title: Arterial-esophageal fistula: a complication of nasogastric tube placement after lumbar spine surgery: a case report.
abstract: METHODS
  A case of arterial-esophageal fistula related to nasogastric tube placement in a 13-year-old girl after surgical correction of her progressive congenital lumbar kyphosis is presented.
  
  
  OBJECTIVE
  This case report illustrates the importance of early recognition of "sentinel" hematemesis before massive hemorrhage, as this may allow for timely surgical intervention to prevent fatal exsanguination. The proposed pathogenesis of the arterial-esophageal fistula in the reported patient is discussed.
  
  
  BACKGROUND
  Although arterial-esophageal fistula formation has been recognized as an unusual complication of prolonged nasogastric intubation, to the authors' knowledge, this is the only case that illustrates an association of this complication with short-term nasogastric tube placement.
  
  
  METHODS
  A 13-year-old girl was evaluated for progressive congenital lumbar kyphosis. Failure of segmentation and an anterior bar at L4-L5 was diagnosed when the patient was 7 years of age. At that time, she showed 28 degrees of kyphosis from L3 to L5. Because of her cardiopulmonary status at the time, she was deemed not to be a candidate for a corrective surgical procedure and followed conservatively until the age of 13 years. At that time, her gibbus deformity was 56 degrees from L3 to L5. She had significant ventral sagittal imbalance, which in combination with her cardiopulmonary abnormalities created difficulty with ambulation. Her preoperative neurologic examination was within normal limits. The patient had an extensive history of congenital cyanotic cardiopulmonary disease. She was born with pulmonary atresia, right-sided aortic arch with mirror image branching, a large coronary sinus type atrial septal defect, and a large ventricular septal defect. She had history of multiple surgical procedures for correction of her congenital cardiopulmonary abnormalities. The patient underwent posterior L3 and L5 wedge pedicle reduction osteotomies with posterior instrumentation and fusion from L2 to S1 using pedicle screw segmental fixation. A nasogastric tube was placed after surgery. On postoperative day 7, profuse bleeding from the patient's mouth and nose developed, which subsequently ceased. Shortly afterward, she became hypotensive and tachycardic. Upper gastrointestinal endoscopy showed a large amount of blood in her stomach without an active source. Cardiac arrest then developed, and she could not be resuscitated. The autopsy findings were consistent with an arterial-esophageal fistula.
  
  
  RESULTS
  In the reported patient, the anomalous aortic arch system provided direct contact between the aorta and the esophagus. Dense fibrous adhesions between the aorta and esophagus resulting from multiple previous thoracic surgeries also may have facilitated the development of the fistula by the nasogastric tube in this patient.
  
  
  CONCLUSIONS
  Patients with congenital cardiac abnormalities frequently also have congenital spinal deformities. These patients may undergo spinal correction procedures requiring nasogastric intubation. Increased awareness of arterial-esophageal fistula among the spine surgery community may enhance early recognition and treatment of this potentially lethal condition.
authors.affiliation: Department of Neurologic, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA. cohengadol.aaron@mayo.edu
authors.forename: Aaron A
authors.initials: AA
authors.lastname: Cohen-Gadol
authors.forename: Christopher B
authors.initials: CB
authors.lastname: White
authors.forename: Mark B
authors.initials: MB
authors.lastname: Dekutoski
authors.forename: William J
authors.initials: WJ
authors.lastname: Shaughnessy
mesh_terms: D001158:Arteries / Q000473:pathology*; D002648:Child; D004937:Esophageal Fistula / Q000175:diagnosis* / Q000209:etiology; D017809:Fatal Outcome; D005260:Female; D005402:Fistula / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects; D007738:Kyphosis / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery