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Ann Thorac Surg 1999;68:568-570
© 1999 The Society of Thoracic Surgeons

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Case Reports

Epidural abscess: a delayed complication of esophageal stenting for benign stricture

^a Section of Neurosurgery, Department of SurgeryUniversityof Michigan Medical Center, Ann Arbor, Michigan USA
^b Division of Infectious Disease, Department of Internal Medicine University of Michigan Medical Center, Ann Arbor, Michigan USA
^c and Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA

Address reprint requests to Dr Boulis, Section of Neurosurgery, University of Michigan Medical Center, 1500 East Medical Center Dr, Ann Arbor, MI 48109
e-mail: nboulis{at}umich.edu

	Abstract

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A case of anterior cervical epidural abscess associated with perforation of an endoscopically placed esophageal stent is presented. Although delayed esophageal perforation is a known complication of endoscopic stenting, no cases presenting with epidural abscess have yet been reported. The increasing application of endoscopic stenting for benign esophageal strictures provides greater opportunity for this type of delayed complication.

	Introduction

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Historically, refractory esophageal strictures have been treated with either fundoplication or resection. Recently, placement of chronically indwelling esophageal stents has been utilized for both benign and malignant esophageal strictures. Stenosis of the cervicothoracic esophagus after laryngectomy and postoperative irradiation for laryngeal carcinoma represents a distinct subset of benign disease in which recurrent stenosis presents a particular challenge. Although esophageal stenting is used extensively in the treatment of malignant esophageal strictures, the indications for stenting in benign disease remain unclear. At present, most practitioners utilize stent placement in cases where lasting relief of dysphagia can not be achieved with dilatation, and surgery is not an option [1].

Complications of endoscopic stenting for malignant strictures have been well characterized. These include early stent dislocation, esophageal perforation, cardiorespiratory failure, and endoluminal hemorrhage. Late complications include stent dislocation and esophagitis [2]. The following case report is the first description of a cervical epidural abscess following stenting of a cervicothoracic esophageal stricture.

A 61-year-old woman with type II diabetes presented to our institution for evaluation of right hemiparesis. In 1988 she was found to have a stage T₄N₀M₀ squamous cell carcinoma of the left hemilarynx. Laryngectomy and partial esophageal resection were performed in May 1988, followed by radiation therapy to the neck (6040 Gray over 14 sessions). A routine surveillance biopsy was performed 1 year after laryngectomy. The histopathology was consistent with radiation changes but showed no evidence of recurrent carcinoma. She developed dysphagia due to a benign stricture at the site of the resection that was treated with Maloney dilatation every 6 months. Each of these dilations was accompanied by direct laryngoscopy with no visual evidence of recurrence of tumor in 9 years of observation. Esophagograms performed in 1990 and 1991 also showed no evidence of tumor. In July 1997 the cervical esophageal stricture was noted to be stenotic to 8 mm. It was dilated to 36 French followed by endoscopic placement of a Montgomery stent (17.5 mm diameter; E. Benson Hood Laboratories, Pembroke, MA). Both the dilation and stent placement were performed without difficulty.

The patient did well without apparent complications until March 1998 when she presented to her physicians with a 2 month history of gradually developing neck and right shoulder pain followed by acute right-sided weakness. A computerized tomographic scan showed free air in the cervical spinal canal posterior to the body of C4 (Fig 1). A magnetic resonance image was obtained that demonstrated abnormal signal throughout the body of C4 associated with a right-sided epidural mass extending from the C3/4 disk space to the body of C5 (Fig 2). This scan demonstrated critical spinal cord compression. The patient underwent emergent anterior C4–5 diskectomy and drainage of an epidural abscess. During the approach, erosion of the esophageal stent into the prevertebral fascia was noted. Dense fibrosis had caused adherence of the longus coli muscle to the perforated posterior wall of the esophagus. Purulent necrotic material was debrided from the prevertebral space and the esophageal stent was extracted. No gross evidence for recurrent carcinoma was noted. Penrose drains were placed into the esophageal defect to allow establishment of a controlled esophagocutaneous fistula. A feeding jejunostomy tube was inserted. Epidural cultures grew Enterococcus species as well as Candida tropicalis. The patient was treated with piperacillin, gentamicin, and oral fluconazole.

