Multidisciplinary Management of Early Esophageal Fistula After Anterior Cervical Spine Surgery: A Case Report Emphasizing Team-Based Care

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Anterior cervical spine surgery is a commonly performed procedure to address various spinal conditions.¹ While it generally provides positive outcomes, there is a risk of complications, including early esophageal fistula development.² Although rare, these fistulas can lead to serious consequences such as mediastinitis, sepsis, and respiratory compromise.³ Timely and comprehensive nursing management plays a crucial role in addressing these complex challenges and optimizing patient outcomes.

Nurses, with their expertise in assessment, intervention, and patient education, play a critical role in ensuring the timely identification of complications, initiating appropriate interventions, and providing holistic care.⁴ By understanding the unique demands of caring for patients with early esophageal fistula, nurses can minimize further complications, promote healing, and support patients and their families throughout the recovery process.⁵

This case report presents the experience of a patient with early esophageal fistula after anterior cervical spine surgery. It highlights the importance of a multidisciplinary and holistic treatment approach and meticulous nursing care to ensure positive outcomes for the patient. Through comprehensive nursing management, patients with early esophageal fistula after anterior cervical spine surgery can receive the necessary care and support to effectively manage these complications, ultimately enhancing their overall well-being and quality of life.

On July 5 2022, a 64-year-old female weighing 49 kg and standing 159 cm tall presented at the outpatient clinic with complaints of persistent right shoulder pain and diminished grip strength in her right hand, which had persisted for 3 months. Her medical history included diabetes and osteoporosis. Initial diagnostic assessment by the outpatient physician suggested a cervical herniated disc as the underlying etiology.

On July 6, 2022, the patient underwent anterior cervical spine surgery—involving a subtotal C5 vertebral body resection, removal of C4/5 and C5/6 discs, and subsequent internal fixation and fusion—under general anesthesia. The patient received postoperative wound drain placement and was administered anti-inflammatory, analgesic, gastroprotective, and phlegmolytic treatments.

On the second postoperative day (July 7, 2022), the patient’s clinical parameters were evaluated. Her blood leukocyte count was 12.56 × 10⁹/L, with neutrophils accounting for 90.0% of the differential count. The ultrasensitive C-reactive protein level was 6.78 mg/L. As part of the treatment plan, the patient received cefuroxime sodium at a dose of 750 mg twice daily for 3 days. Subsequently, the patient reported mild throat discomfort with a Pain Numeric Rating Scale (NRS) score of 1 and the sensation of swallowing a foreign body.

On July 11, 2022, a hematology review revealed a leukocyte count of 9.12 × 10⁹/L, with neutrophils accounting for 6.07% of the differential count. The ultrasensitive C-reactive protein level was 5.47 mg/L. The patient presented with persistent pharyngeal discomfort and an NRS score of 3. The Kubota water swallowing test showed a type IV result, and approximately 10 mL of milky white cloudy fluid was discharged from the wound drain. The attending physician was immediately informed and an oral methylene blue test was performed, resulting in the discharge of blue fluid from the wound drain. This raised suspicion of an esophageal fistula, leading the physician to disallow oral intake and initiate total parenteral nutrition. The patient received 1440 mL of Kabiven parental nutrition and 20 units of regular insulin. To protect the gastrointestinal mucosal barrier, the patient required static injections of a growth inhibitor (3 mg) and saline (48 mL/4 mL/hour) via a micro-pump. An infusion of omeprazole 40 mg was also initiated to protect the gastrointestinal mucosal barrier.

Subsequent painless gastroscopy revealed a fistula approximately 1.0 cm in diameter near the pyriform fossa (Figure 1). Attempted closure of the fistula with an endoscopic clip during the procedure was unsuccessful. Under general anesthesia, the patient underwent cervical internal fixation removal, iliac bone grafting, and esophageal fistula repair. Postoperatively, a wound drain was retained. Considering the patient’s significant osteoporosis (T-score < -3.2), she underwent secondary iliac bone grafting. To prevent implant displacement and exacerbation of the fracture at the implant site, the patient was instructed to rest in bed with her head elevated less than 30 degrees. Additionally, the patient received desucumab injection (60 mg) subcutaneously. The patient’s ability to perform activities of daily living (ADL) score was 40, and the patient had severe life dysfunction; therefore, postoperative pulmonary rehabilitation was performed to promote the patient's functional recovery.

