Esophageal fistula complicating thyroid lobectomy

Navigating the challenges: A case of iatrogenic cervical esophageal perforation following thyroid surgery

INTRODUCTION

Iatrogenic cervical esophageal perforation (ICEP) represents a rare and challenging surgical complication that results in significant morbidity and mortality. This is a case report of a cervical esophageal fistula that resulted from an iatrogenic perforation following thyroid surgery, treated with surgical repair followed by negative pressure wound therapy (NPWT).

PRESENTATION OF CASE

A 43-year-old female was presented with an infected post-total thyroidectomy and bilateral radical neck dissection two weeks prior. Esophagography revealed contrast leakage from the anterolateral aspect of the esophagus at the level of C7-T1. Surgical debridement exposed large (4 × 1 cm) esophageal damage. The esophageal repair was performed using a sternocleidomastoids flap reinforced with BioGlue® followed by placement of a feeding tube through a gastrostomy. Subsequent mucus leakage was observed two weeks after the repair. Conservative approach using NPWT was used to promote wound closure. Over a 3-week period, serial imaging demonstrated fistula closure and complete wound healing by 8 weeks.

DISCUSSION

A delay in diagnosis and treatment for esophageal perforation leads to severe complications, highlighting the need for standardized treatment algorithms. Larger perforations illustrated in this case report require primary repair with muscle flaps. When reconstructive surgery fails, a follow-up conservative therapy utilizing proper NPWT was able to heal the leakage.

CONCLUSION

This case report illustrates rare but devastating potential complications from a commonly performed oncologic surgery. The involvement of a multidisciplinary team from the very first identification of surgical complications is crucial for ensuring proper treatment.

Professional liability due to complete esophagus section during thyroidectomy: a rare case report

Background

Several diagnostic and therapeutic processes are regulated by guidelines and recommendations provided by International and National Societies which offer standardized indications for health-care practitioners, including the treatment of pathologies that may affect the thyroid gland. These documents are very important for patient health promotion and, also, for preventing adverse events associated with patient injuries and related malpractice litigations. Particularly, thyroid surgery can be a cause of professional liability due to complications from surgical errors. Even if the most frequent complications are hypocalcemia and recurrent laryngeal nerve injury, this surgical specialty can be also burdened by other rare and serious adverse events such as esophagus lesions.

Case Description

Here a case of alleged medical malpractice involving a 22-year-old woman reporting a complete esophagus section during thyroidectomy was described. The case analysis highlighted that the surgical treatment was performed for an unconfirmed Graves-Basedow disease which was then assessed as Hashimoto thyroiditis by histological exam of the removed gland. The esophagus section was treated by termino-terminal pharyngo-jejunal anastomosis and termino-terminal jejuno-esophagus anastomosis. The medico-legal analysis of the case revealed two different profiles of medical malpractice related, respectively, to the misdiagnosis of the pathology due to an inappropriate diagnostic-therapeutic procedure and the production of the complete section of the esophagus, representing an extremely rare complication of thyroidectomy.

Conclusions

Clinicians should ensure an adequate diagnostic-therapeutic path based on guidelines, operational procedures, and evidence-based publications. The non-observance of the "required rules" for diagnosis and treatment of thyroid disease can be associated with a very rare and severe complication that strongly compromises the patient quality of life.