Iatrogenic Esophageal Transection, an Exceptional Complication of Selective Parathyroidectomy

Abstract

A large variety of diagnostic and therapeutic procedures can occasionally cause an accidental perforation of the esophagus. We report a case of a selective parathyroidectomy for primary hyperparathyroidism that was complicated by inadvertent iatrogenic segmental resection of the cervical esophagus. The proximal location of the injury and its delayed discovery led to a challenging 2-stage repair with an unsuccessful esophagostomy initially, followed by laparoscopic transhiatal esophagectomy and gastric transposition with high cervical anastomosis, with favorable outcome.

Many different medical procedures in the neck can lead to accidental esophageal perforation. Simple selective resection of parathyroid adenomas is a low-risk operation not prone to cause esophageal injury. We report such a complication.

A 73-year-old female patient with primary hyperparathyroidism (PHPT) was operated on by an otorhinolaryngology surgeon for suspicion of a left-sided parathyroid adenoma. The patient’s medical history included breast cancer, type 2 diabetes, arterial hypertension, takotsubo syndrome, and obesity (body mass index of 33 kg/m²).

According to operative notes, a parathyroid-like structure of 1 cm was removed underneath the left thyroid gland. There, the surgeon also found and resected a “cystic lesion described as a 2-3 cm fleshy mass, exposing a cylindrical lumen without secretions.” Final histopathologic evaluation later reported a normal parathyroid gland and a 3.8-cm-long circular segment of esophagus.

The next morning, the thoracic surgeon was called by the attending intensive care unit physician as massive cervical subcutaneous emphysema and pneumomediastinum had developed on the computed tomography scan (Figure 1A). A contrast study showed massive mediastinal leakage right from the upper esophageal sphincter (Figure 1B). The patient’s respiratory status deteriorated as the emphysema progressed rapidly. Bedside opening of the cervical wound was necessary to allow cervicomediastinal decompression and intubation before the patient was taken to the operating room.

Figure 1.

Computed tomography scan and contrast swallow study. (A) Retrotracheal emphysema (arrow) and absent esophagus. (B) Contrast study showing pneumomediastinum (white arrows) and uncontained leakage from cut proximal esophagus (upper black arrow) with reuptake into the esophageal lumen at the distal section level (lower black arrow).

There, the left cervical incision was widened to expose the pharyngoesophageal junction, showing that the esophagus had been transected flush to the cricopharyngeal muscle (Figure 2A). The proximal lumen of the transected esophagus was found lying behind the carina (Figure 2B). Attempts at upward traction were unsuccessful because of a persisting gap of 5 cm, making primary repair and anastomosis impossible. To gain time and to stabilize the septic condition of the unstable patient, a damage control procedure was decided on, with transcervical sutures to close the esophageal opening in the mediastinum, mediastinal drainage, and a temporary cervical esophagostomy. However, as there was insufficient residual cervical esophagus, the esophagostomy was more a funnel-shaped conduit made from skin plicated toward the esophagus than a real esophagostomy. Skin traction led to early dehiscence on day 2 after injury, making this esophagostomy unfit to serve as a durable solution. Fortunately, the hemodynamic status of the patient had improved to allow restorative surgery.

Figure 2.

(A) Transcervical mediastinal view on retrotracheal esophageal lumen canulated with nasogastric tube (NGT). (B) Cervical view of transected esophagus before creation of temporary esophagostomy. (C) Laparoscopic view of vein stripper in the remaining esophagus.

A transhiatal esophagectomy was performed by laparoscopy and left cervicotomy, including the stripping of the remaining esophagus toward the neck (Figure 2C), laparoscopic creation of a long gastric tube, and posterior mediastinal gastroplasty. A high manual anastomosis was necessary between the pharyngoesophageal junction and the gastroplasty using 2 layers of single sutures. A feeding jejunostomy was added. Operative duration was 280 minutes.

The patient’s sepsis resolved subsequently, allowing extubation on day 6. On day 11, an anastomotic fistula was drained through the neck incision with subsequent vacuum therapy of the neck wound. Critical care neuropathy subsequently slowed the patient’s recovery. The patient left the intensive care unit on day 28, and after speech and swallowing therapy, oral feeding was resumed on day 40. No local rehabilitation center accepted the patient, who was finally discharged home on postoperative day 75. The jejunostomy tube was removed on day 95.