On July 26, 2022, another computed tomography (CT) scan of the esophagus was performed, which showed no abnormality at the anastomosis site (Figure 2A). At the same time, the patient’s inflammatory index returned to baseline levels and her temperature returned to normal. On August 15, 2022, a repeat CT scan of the esophagus (Figure 2B) showed no abnormal enhancement or exudation at the anastomosis. Consequently, the gastrointestinal decompression tube and wound drain were removed on the same day. On August 17, 2022, a fiberoptic endoscopic swallowing function test (Figure 2C) confirmed the presence of laryngitis with normal vocal cord movement and closure. According to the Rosenbeck leaky-suction grading system, food entered the airway but stayed above the vocal cords and was subsequently cleared without complication.

On August 19, 2022, the nasoenteric tube was removed, and the patient’s diet was transitioned to 1440 ml of Kabiven and small, frequent meals of a pasty diet to promote oral nutritional support until complete oral nutrition was achieved by the time of discharge. The patient’s diet was adapted to include warm, cool, and thick-paste foods with a gradual transition to ensure the patient did not choke or aspirate. Of note, the patient’s blood glucose levels were effectively controlled and consistently remained within a range of 7.2 mmol/L to 10.3 mmol/L.

On September 19, 2022, a CT scan of the patient’s pelvis revealed a comminuted fracture of the left iliac wing with a small amount of crusting. After a thorough evaluation of the patient’s general condition, a program of gradual mobilization was implemented. This process required the assistance of a walker and neck brace. Intensity of movement was increased based on the patient’s ability to tolerate it in the hospital setting.

Ultimately, the patient was discharged on September 25, 2022. Over 3 months, the patient received regular follow-up visits and weekly monitoring of nutrition-related indicators. Notably, the patient’s albumin concentration consistently exceeded 35 g/L and she gained 2 kg. The patient was well cared for and had no incision-related complications or lung infections during the course of treatment. The patient’s consultation, outpatient, surgery, and recovery details are summarized in Table 1.

Esophageal fistulas, categorized as either congenital or acquired, arise from a variety of etiologies contingent upon the underlying condition. Congenital esophageal fistulas often manifest from developmental disruptions during fetal growth, commonly associated with esophageal atresia, where the esophagus fails to form correctly. These anomalies result from incomplete separation of the embryonic esophagus and trachea, establishing an abnormal connection between the esophagus and the trachea or other adjacent structures. These are relatively rare, with an incidence of approximately 1 in 3000 to 5000 live births. They often occur alongside esophageal atresia.⁶

The etiology of acquired esophageal fistulas encompasses a range of factors. In cases involving cancers of the esophagus or adjacent structures like the lungs or thyroid, tumor progression may erode the esophageal wall, leading to fistula formation with nearby organs, such as the trachea (tracheoesophageal fistula) or other gastrointestinal regions.⁷ Approximately 10% to 15% of patients with advanced esophageal cancer are estimated to develop a tracheoesophageal fistula as the tumor invades the esophageal wall.^{7, 8}

Chronic inflammation from conditions such as Crohn’s disease or tuberculosis may also lead to fistula formation as ongoing inflammation induces tissue necrosis or ulceration,⁹ which in turn facilitates abnormal connections. However, the likelihood of fistula formation from such inflammatory conditions is generally lower compared to malignancy.¹⁰

Esophageal trauma—whether from blunt or penetrating injuries, medical interventions, or accidents—can precipitate fistula development. While the development of an esophageal fistula following trauma is relatively rare, it constitutes a severe complication. Potential injuries include contusions, lacerations, or rupture, although fistula formation is not the most frequent outcome.¹¹

