keun-Ik Yi a, Ji-Hun Kang a, Soon Gu Kim a, Wonjae Cha
a,b,
*
a
Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Hospital, Busan, Republic of Korea b Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 June 2014 Accepted 19 November 2014 Available online 12 December 2014
Perforation of the cervical esophagus is a rare but life-threatening condition. Cervical esophageal perforation with abscess formation can be usually treated with conservative treatments of simple drainage and antibiotics. Aggressive surgical treatments are considered if conservative treatments fail. But the aggressive treatments have low success rate and high morbidity in cervical esophageal perforation. Negative pressure wound therapy (NPWT) was widely used in various complicated wounds, such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps since it had been introduced in 1997. NPWT is known to be a valuable tool in the management of various complicated wounds. In this report, we described a case of intractable cervical esophageal perforation with abscess, which was successfully treated with NPWT after the failure of conservative management. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cervical esophageal perforation Neck Abscess Negative pressure wound therapy
1. Introduction Perforation of the cervical esophagus is an uncommon but lifethreatening condition because of the rapid spreading inflammation around esophagus and the possibility of mediastinitis or mediastinal abscess. The most common cause of esophageal perforation is instrumentation. But in cervical esophageal perforation, foreign bodies account for 80% [1]. Cervical esophageal perforation with abscess formation can be usually treated with simple drainage [2]. When conservative treatments of drainage, antibiotics and nutritional support fail in cervical esophageal perforation, individualized treatments such as primary repair, reinforced repair, debridement, esophageal resection and esophago-gastro-anastomosis could be considered. But the aggressive treatments mentioned above have low success rate and high morbidity [3]. Negative pressure wound therapy (NPWT) was widely used in various complicated wounds, such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps since it had been introduced in 1997 [4,5]. And NPWT is
* Corresponding author at: Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan 602-739, Republic of Korea. Tel.: +82 51 240 7336; fax: +82 51 246 8668. E-mail address: [email protected] (W. Cha). http://dx.doi.org/10.1016/j.anl.2014.11.003 0385-8146/ß 2014 Elsevier Ireland Ltd. All rights reserved.
known to be a valuable tool in the management of complicated head and neck wounds [6]. Herein, we report a case of intractable cervical esophageal perforation with retropharyngeal abscess, which was successfully treated with NPWT after the failure of conservative managements.
2. Case report A 69-year old male patient visited to our emergency center with the symptoms of foreign body sensation and painful neck. He had recent travel history to China and ate a steamed fish 7 days before admission. At that time, he visited a district hospital in China but nothing could be detected in laryngoscopic exam. And he felt hoarseness and halitosis 2 days before admission. He had no previous medical history of diabetes mellitus, hypertension and liver disease. Initial work-up revealed that white blood cell count, C-reactive protein concentration and erythrocyte sedimentation rate were 17,080/ml, 23.51 mg/dl and 79. Indirect laryngoscopic exam showed left vocal fold palsy with paramedian position and bulging of posterior pharyngeal wall (Fig. 1A and B). Computed tomography revealed a 3 cm foreign body with bone density penetrating the posterior wall of the upper esophagus and abscess formation in retropharyngeal space (Fig. 1C and D). The emergency operation was planned on the diagnosis of esophageal perforation with retropharyngeal abscess due to foreign body.
B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
255
Fig. 1. Fiberscopic examination showing left vocal fold palsy with paramedian position and bulging of posterior pharyngeal wall (A: abduction; B: adduction). Computed tomography revealed a 3 cm foreign body with bone density penetrating the posterior wall of the upper esophagus and abscess formation in retropharyngeal space (C, D, white arrows: foreign body suspected as a fish bone).
The operation was performed under general anesthesia. The transverse incision was made between inferior border of cricoid cartilage and left posterior margin of sternocleidomastoid muscle. The retropharyngeal abscess pocket was approached between the carotid sheath and cricotracheal complex. The abscess was drained with greenish color and foul odor. The pus was cultured and saline irrigation followed in the wound. The 3 cm long fish bone penetrating cervical esophagus was found and removed completely (Fig. 2A and B). The tissue around the perforated esophagus was fragile and inflammatory. But primary closure of the perforation site was performed and a Jack-Pratt drain was inserted.
