Flap Reconstruction for Esophageal Perforation Complicating Anterior Cervical Spinal Fusion: An 18-year Experience.

Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention in the treatment of traumatic and degenerative changes of the spine. Esophageal injury is a rare but devastating complication of ACDF, with a reported incidence of approximately 1%.1,2 The pattern of esophageal injuries after ACDF is bimodal. Iatrogenic injuries typically present early in the perioperative period, whereas late perforations are generally ascribed to soft-tissue erosion of the posterior esophagus by spinal hardware, bone grafts, or osteophytes. The management of esophageal perforations remains a significant reconstructive challenge as a poor intrinsic blood supply, contamination, and flow of saliva through the perforation impair wound healing. In the setting of ACDF, treatment is further confounded as the native soft-tissue surroundings have been replaced by a more hostile postoperative milieu of scar, unyielding bone and bone graft, and exposed metal. In cases where adequate bony fusion has not yet occurred, fixation hardware must often remain in place, which can complicate bacterial eradication and impose repetitive friction and persistent pressure upon an already tenuous posterior esophagus. Finally, unlike head and neck cancer esophageal reconstructions, there is minimal surgical room to maneuver to expose and repair these perforations. Primary closure has been successful in select cases; however, high rates of recurrence led to the development of reinforced primary repairs with vascularized tissue flaps incorporated into the reconstruction.3–6 Flap interposition serves to bolster against further erosion, increases antibiotic delivery, contains leaks, and is associated with decreased rates of recurrence and earlier reintroduction of oral feedings.3,7–9 Grillo and Wilkins6 first described the concept of a buttressed esophageal repair using vascularized pleural flaps for thoracic perforations, and since this introduction, a myriad of flaps have been utilized, including pedicled pectoralis major,8,10–14 sternocleidomastoid (SCM),3,4,11,15–19 longus colli,20 free radial forearm,8,11,14 and omental10 flaps. Given the low incidence of this complication, there remains a paucity of data and lack of consensus regarding optimal flap selection. Given the significant nature of esophageal perforations, with reports of up to 18% mortality, it is an important problem to address.5 In this article, we present our experience with 18 years of flap reconstruction for perforation in the context of ACDF. We intend to describe our surgical technique, lessons learned, and how our practice has evolved in the care of this challenging problem.