Ann Thorac Surg 2009;88:1700-1702. doi:10.1016/j.athoracsur.2009.02.079
© 2009 The Society of Thoracic Surgeons
Case Reports
A Rare Complication of Esophageal Stent: Spinal Epidural Abscess
Chia-Ying Li, MDa,
Wei-Chou Chen, MDa,
Shih-Hung Yang, MDb,
Yung-Chie Lee, MD, PhDa,*
a Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
b Division of Neurologic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
Accepted for publication February 24, 2009.
* Address correspondence to Dr Lee, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, #7, Jhong-Shan South Rd, Taipei, 100, Taiwan (Email: yclee{at}ntuh.gov.tw).
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Abstract
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The esophageal stent is used extensively for a malignant stricture, and many complications have been reported. We present a case of esophageal cancer with surgical esophageal stenting. Spinal epidural abscess occurred postoperatively, and we believe that the pathogenesis may be related to the esophageal stent.
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Introduction
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In 1990, Domschke and associates [1] reported the first successful uncovered metallic stent in a malignant esophageal stricture. Afterward, it was believed to be a safe, easy, and effective treatment for a malignant stricture. However, since then, many complications have been reported due to the esophageal stent. We describe the case of a patient who received esophageal stenting for esophageal cancer. He suffered from a postoperative spinal epidural abscess that may have been related to the stent.
A 53-year-old man with alcoholic liver cirrhosis and stone sculptor-related pneumoconiosis presented to our emergency department for paraparesis of the lower extremities and persistent fever for 3 days. Approximately 1 year prior, he was diagnosed as having stage IIA squamous cell carcinoma of the upper third esophagus and received concurrent chemo-irradiation therapy. Because of his underlying diseases, we performed an esophageal stenting for the malignant stricture after concurrent chemo-irradiation therapy.
Four months later, a tracheoesophageal fistula was found at the proximal end of the esophageal stent during the panendoscopic examination. An operation for stent removal and repair of the fistula with a sternocleidomastoid muscle flap and esophageal T-tube insertion for drainage were performed. His discharge was smooth after 5 weeks of antibiotic therapy.
After that episode, he complained of persistent upper back pain. Two months later, he suffered from paraparesis of the bilateral lower limbs with fever, and he was sent to our emergency service. The laboratory examination revealed leukocytosis. His symptoms progressed to paraplegia within 12 hours. Magnetic resonance imaging of the spine showed a focal inflammatory change of the esophageal wall where the previous stent was located, C7 to T4 osteomyelitis, and T1 to T6 epidural abscess with spinal compression, which may have caused his neurologic signs (Figs 1, 2).
He underwent an emergent T1 to T6 laminectomy for abscess drainage and decompression. Pus-like fluid accumulation over the epidural space from T1 to T6 was noted. The culture results revealed Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterococcus species. The antibiotics were adjusted based on the culture results. As the lesion site was near the location of the previous stent, and the pus culture showed multiple organisms, we believed that this epidural abscess may be esophageal stent-related. After the secondary operation, his neurologic status improved slightly to date with the muscle power of bilateral lower limbs at 1 to 2 points.
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Fig 1. Sagittal contrast-enhanced T1 magnetic resonance image of neck showing diffusely increased signal intensity at the esophageal wall (white arrow) and vertebral bodies at C7 to T4 (white dotted arrow), which means an inflammatory change. Epidural collection with rim enhancement is evident on the dorsal aspect of T1 to T6, which is due to epidural abscess (black arrow).
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Fig 2. Axial T2 magnetic resonance image of T3 showing the cervicothoracic cord (white dotted arrow) is compressed and anteriorly displaced by the spinal epidural abscess (black arrow), which may cause the neurologic signs. The esophageal, peri-esophageal tissue (white arrow) and vertebral body show inflammatory change, which supported the impression of this infection from the esophagus.
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Comment
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Complications of the esophageal stent, especially in those patients who have received concurrent chemo-irradiation therapy or photodynamic therapy, may include stent dislocation, esophageal perforation, trachea compression, endoluminal hemorrhage, esophagitis, re-stenosis, stent erosion into the adjacent organs and so on [2–4].
Stent erosion can involve incorporating itself into the esophageal wall and can decrease the tendency for migration. However, it may cause a secondary stricture from granulation or erode to adjacent organs, such as the vessel, bronchus, pericardium, bowel, vertebra, and so forth [4]. Previous radiotherapy is the most important precipitating factor.
When the esophageal stent erodes to the nearby vertebra, it may cause an osteomyelitis, which may present with back pain and fever. An osteomyelitis can cause a further spinal epidural abscess that may take 2 to 4 months [1, 2, 5].
The presentation of a spinal epidural abscess is typically associated with a classic triad (localized back pain, neurologic deficit, and fever). Because only 37% of cases present with this triad, and as these symptoms are nonspecific, it is quite often initially misdiagnosed. Magnetic resonance imaging is the gold standard for a definite diagnosis, which is rapid and can localize lesions accurately. Computed tomographic myelography is another option, but some authors believe that this option may transfer an epidural infection into the subarachnoid space [6].
The clinical course will progress rapidly without an appropriate intervention [5]. Early operation for the spinal cord decompression and abscess drainage may limit morbidity and is the first of choice for most patients. If the neurologic symptoms persisted for more than 3 days, the infarction of the spinal cord may have already occurred, and this may be irreversible. Staphylococcus aureus is the most common pathogen, but when gastroenteral-related spinal epidural abscess is suspected, multiple organisms with anaerobes should be considered [2, 5].
In this case, the history of previous concurrent chemo-irradiation therapy increased the risk of stent-related complications. We categorize the spinal epidural abscess as an esophageal stent-related complication for the culture result of multiple organisms, and the lesion site was near the previous stent with focal inflammatory change on magnetic resonance imaging. Furthermore, the esophageal stent eroded to the trachea and caused a tracheoesophageal fistula before the episode of a spinal epidural abscess occurred.
In conclusion, because spinal epidural abscess is a rare, but catastrophic complication of esophageal stenting, we should always be alert to it when patients with risk factors present with neurologic signs. Early surgical intervention with antibiotic treatment is the key for successful therapy and prevention of the neurologic sequelae.
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References
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- Song HT, Park SI, Do YS, et al. Expandable metallic stent placement in patients with benign esophageal strictures: result of long term follow-up Radiology 1997;203:131-136.[Abstract/Free Full Text]
- Nicholas MB, Wendy SA, William FC. Epidural abscess: a delayed complications of esophageal stenting for benign stricture Ann Thorac Surg 1999;68:568-570.[Abstract/Free Full Text]
- Wang MQ, Sze DY, Wang ZP, et al. Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas J Vasc Interv Radiol 2001;12:465-474.[Medline]
- Low DE, Korzarek RA. Removal of esophageal expandable metal stents Surg Endosc 2003;17:990-996.[Medline]
- Dale CE, Joanna DE, Brandon I. Spinal epidural abscess after cervical pharyngoesophageal dilation Head Neck 2005;27:543-548.[Medline]
- Chen Y, Kim BJ, Lee SH, et al. High thoracic spinal infection following upper gastrointestinal work-up J Neurosci 2007;14:1132-1135.
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Abstract
Introduction
