Arterial-esophageal fistula: a complication of nasogastric tube placement after lumbar spine surgery: a case report

Outcomes of spinal fusion in children with congenital heart disease

BACKGROUND

The children with congenital heart disease (CHD) have an increased risk of developing scoliosis. Many children with CHD may benefit from surgical intervention for scoliosis. However, there is uncertainty about the safety of spinal fusion in children with heart disease. The purpose of this study is to assess whether spinal fusion is safe and effective for children who have CHD.

METHODS

We reviewed all the cases of children with CHD undergoing first-time spinal fusion for spinal deformity at Mayo Clinic between August 1976 and June 2008. Data were abstracted regarding cardiac history, major Cobb angle, type of spinal fusion (anterior, posterior, or both), intraoperative and postoperative complications, mortality, and follow-up.

RESULTS

Sixty-four children under the age of 18 (64% female patients; mean age=11.5 y) were included in the study. The most common types of CHD were pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Sixty-three percent of all patients had had prior cardiac surgery; 22% were cyanotic at the time of spinal fusion. Nine patients had single-ventricle physiology; 5 of whom had had Fontan palliation. Nine patients had pulmonary hypertension. Posterior fusion alone was carried out for 69% of the patients. Spinal instrumentation was used in 70% of cases. Average anesthesia time was 7.3 hours. Mean hospital stay was 9 days. Eighteen children (30%) required prolonged intubation of 1 day or longer. Prolonged intubation was more common in patients with a larger Cobb angle and in patients with pulmonary hypertension. Postoperative complications occurred in 27% of all patients and were more common in the patients with pulmonary hypertension. One child died postoperatively from a hemorrhage because of an arterial-esophageal fistula unrelated to her spinal fusion.

CONCLUSIONS

Spinal fusion in children with CHD is generally safe and effective. Children with pulmonary hypertension are at higher risk for complications from spinal fusion.

LEVEL OF EVIDENCE

Level IV--Case Series.

Aortoesophageal fistula following nasogastric tube placement

A 78-year-old woman was admitted to our hospital because of fresh cerebral infarction. She had been diagnosed as having rheumatoid arthritis, but had not been treated for 50 years. She could not take in sufficient food. Upper gastrointestinal endoscopy revealed no esophageal or gastric lesions, but the procedure was difficult because of her stiff neck from severe rheumatoid degenerative changes of the cervical spine. A nasogastric (NG) tube was placed, and enteral nutrition was initiated. On the 15th day from initiation of enteral nutrition, she presented hematemesis, and suddenly went into a state of shock and died. An autopsy revealed two esophageal ulcers, one of which penetrated into the descending thoracic aorta. The patient was diagnosed with hemorrhagic shock due to aortoesophageal fistula. We suspect that the NG tube compressed the esophageal wall, and ischemia caused the ulcers.

Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis

Nasogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. We report a case of fatal hemorrhagic shock immediately after nasogastric tube insertion in a patient undergoing debridement by video-assisted thoracoscopic surgery for mediastinitis. Emergency endoscopy showed that the bleeding came from the nasogastric tube which had perforated the esophagus and possibly tore an intrathoracic large vessel. The nasogastric tube insertion was considered to have directly produced the perforation because no esophageal perforation had been found on preoperative endoscopy. Factors contributing to the risk of esophageal perforation in this case included coexisting mediastinitis, surgical manipulation, endotracheal intubation, inability to cooperate during general anesthesia, and repetitive advancement of the nasogastric tube. Prompt clamping of the nasogastric tube or delayed insertion after failed attempts might have improved the outcome. This report illustrates the complication of massive bleeding that can occur immediately after misplaced insertion of a nasogastric tube. Extraordinary care should be taken to avoid misplacement of the nasogastric tube during insertion.