Post-operative complications from esophageal surgeries or related procedures can also lead to fistula formation. Poor wound healing, infection, or wound dehiscence are significant contributory factors. The incidence of fistula following esophagectomy, a common procedure for esophageal cancer, ranges from 5% to 10%.¹² Additional factors such as diabetes, malnutrition, or immunosuppressive medications can exacerbate the risk. The occurrence of esophageal fistula following anterior cervical spine surgery, though rare at 0.04% to 0.25%, carries a significant mortality rate of 20% to 50%.¹³

Severe infections or abscesses near the esophagus can initiate tissue destruction leading to fistula formation, whether primary or secondary to other conditions.¹⁴ Furthermore, the ingestion of corrosive substances, such as strong acids or bases, can damage the esophageal lining, leading to necrosis and potential fistula formation.¹⁵

Radiation treatment for thoracic cancers may damage the esophageal mucosa, predisposing patients to radiation-induced esophageal fistulas. The risk is estimated to be less than 5% among those receiving radiation therapy for thoracic malignancies, although this figure can vary based on specific studies and patient demographics.¹⁶

There is no significant gender difference in the incidence of congenital esophageal fistulas; they occur in both males and females at roughly equal rates. Gender differences in the incidence of acquired esophageal fistulas reflect variations in underlying causes. For instance, esophageal cancer, which is more prevalent in males, may lead to a higher occurrence of related fistulas in men. In contrast, certain infections or trauma-related incidents may exhibit gender-based differences contingent on exposure and risk factors.¹⁷ Due to the low incidence of esophageal fistula, the clinical manifestations are diverse. Some early manifestations are not specific, so it can be easily overlooked. Early recognition of esophageal fistula and active treatment and care are critical in reducing complications and mortality.¹⁸ ERAS is a postoperative management concept that aims to minimize the patient’s post-surgical stress,¹⁹ accelerate the speed of recovery, reduce the rate of complications, and improve the success rate of surgery by optimizing preoperative, intraoperative, and postoperative treatment protocols.²⁰ The present case is based on the ERAS concept of establishing a physician, nurse, anesthesiologist, nutritionist, and rehabilitator team,²¹ where medical and nursing staff work together to ensure that the patient receives comprehensive care and attention before, during, and after surgery to maximize treatment success, reduce postoperative pain, and accelerate recovery.²²

In the present case, nursing personnel noted persistent, indistinct pharyngeal pain in the patient on the sixth day following anterior cervical discectomy and fusion (ACDF) performed on July 15, 2022. Concurrently, approximately 10 mL of milky-white turbid fluid was evacuated from the wound drain. This observation prompted immediate communication with the attending medical team and precipitated urgent medical intervention, given the suspicion of an esophageal perforation. Subsequent painless gastroscopy revealed a fistula approximately 1.0 cm in diameter. A multidisciplinary approach was swiftly implemented, involving specialists from general thoracic surgery, otolaryngology, gastroenterology, infectious diseases, and the nursing department. This team collaboratively decided to proceed with immediate surgical intervention. Postoperatively, the nursing staff diligently monitored the patient’s vital signs, pain levels, and overall recovery trajectory, while also evaluating and managing potential complications. Throughout this period, the health care team developed and adhered to a comprehensive nursing management protocol for the nasal enteral tube, as outlined in Table 2. By identifying and addressing clinical issues in a timely manner, the nursing team played a pivotal role in facilitating the patient’s recovery and reducing the likelihood of additional complications. This case underscores the critical importance of integrated, responsive care and precise nursing interventions in managing complex postoperative outcomes.

To mitigate the risk of developing complications associated with ACDF, individuals must adopt preventive strategies that encompass both lifestyle modifications and medical interventions. Key recommendations include maintaining proper posture, engaging in regular physical activity, managing chronic conditions effectively, and making health-conscious choices in daily life. Specifically, in the context of ACDF, proactive measures should include stringent glycemic control to minimize perioperative complications. Further, enhancing the surgical proficiency of practitioners is critical to reducing the incidence of intraoperative errors. Prompt detection of anomalous signs is essential for the early diagnosis of potential complications such as esophageal fistulas. Initiating early enteral nutrition can facilitate the healing of fistulas, thereby shortening recovery times and improving outcomes. Moreover, rigorous infection control measures and meticulous monitoring and management of esophageal fistulas are vital to improve patient prognoses. These comprehensive approaches are designed not only to prevent the occurrence of complications but also to promote overall surgical success and patient well-being.