At postoperative day (POD) 2, vital sign was stable and the symptoms of dysphagia and odynophagia were subsided but hoarseness was not resolved. In postoperative laryngoscopic exam, left vocal fold palsy remained. Tube feeding started and ampicillinsulbactam and metronidazole were empirically administered. At POD 7, all laboratory results returned to normal. But the accumulation of saliva in closed drain continued. At POD 14, esophagography and follow-up CT showed that the fish bone was completely removed but esophageal fistula was not closed. We decided to treat the remained esophageal fistula with conservative management of a closed drain and broad-spectrum antibiotics as possible because there was no evidence of infection sign and
Fig. 2. A 3 cm-sized fish bone penetrating cervical esophagus was found and removed (A, B, black arrow: fish bone) and V.A.C.1 GranufoamTM dressing (Kinetic Concepts, Inc., San Antonio, TX, USA) was applied. (C) The V.A.C. dressing was connected to the vacuum pump and negative pressure ranged from 70 to 100 mm Hg.
256
B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
progression to mediastinitis. At POD 30, esophageal fistula was still open in radiologic studies and saliva drained. We explained the situation to the patient and recommended surgical exploration such as primary closure or end-to-end anastomosis to prevent possible complications. But he refused aggressive surgical treatments. Thus, we alternatively tried to use negative pressure wound therapy for the intractable esophageal fistula. Under general anesthesia, the wound was re-opened and V.A.C.1 GranufoamTM dressing (Kinetic Concepts, Inc., San Antonio, TX, USA) was applied (Fig. 2C). The V.A.C. dressing was connected to the vacuum pump and negative pressure ranged from 70 to 100 mm Hg. The dressings were changed every 3 or 4 days with saline irrigation under local anesthesia. At POD 46, esophagography showed that there was no saliva leakage in the fistula site but esophageal diverticulum was detected in the cricoid level (Fig. 3). Oral diet followed and no food material was detected in the vacuum pump. The hospital course was uneventful and he did not complain the symptoms related to esophageal diverticulum. At POD 55, he was discharged but the left vocal fold paralysis remained. Left vocal fold palsy completely recovered after 3 months and he had no difficulty of swallowing at 6 months after discharge.
3. Discussion There are numerous causes of esophageal perforation. The most frequently reported cause of esophageal perforation is iatrogenic and instrumental injury accounts for most perforations [7]. Especially, foreign body is the most frequent cause of cervical esophageal perforation because of the custom of eating fish and poultry in Asian population [2].
Fig. 3. At postoperative day 46, esophagography showed that there was no saliva leakage in the fistula site but esophageal diverticulum was detected in the cricoid level.
The treatment of esophageal perforation is different according to status of the patient, the cause, the location and the timing of perforation. Generally, the strategies are divided to non-operative and operative treatment [8]. Cervical esophageal perforation has relatively low mortality and more easily treated than intra-thoracic or intra-abdominal perforation (5.9% versus 10.9% and 13.2%) [2,9]. Nevertheless, the treatment for cervical esophageal perforation is still a challenge and the guideline for treating this condition has not been established because of its rarity. Jiang et al. reported the experience of 42 patients of cervical esophageal perforation and they concluded that most of the cases can be treated conservatively or by drainage alone. If the foreign bodies of the esophagus could not be extracted using endoscope, surgical treatments including removal of the foreign bodies, primary repair, and drainage should be performed [2]. When conservative treatments of drainage, broadspectrum antibiotics and nutritional support are unsuccessful, individualized operative treatments such as primary repair, reinforced repair, esophageal resection and esophago-gastroanastomosis may be considered [3,9]. But the aggressive treatments mentioned above have low success rate and high morbidity [3,8]. Negative pressure wound therapy (NPWT) was firstly introduced to manage complicated surgical or non-surgical wounds by Argenta and Morykwas. It entails placing an open-cell foam dressing into the wound cavity and applying a controlled subatmospheric pressure. The optimal pressure of device was recommended at 125 mm Hg below ambient pressure [5]. The four primary mechanisms of action have been proposed as wound shrinkage or macrodeformation, microdeformation at the foamwound surface interface, fluid removal and stabilization of the wound environment [10]. There are also several secondary effects likely involved in mechanotransduction pathways that alter the biology of wound healing including angiogenesis, neurogenesis, granulation tissue formation, cellular proliferation, differentiation, and migration [11]. The common clinical value of optimal NPWT pressure has been known as 125 mm Hg based on the pioneering work of