ABSTRACT
Anterior cervical discectomy and fusion (ACDF) is indicated for the treatment of various cervical pathologies, including myelopathy, cervical disc degeneration, and radiculopathy. Esophageal perforation is a rare postsurgical complication of ACDF, although it poses serious and potentially fatal outcomes. Esophageal perforation has been described as the most fatal complication of the gastrointestinal tract as delayed diagnosis can lead to sepsis and death. Diagnosis of this complication is often difficult because it can be masked by various symptoms such as recurrent aspiration pneumonia, fever, dysphagia, and neck pain. While this complication usually occurs within the first 24 h post-surgery, it can also develop later and persist chronically in rare cases. Awareness and early recognition of this complication may improve outcomes and reduce mortality and morbidity. A 76-year-old man underwent C5-C7 ACDF in October 2017. A thorough review of the patient's postoperative condition included computed tomography (CT) and esophagogram, which were negative for signs of acute complications. The postoperative recovery was uneventful until several months post-procedure when he began to develop vague dysphagia and weight loss of unknown etiology. A CT scan was obtained 6 months postoperatively and was negative for perforation. He then underwent a battery of inconclusive procedures and scans at multiple institutions. After several months of persistent dysphagia and weight loss without a diagnosis, the patient presented to our network for further workup and treatment recommendations. Upper endoscopy was performed and showed fistulization between the esophagus and the metal hardware in the cervical spine. Esophagram demonstrated no obstruction but decreased peristalsis of the lower esophagus and lateral rightward deviation of the left upper cervical esophagus with minimal mucosal irregularities. These findings were secondary to mass effect of the cervical plate. The patient was successfully treated with a surgical approach using esophagogastroduodenoscopy (EGD) guided repair in layers and a sternocleidomastoid muscle flap. This report demonstrates a rare case of delayed esophageal perforation after ACDF and successful treatment of the perforation by surgical repair using the dual technique.
ABSTRACT
The jaguar Panthera onca requires large areas of relatively intact habitats containing adequate amounts of prey to survive. Since a substantial portion of jaguar range occurs outside of strict protected areas, there is a need for economic incentives for habitat conservation, which carefully managed selective logging can provide. Forest Stewardship Council and Pan European Forest Council certifications intended to regulate wood extraction to maintain the ecological functions of forests require evidence of biodiversity and ecosystem conservation. We draw on twelve surveys across four countries and a range of biomes to present evidence that adequate logging management can maintain jaguar populations, but that they are at risk without efficient control of secondary impacts of access and hunting. Where resident, the presence of jaguars can serve as an indication that the ecological requirements of certified timber extraction are being met. We present a gradient of rigor for monitoring, recommending cost-effective options.