View larger version (101K): [in this window] [in a new window]   Fig 1. Axial cervical computed tomographic scan through the body of C4. Air is present in the anterior epidural space and the esophageal stent is visible in situ.

View larger version (123K): [in this window] [in a new window]   Fig 2. Axial T1-weighted contrast-enhanced cervical magnetic resonance imaging scan through the C4/5 disk space. (A) Right paracentral ring-enhancing epidural abscess compressing the spinal cord. (B) Esophageal stent in situ. (C) Enhancing disk space consistent with diskitis.

	Comment

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The application of endoscopic esophageal stenting to benign strictures is expanding. The majority of benign strictures of the proximal esophagus result from cervical irradiation, generally in doses no greater than 6000 Gray [3]. The limited survival of patients undergoing palliative stenting for malignant disease resulted in few delayed complications. Increased utilization of this technology for benign disease is likely to lead to previously unreported delayed complications. One such series of 12 patients reported a 100% delayed complication rate [4]. Our report of an epidural abscess is an example of one such complication. Elective stent removal following stricture healing represents a potential solution to this problem.

The position of the epidural abscess found in the current case is unusual. Only 29% of epidural abscesses are located anteriorly, and only 21% are found in the cervical region [5]. Nonetheless, direct extension from contiguous infections is a well-recognized etiology of epidural abscess and explains the location observed in the present case. Although multiple organisms may be seen in 5%–10% of epidural abscesses, neither Enterococcus nor Candida tropicalis is common [5]. In the current case, pressure necrosis of the posterior esophageal wall compressed between the prosthesis and the spine occurred. Erosion of the esophageal wall allowed for exposure of the disk space to oral flora and accounts for the unusual flora noted in this case [5].

Additional cases of epidural abscess in association with esophageal disease have been reported. Kimura and associates [6] described an abscess in a patient with esophageal carcinoma but without frank perforation. Wax and associates [7] reported an epidural abscess after esophagoscopy and dilatation of a radiation-induced stricture complicated by esophageal perforation. Finally, two epidural abscesses in association with diskitis have been described following transhiatal esophagectomy and cervical esophagogastric anastomosis [8]. The present report is the first of an epidural abscess to complicate esophageal stent placement for benign stenosis. This delayed complication may be seen more frequently in the future with increased application of endoscopic stenting in benign disease. Physicians should be alert to this complication in patients with esophageal stents who develop new neurologic symptoms, neck pain or undifferentiated fever. A high index of suspicion leading to early operative intervention may limit the morbidity and mortality of this complication.

	References

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1. Tan B.-S., Kennedy C., Morgan R., Owen W., Adam A. Using uncovered metallic endoprostheses to treat recurrent benign esophageal strictures. AJR 1997;169:1281-1284.[Abstract/Free Full Text]
2. Spinelli P., Cerrai F., Casella G., et al. Prevention and treatment of complications after endoscopic prostheses placement in tumors of the upper gastrointestinal tract. Minerva Chir 1995;50:843-848.[Medline]
3. Phillips T., Fu K. Quantification of combined radiation therapy and chemotherapy effects of critical normal tissues. Cancer 1976;37:1186-1200.[Medline]
4. Song H.-Y., Park S.-I., Do Y.-S., et al. Expandable metallic stent placement in patients with benign esophageal strictures. Radiology 1997;203:131-136.[Abstract/Free Full Text]
5. Gellin B., Weingarten K., Gamache F.J., Hartman B. Epidural abscess. In: Scheld W., Whitley R., Durack D., eds. Infections of the central nervous system. Philadelphia: Lippincott-Raven, 1997:507-522.
6. Kimura T., Hashizume K., Tanaka T., Yonemasu Y. A case of acute cervical epidural abscess. No To Shinkei 1997;49:359-363.[Medline]
7. Wax M., Amirali A., Ulewicz D., Lough R. Safety of esophagoscopy in the irradiated esophagus. Ann Otol Rhinol Laryngol 1996;106:297-300.
8. Iannettoni M., Whyte R., Orringer M. Catastrophic complications of the cervical esophagogastric anastomosis. J Thorac Cardiovasc Surg 1995;110:1493-1501.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark B. Orringer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boulis, N. M. Articles by Orringer, M. B. Search for Related Content PubMed PubMed Citation Articles by Boulis, N. M. Articles by Orringer, M. B.