Argenta and Morykwas [5]. Various complicated wounds such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps could be treated using NPWT [4]. Also, in the field of head and neck surgery, NPWT has been used for large skin defect, necrotizing fasciitis, pharyngo-cutaneous fistula, stoma dehiscence, osteo-radionecrosis of mandible, chyle fistula, flap failure and lymphangioma [6]. In this case, the patient visited our hospital 7 days after eating a fishbone. The size of abscess pocket was large and the anaerobic infection was strongly suspected on CT scan because of the gas around the abscess. Thus, open approach for immediate drainage was needed rather than endoscopic approach. Intraoperatively, the fishbone was found and the ruptured esophagus was detected. And primary closure was tried but failed because the tissue of esophagus was severely infected and fragile. A Jack-Pratt drain was inserted and empirical broad-spectrum antibiotics were administered for infection control. But, after two weeks, esophagography showed that the perforation was not closed and the retropharyngeal space was filled with dye. The simple drainage was thought to be insufficient due to high possibility of mediastinitis or mediastinal abscess. Because the fistula was not completely closed after conservative managements, the further managements were needed. The site of fistula was post-cricoid or upper esophageal sphincter portion of esophagus. The primary closure was initially considered. But the possibility of reperforation was very high due to fragile infected tissue and the patient refused reoperation. Also, recurrent laryngeal nerve injury might be at risk because of anatomical site of the lesion. The other aggressive procedures such as esophageal resection and esophagogastro-anastomosis were not considered due to high morbidity
B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
and mortality. We initially applied the system to the esophageal perforation wound at the recommended pressure of 125 mm Hg. But the patient could not tolerate the pressure of 125 mm Hg due to severe pain in his neck. Because the form was inserted between esophagus and carotid sheath, the high pressure provoking severe pain could be dangerous. To maintain the system without intolerable pain, the pressure was modified to the lower level of 70–100 mm Hg than the pressure for common clinical situations. The perforation was successfully treated and the oral diet started without leakage 16 days after NPWT. Cervical esophageal perforation with abscess formation can be usually treated with the conservative management of simple drainage and antibiotics [2]. The adjuvant use of NPWT in cervical wounds was well described in many literatures [6]. But to the best of our knowledge, this technique has not been described in the management of cervical esophageal perforation intractable to conservative management. When the closure of the perforation is intractable or delayed similar to our case, it is suggested that NPWT might be an alternative or adjunctive tool for the treatment of cervical esophageal perforation with abscess formation. But if carotid sheath would be exposed and the foam might be in direct contact to the carotid artery, the use of NPWT should be contraindicated. 4. Conclusion NPWT might be an efficient and safe adjunct to treat cervical esophageal perforation with abscess formation when conservative managements fail. Also it could be considered as a bridging procedure before aggressive surgical treatment. Financial disclosure No financial and material support for this work.
257
Conflict of interest No potential conflict of interest relevant to this article was reported. Acknowledgement None. References [1] Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475–83. [2] Jiang J, Yu T, Zhang YF, Li JY, Yang L. Treatment of cervical esophageal perforation caused by foreign bodies. Dis Esophagus 2012;25:590–4. [3] Peng A, Li Y, Xiao Z, Wu W. Study of clinical treatment of esophageal foreign body-induced esophageal perforation with lethal complications. Eur Arch Otorhinolaryngol 2012;269:2027–36. [4] Desai KK, Hahn E, Pulikkottil B, Lee E. Negative pressure wound therapy: an algorithm. Clin Plast Surg 2012;39:311–24. [5] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563–76 [discussion 577]. [6] Andrews BT, Smith RB, Goldstein DP, Funk GF. Management of complicated head and neck wounds with vacuum-assisted closure system. Head Neck 2006;28:974–81. [7] Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Luketich JD, et al. Contemporaneous management of esophageal perforation. Surgery 2009;146:749–55 [discussion 755–6]. [8] Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJ, Molnar JA, David LR. Vacuum-assisted closure: state of clinic art. Plast Reconstr Surg 2006;117:127S–42S. [9] Biancari F, D’Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, et al. Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013;37:1051–9. [10] Orgill DP, Manders EK, Sumpio BE, Lee RC, Attinger CE, Gurtner GC, et al. The mechanisms of action of vacuum assisted closure: more to learn. Surgery 2009;146:40–51. [11] Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg 2014;51:301–31.
Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Negative pressure wound therapy for cervical esophageal perforation with abscess Byung-Woo Yoon a, Keun-Ik Yi a, Ji-Hun Kang a, Soon Gu Kim a, Wonjae Cha
a,b,
*
a
Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Hospital, Busan, Republic of Korea b Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 June 2014 Accepted 19 November 2014 Available online 12 December 2014
Perforation of the cervical esophagus is a rare but life-threatening condition. Cervical esophageal perforation with abscess formation can be usually treated with conservative treatments of simple drainage and antibiotics. Aggressive surgical treatments are considered if conservative treatments fail. But the aggressive treatments have low success rate and high morbidity in cervical esophageal perforation. Negative pressure wound therapy (NPWT) was widely used in various complicated wounds, such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps since it had been introduced in 1997. NPWT is known to be a valuable tool in the management of various complicated wounds. In this report, we described a case of intractable cervical esophageal perforation with abscess, which was successfully treated with NPWT after the failure of conservative management. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cervical esophageal perforation Neck Abscess Negative pressure wound therapy
1. Introduction Perforation of the cervical esophagus is an uncommon but lifethreatening condition because of the rapid spreading inflammation around esophagus and the possibility of mediastinitis or mediastinal abscess. The most common cause of esophageal perforation is instrumentation. But in cervical esophageal perforation, foreign bodies account for 80% [1]. Cervical esophageal perforation with abscess formation can be usually treated with simple drainage [2]. When conservative treatments of drainage, antibiotics and nutritional support fail in cervical esophageal perforation, individualized treatments such as primary repair, reinforced repair, debridement, esophageal resection and esophago-gastro-anastomosis could be considered. But the aggressive treatments mentioned above have low success rate and high morbidity [3]. Negative pressure wound therapy (NPWT) was widely used in various complicated wounds, such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps since it had been introduced in 1997 [4,5]. And NPWT is
* Corresponding author at: Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan 602-739, Republic of Korea. Tel.: +82 51 240 7336; fax: +82 51 246 8668. E-mail address: [email protected] (W. Cha). http://dx.doi.org/10.1016/j.anl.2014.11.003 0385-8146/ß 2014 Elsevier Ireland Ltd. All rights reserved.
known to be a valuable tool in the management of complicated head and neck wounds [6]. Herein, we report a case of intractable cervical esophageal perforation with retropharyngeal abscess, which was successfully treated with NPWT after the failure of conservative managements.
2. Case report A 69-year old male patient visited to our emergency center with the symptoms of foreign body sensation and painful neck. He had recent travel history to China and ate a steamed fish 7 days before admission. At that time, he visited a district hospital in China but nothing could be detected in laryngoscopic exam. And he felt hoarseness and halitosis 2 days before admission. He had no previous medical history of diabetes mellitus, hypertension and liver disease. Initial work-up revealed that white blood cell count, C-reactive protein concentration and erythrocyte sedimentation rate were 17,080/ml, 23.51 mg/dl and 79. Indirect laryngoscopic exam showed left vocal fold palsy with paramedian position and bulging of posterior pharyngeal wall (Fig. 1A and B). Computed tomography revealed a 3 cm foreign body with bone density penetrating the posterior wall of the upper esophagus and abscess formation in retropharyngeal space (Fig. 1C and D). The emergency operation was planned on the diagnosis of esophageal perforation with retropharyngeal abscess due to foreign body.
B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
255
Fig. 1. Fiberscopic examination showing left vocal fold palsy with paramedian position and bulging of posterior pharyngeal wall (A: abduction; B: adduction). Computed tomography revealed a 3 cm foreign body with bone density penetrating the posterior wall of the upper esophagus and abscess formation in retropharyngeal space (C, D, white arrows: foreign body suspected as a fish bone).
The operation was performed under general anesthesia. The transverse incision was made between inferior border of cricoid cartilage and left posterior margin of sternocleidomastoid muscle. The retropharyngeal abscess pocket was approached between the carotid sheath and cricotracheal complex. The abscess was drained with greenish color and foul odor. The pus was cultured and saline irrigation followed in the wound. The 3 cm long fish bone penetrating cervical esophagus was found and removed completely (Fig. 2A and B). The tissue around the perforated esophagus was fragile and inflammatory. But primary closure of the perforation site was performed and a Jack-Pratt drain was inserted.
