Esophageal Rupture in a Child After Vertical Expandable Prosthetic Titanium Rib Expansion Thoracoplasty First Report of a Rare Complication

Department of Orthopedics, Isala Clinics, Zwolle, The Netherlands.
Spine (Impact Factor: 2.45). 05/2011; 36(10):E669-72. DOI: 10.1097/BRS.0b013e3181f92c1c
Source: PubMed

ABSTRACT Case report and clinical discussion.
To illustrate the significance of esophageal rupture as a rare complication after expansion thoracoplasty with implementation of a vertical expandable prosthetic titanium rib (VEPTR).
Chest wall deformities and secondary scoliosis are rare complications after a repair operation for esophageal atresia. The new technique of VEPTR expansion thoracoplasty directly treats the chest wall deformity and indirectly corrects the scoliosis. We describe a patient with an esophageal rupture after VEPTR expansion thoracoplasty.
We report the case of an 11-year-old boy who developed a progressive scoliosis caused by fused ribs after multiple reoperations for esophageal atresia. The patient was treated operatively by an expansion thoracoplasty via an opening wedge thoracostomy with implementation of two VEPTRs.
After surgery, the patient developed a respiratory insufficiency because of rupture of the esophagus. The complication was treated conservatively. A second operation was needed to remove an infected VEPTR. The patient fully recovered after this severe complication.
To our knowledge, this is the first report of esophageal rupture after VEPTR expansion thoracoplasty. This promising new technique treats scoliosis in patients with severe chest wall deformities. When a patient presents with fused ribs and there is a history of esophageal atresia, we should keep in mind that the esophagus is at risk of rupturing during the scoliosis correcting procedure.

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    ABSTRACT: Study Design. Multicenter retrospective study of 54 children.Objective. To describe the complication rate of the French VEPTR series involving patients treated between August 2005 and January 2012.Summary of Background Data. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopaedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery.Methods. Out of 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 months-14 years and 2 months) at primary VEPTR surgery. During the follow-up period, several complications occurred.Results. Mean follow-up was 22.5 months (range, 6-64 months). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 non-scheduled procedures for different types of complications: mechanical complications (i.e. fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients, that is, a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence.Conclusion. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.
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    ABSTRACT: Study design Retrospective study. Objectives To evaluate progression of various types of congenital scoliosis (CS) with rib anomalies (RA) during the various stages of the growth period, and to assess severity of progression in order to make a strategic planning of expansion thoracoplasty. Summary of background data VEPTR is approved for the treatment of patients with TIS in more than 30 countries. However, there is no consensus on the surgical indications, or the age or time when VEPTR surgery should be performed. Furthermore, there is no study related to natural history of congenital scoliosis with rib anomalies except two reports that are not sufficient to indicate risk factors of progression during the growth period. Methods Based on a survey of CS and RA via questionnaires, 70 patients (32 males and 38 females with an average age of 2.6 years at the first visit.) matched the inclusion criteria: CS with RA, no procedures that could influence natural history during follow-up periods, repeated plain X-ray check-ups with at least two years interval during growth periods. Average follow-up (F/U) time was 5.4 years (2–14). Plain X-ray images of 70 patients were divided into three age groups: infantile (0–5,6), juvenile (5–10,11), and adolescent (11,12-). Each X-ray image was evaluated in terms of laterality, range and type of RA, severity of scoliosis, type of CS, thoracic height ratio, SAL, and associated anomalies. Results 54 of the 70 patients had unilateral rib anomalies. Rib anomalies included rib fusion in 52, mixed type (fusion and defect) in 8, rib proximity in 6, and rib defect in 4. Vertebral anomalies included formation failure in 1, segmentation failure in 16 and mixed type in 53. The magnitude of scoliosis was 46.9° at the first visit and 65.7° at the final F/U. Scoliosis progressed at the rate of 4.6°/year in 70, 3.6°/year in bilateral RA involvement and 4.9°/year in unilateral. Scoliosis progressed with the rate of 4.6°/year in 70, 3.6°/year in bilateral RA involvement and 4.9°/year in unilateral. Scoliosis progressed most severely during infantile period with the rate of 5.0°/year, followed by adolescent of 3.8°/year and juvenile of 2.3°/year. Patients with rib defect or unilateral unsegmented bar showed higher progression rates (10.7°/year and 7.0°/year) during infantile period. According to the relationship between SAL and scoliosis, four grades in severity of progression (most severe, severe, moderate, mild) were set up with the cut-off value of 70%, 85% of SAL and 45°, 85° of scoliosis for making the strategic planning of ET. Those grades were significantly related with types and location of RA and types of vertebral anomalies. Conclusions Progression of scoliosis was analysed in 70 patients with CS & RA. Congenital scoliosis with rib anomalies progressed most rapidly during the early infantile period (7.8°/year), followed by the late infantile period (5.0°/year), and the adolescent period (3.8°/year). Progression of scoliosis in patients with CS and RA occurred in early phase of growth periods and significantly related with types and location of RA as well as type of vertebral anomalies. The results of this study surely suggest the timing of ET for the patients with CS and RA.
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