At 29 months of follow-up, the patient had normal oral food tolerance but ongoing hypercalcemia and increased parathormone levels. An ¹⁸F-fluorocholine positron emission tomography scan subsequently showed the parathyroid adenoma on the right side, but the patient refused any proposals for selective parathyroidectomy (Figure 3).

Figure 3.

Postoperative ¹⁸F-fluorocholine positron emission tomography showing parathyroid adenoma in the right side of the neck next to gastroplasty staple line.

Comment

Literature reviews on esophageal perforations suggest that they are more frequently iatrogenic than spontaneous.^1,2 Of all reported causes for iatrogenic cervical esophageal injury, anterior cervical spine surgery seems the most prominent.³ Rarely, thyroidectomy has been cited to cause injuries to the trachea or cervical esophagus.^4,5 In difficult thyroidectomies, the dissection plane between the esophagus and thyroid may be obliterated after previous neck surgery, inflammatory conditions, or neoplasms resulting in fibrosis of the dissection planes. This could theoretically increase the risk of esophageal injuries.^4,5

PHPT usually does not cause such tissue alterations, and no case of esophageal injury after parathyroidectomy was found in the English-language literature. In a German publication, 1 case was reported after a bilateral subtotal parathyroidectomy for secondary hyperparathyroidism.⁶ An accidental esophageal transection was recognized intraoperatively, and the patient was flown still intubated to a reference center where she underwent a gastric pull-up with complex pharyngogastric anastomosis. As in our case, this was complicated by a late anastomotic fistula (2 weeks after reconstructive surgery) and lasting swallowing problems requiring prolonged hospitalization. The patient had persistent hyperparathyroidism, and the subsequent medicolegal case concluded by negligence on the initial procedure. The lawsuit noted that no previous case of esophageal injury caused by a parathyroidectomy had ever been reported.⁶ Selective parathyroidectomy for PHPT is an even more benign and straightforward surgery than subtotal or total parathyroidectomy, often performed as an outpatient procedure. Foremost complications are failure to find the adenoma, cervical hematoma, wound infection, transient hypocalcemia, and recurrent laryngeal nerve injury.² To our knowledge, simple parathyroidectomy has not been reported to cause such major esophageal injury and is also missing in literature reviews on esophageal perforation.^1,2,6

The foremost learning point of this case is the mistakes by the initial operator once the targeted parathyroid gland was normal and he became “anatomically lost.” Help by a more experienced surgeon should have been sought rather than continuing resecting anatomically unidentified structures. Stopping the procedure would have avoided injury, allowing additional localization tests (eg, ¹⁸F-fluorocholine positron emission tomography) before expert reoperative parathyroidectomy.⁷

In our case, the long esophageal gap and initially unstable patient made a primary repair or immediate reconstructive surgery impossible. Damage control was initially done, allowing reflection on all options and obtaining informed consent by the patient’s kin for restorative surgery in better conditions. Because of the patient’s age, comorbidities, and impossibility of colon preparation, long-segment coloplasty did not appear to be a valid option. Theoretically, a free jejunal flap interposition could have been an option, but the inflamed cervical tissues could have made microvascular anastomosis hazardous. Using the stomach for reconstruction, with a laparoscopic approach without opening the chest, seemed the least invasive option in this patient with significant comorbidities.

Our patient chose not to initiate legal action against the initial surgeon. From a medicolegal point of view, a discussion could arise if the informed consent before any parathyroidectomy or thyroidectomy should include explicit enumeration of this catastrophic complication.^5,6 Our point of view is that obligation to include such exceptionally rare complications might generate more patient anxiety than potential benefit and could incite patients with PHPT to refuse such benign surgery, exposing them to persisting harmful and unnecessary hypercalcemia.

In conclusion, this case of complete proximal esophageal section during selective parathyroidectomy extends the list of possible complications of parathyroidectomy and the causes of iatrogenic esophageal injuries.