At postoperative day (POD) 2, vital sign was stable and the symptoms of dysphagia and odynophagia were subsided but hoarseness was not resolved. In postoperative laryngoscopic exam, left vocal fold palsy remained. Tube feeding started and ampicillinsulbactam and metronidazole were empirically administered. At POD 7, all laboratory results returned to normal. But the accumulation of saliva in closed drain continued. At POD 14, esophagography and follow-up CT showed that the fish bone was completely removed but esophageal fistula was not closed. We decided to treat the remained esophageal fistula with conservative management of a closed drain and broad-spectrum antibiotics as possible because there was no evidence of infection sign and
Fig. 2. A 3 cm-sized fish bone penetrating cervical esophagus was found and removed (A, B, black arrow: fish bone) and V.A.C.1 GranufoamTM dressing (Kinetic Concepts, Inc., San Antonio, TX, USA) was applied. (C) The V.A.C. dressing was connected to the vacuum pump and negative pressure ranged from 70 to 100 mm Hg.
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B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
progression to mediastinitis. At POD 30, esophageal fistula was still open in radiologic studies and saliva drained. We explained the situation to the patient and recommended surgical exploration such as primary closure or end-to-end anastomosis to prevent possible complications. But he refused aggressive surgical treatments. Thus, we alternatively tried to use negative pressure wound therapy for the intractable esophageal fistula. Under general anesthesia, the wound was re-opened and V.A.C.1 GranufoamTM dressing (Kinetic Concepts, Inc., San Antonio, TX, USA) was applied (Fig. 2C). The V.A.C. dressing was connected to the vacuum pump and negative pressure ranged from 70 to 100 mm Hg. The dressings were changed every 3 or 4 days with saline irrigation under local anesthesia. At POD 46, esophagography showed that there was no saliva leakage in the fistula site but esophageal diverticulum was detected in the cricoid level (Fig. 3). Oral diet followed and no food material was detected in the vacuum pump. The hospital course was uneventful and he did not complain the symptoms related to esophageal diverticulum. At POD 55, he was discharged but the left vocal fold paralysis remained. Left vocal fold palsy completely recovered after 3 months and he had no difficulty of swallowing at 6 months after discharge.
3. Discussion There are numerous causes of esophageal perforation. The most frequently reported cause of esophageal perforation is iatrogenic and instrumental injury accounts for most perforations [7]. Especially, foreign body is the most frequent cause of cervical esophageal perforation because of the custom of eating fish and poultry in Asian population [2].
Fig. 3. At postoperative day 46, esophagography showed that there was no saliva leakage in the fistula site but esophageal diverticulum was detected in the cricoid level.
The treatment of esophageal perforation is different according to status of the patient, the cause, the location and the timing of perforation. Generally, the strategies are divided to non-operative and operative treatment [8]. Cervical esophageal perforation has relatively low mortality and more easily treated than intra-thoracic or intra-abdominal perforation (5.9% versus 10.9% and 13.2%) [2,9]. Nevertheless, the treatment for cervical esophageal perforation is still a challenge and the guideline for treating this condition has not been established because of its rarity. Jiang et al. reported the experience of 42 patients of cervical esophageal perforation and they concluded that most of the cases can be treated conservatively or by drainage alone. If the foreign bodies of the esophagus could not be extracted using endoscope, surgical treatments including removal of the foreign bodies, primary repair, and drainage should be performed [2]. When conservative treatments of drainage, broadspectrum antibiotics and nutritional support are unsuccessful, individualized operative treatments such as primary repair, reinforced repair, esophageal resection and esophago-gastroanastomosis may be considered [3,9]. But the aggressive treatments mentioned above have low success rate and high morbidity [3,8]. Negative pressure wound therapy (NPWT) was firstly introduced to manage complicated surgical or non-surgical wounds by Argenta and Morykwas. It entails placing an open-cell foam dressing into the wound cavity and applying a controlled subatmospheric pressure. The optimal pressure of device was recommended at 125 mm Hg below ambient pressure [5]. The four primary mechanisms of action have been proposed as wound shrinkage or macrodeformation, microdeformation at the foamwound surface interface, fluid removal and stabilization of the wound environment [10]. There are also several secondary effects likely involved in mechanotransduction pathways that alter the biology of wound healing including angiogenesis, neurogenesis, granulation tissue formation, cellular proliferation, differentiation, and migration [11]. The common clinical value of optimal NPWT pressure has been known as 125 mm Hg based on the pioneering work of