To better assist the patient through the ERAS model, the treatment team conducted meticulous monitoring of her postoperative status, employing early rehabilitation goal management to evaluate vital signs, neurological manifestations, limb sensation, and blood flow on an hourly basis post-surgery. Periodic assessments were made to check for swelling around the surgical site, as well as the color, consistency, and volume of fluid from the wound’s drainage system. Concurrently, rehabilitation specialists curated a tailored post-operative recovery regimen, incorporating exercises to enhance swallowing and respiratory functions, as well as training for orofacial muscles. In parallel, a dietitian calculated the patient’s daily caloric requirements based on body weight, devising a nutrition plan that initiated with partial parenteral nutrition supplemented by enteral feeding. This regimen was progressively transitioned to full enteral nutrition and ultimately to exclusive oral intake, facilitating a comprehensive nutritional recovery.

In this documented instance, an esophageal fistula manifested early postoperatively in a patient following anterior cervical spine surgery, which is a relatively uncommon complication. The patient’s recovery was significantly supported through the application of the ERAS management model, supplemented by comprehensive multidisciplinary involvement. However, the diagnostic and therapeutic journey showcased several deficiencies.

First, the rarity of such a complication meant that some of the medical personnel involved lacked specific practical experience, which may have led to operational missteps or inadequate oversight. Second, the extensive consultation process, requiring coordination among a diverse array of multidisciplinary teams and departments, occasionally suffered from delays and miscommunications. These were primarily due to asynchronous work schedules, potentially prolonging the patient’s recovery period. Finally, although nursing staff provided substantial psychological support throughout the patient’s treatment trajectory, the absence of professional psychologists and a lack of quantitative measures for assessing patient mental health possibly led to the under-recognition or delayed identification of psychological issues. This situation highlights the need for integrating specialized psychological expertise and robust metrics into patient care protocols to enhance the detection and management of psychological conditions in postoperative settings.

The present case study reports a notable incidence of esophageal perforation after ACDF, a rare postoperative complication. Leveraging the principles of ERAS, the treatment approach involved meticulous monitoring of the patient’s postoperative progression. Diagnostic strategies, including the Kubota water swallowing test and methylene blue test, were employed to swiftly identify the onset of esophageal fistula complications. A multidisciplinary strategy facilitated the implementation of an integrated medical, nursing, and personalized rehabilitation care plan, significantly reducing postoperative pain and expediting the patient’s recovery. These interventions not only diminished physical discomfort but also enhanced patient mobility and emotional well-being early in the recovery process. This case exemplifies the efficacy of comprehensive postoperative care, incorporating pain management, early rehabilitation, emotional support, and educational guidance, all coordinated by a multidisciplinary team. The success of these measures offers valuable insights for medical practitioners, emphasizing the importance of holistic and patient-centered care approaches in complex surgical recoveries. These findings underscore the potential for such strategies to improve outcomes and patient satisfaction, thereby providing a template for similar cases in the future.

Authors: Lihua Bao, BS^1,2; Jiaqian Wu, BS²; Xiaojing Ye, BS²; Laiyu Xu, MS²; Huiwen Zhan, BS²; and Yue Qi, BS²

Affiliations: ¹Zhejiang University of Traditional Chinese Medicine, China; ²The First Affiliated Hospital, Unit of Nurses, Zhejiang University School of Medicine, Hangzhou, China

Correspondence: Jiaqian Wu, The First Affiliated Hospital, Unit of Nurses, Zhejiang University School of Medicine, Hangzhou, China 310000; 36734260@qq.com

Disclosure: The authors have no financial or other conflicts of interest to disclose.

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