Argenta and Morykwas [5]. Various complicated wounds such as diabetic foot ulcers, open abdomen, pressure ulcers, open fractures, sterna wounds, grafts, and flaps could be treated using NPWT [4]. Also, in the field of head and neck surgery, NPWT has been used for large skin defect, necrotizing fasciitis, pharyngo-cutaneous fistula, stoma dehiscence, osteo-radionecrosis of mandible, chyle fistula, flap failure and lymphangioma [6]. In this case, the patient visited our hospital 7 days after eating a fishbone. The size of abscess pocket was large and the anaerobic infection was strongly suspected on CT scan because of the gas around the abscess. Thus, open approach for immediate drainage was needed rather than endoscopic approach. Intraoperatively, the fishbone was found and the ruptured esophagus was detected. And primary closure was tried but failed because the tissue of esophagus was severely infected and fragile. A Jack-Pratt drain was inserted and empirical broad-spectrum antibiotics were administered for infection control. But, after two weeks, esophagography showed that the perforation was not closed and the retropharyngeal space was filled with dye. The simple drainage was thought to be insufficient due to high possibility of mediastinitis or mediastinal abscess. Because the fistula was not completely closed after conservative managements, the further managements were needed. The site of fistula was post-cricoid or upper esophageal sphincter portion of esophagus. The primary closure was initially considered. But the possibility of reperforation was very high due to fragile infected tissue and the patient refused reoperation. Also, recurrent laryngeal nerve injury might be at risk because of anatomical site of the lesion. The other aggressive procedures such as esophageal resection and esophagogastro-anastomosis were not considered due to high morbidity
B.-W. Yoon et al. / Auris Nasus Larynx 42 (2015) 254–257
and mortality. We initially applied the system to the esophageal perforation wound at the recommended pressure of 125 mm Hg. But the patient could not tolerate the pressure of 125 mm Hg due to severe pain in his neck. Because the form was inserted between esophagus and carotid sheath, the high pressure provoking severe pain could be dangerous. To maintain the system without intolerable pain, the pressure was modified to the lower level of 70–100 mm Hg than the pressure for common clinical situations. The perforation was successfully treated and the oral diet started without leakage 16 days after NPWT. Cervical esophageal perforation with abscess formation can be usually treated with the conservative management of simple drainage and antibiotics [2]. The adjuvant use of NPWT in cervical wounds was well described in many literatures [6]. But to the best of our knowledge, this technique has not been described in the management of cervical esophageal perforation intractable to conservative management. When the closure of the perforation is intractable or delayed similar to our case, it is suggested that NPWT might be an alternative or adjunctive tool for the treatment of cervical esophageal perforation with abscess formation. But if carotid sheath would be exposed and the foam might be in direct contact to the carotid artery, the use of NPWT should be contraindicated. 4. Conclusion NPWT might be an efficient and safe adjunct to treat cervical esophageal perforation with abscess formation when conservative managements fail. Also it could be considered as a bridging procedure before aggressive surgical treatment. Financial disclosure No financial and material support for this work.
257
Conflict of interest No potential conflict of interest relevant to this article was reported. Acknowledgement None. References [1] Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475–83. [2] Jiang J, Yu T, Zhang YF, Li JY, Yang L. Treatment of cervical esophageal perforation caused by foreign bodies. Dis Esophagus 2012;25:590–4. [3] Peng A, Li Y, Xiao Z, Wu W. Study of clinical treatment of esophageal foreign body-induced esophageal perforation with lethal complications. Eur Arch Otorhinolaryngol 2012;269:2027–36. [4] Desai KK, Hahn E, Pulikkottil B, Lee E. Negative pressure wound therapy: an algorithm. Clin Plast Surg 2012;39:311–24. [5] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563–76 [discussion 577]. [6] Andrews BT, Smith RB, Goldstein DP, Funk GF. Management of complicated head and neck wounds with vacuum-assisted closure system. Head Neck 2006;28:974–81. [7] Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Luketich JD, et al. Contemporaneous management of esophageal perforation. Surgery 2009;146:749–55 [discussion 755–6]. [8] Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJ, Molnar JA, David LR. Vacuum-assisted closure: state of clinic art. Plast Reconstr Surg 2006;117:127S–42S. [9] Biancari F, D’Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, et al. Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013;37:1051–9. [10] Orgill DP, Manders EK, Sumpio BE, Lee RC, Attinger CE, Gurtner GC, et al. The mechanisms of action of vacuum assisted closure: more to learn. Surgery 2009;146:40–51. [11] Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg 2014;51:301–31.
