Adult Chest Surgery

Chapter 41. Blunt and Penetrating Esophageal Trauma 

Esophageal trauma can result from numerous etiologies, including iatrogenic injuries from endoscopic instrumentation or other thoracic surgical procedures, penetrating or blunt trauma, caustic ingestion during suicide attempts, and even spontaneously with forceful vomiting or retching (Boerhaave's syndrome).1–3 These traumatic episodes can lead to esophageal perforation, which is a medial emergency that requires prompt attention. Any delay in diagnosis or treatment leads to increased patient morbidity and mortality. The signs and symptoms of esophageal trauma are presented in this chapter along with recommendations for management.

CLINICAL CHARACTERISTICS

Esophageal perforation can result from numerous etiologies. Iatrogenic injury is the most common and is seen mainly as a complication of esophageal instrumentation (50–70% in modern series).Spontaneous rupture, or Boerhaave's syndrome, can occur, typically after prolonged vomiting or retching. Both blunt and penetrating injuries can lead to esophageal perforation (see Chap. 40). For the normal esophagus, the cervical portion is the most common site of injury during instrumentation.3–7 Middle and distal esophageal injuries usually result from endoscopic stenting or dilation procedures. Iatrogenic injury sustained during endoscopic procedures such as esophagogastroduodenoscopy and transesophageal echocardiography typically are diagnosed more rapidly because the patient is under direct medical observation at the time of the injury. Although rare, esophageal perforation also can result from nasogastric tube placement, esophageal intubation with an endotracheal tube, and nonesophageal surgical procedures such as tracheostomy and thyroidectomy.

Spontaneous esophageal rupture, or Boerhaave's syndrome, is caused by prolonged forceful vomiting or from abrupt Valsalva-type maneuvers that abruptly increase intrathoracic pressure.1,3 The perforation in spontaneous cases typically occurs in the lower esophagus posteriorly into the left chest.

Penetrating injuries to the neck also can lead to esophageal perforation. Owing to proximity to the carotid artery and trachea, penetrating esophageal injury is rarely isolated. Typically, it is associated with more immediate, life-threatening injuries to these adjacent structures.Blunt neck trauma, which can occur with either powerful direct blows to the neck or more commonly from high-speed motor vehicle accidents, usually causes an intramucosal esophageal hematoma and subsequent dysphagia but rarely perforation. Intramucosal hematomas resolve with expectant management. Full-thickness esophageal injuries can be life-threatening and often are missed in this setting, clouded by other more immediately, life-threatening injuries, hence leading to higher morbidity and mortality.4,6 Full-thickness esophageal injuries typically are associated with concurrent airway injury. A high index of suspicion is needed when evaluating trauma patients because unrecognized esophageal injury can have disastrous consequences.

Caustic esophageal injury (discussed in detail in Chap. 42) is a form of "chemically" penetrating trauma. It usually results from suicide attempts, and the severity of the injury depends on the type, quantity, duration, and for children, taste of the chemical ingested. Alkaline exposure (e.g., lye) is typically more severe than acid (e.g., battery acid or bleach) exposure because alkaline agents cause a liquefactive necrosis, whereas acidic agents lead to a coagulative necrosis.2,4,8 Treatment of caustic injuries must be expedient to prevent early- and late-term morbidity of this often-fatal injury.

PREOPERATIVE ASSESSMENT

The clinical manifestations of esophageal perforation secondary to blunt or penetrating trauma are nonspecific and depend on the location (i.e., cervical, thoracic, or abdominal esophagus) of injury rather than mechanism. Tachycardia, fever, subcutaneous air, pain, dysphagia, shortness of breath, and listlessness are all nonspecific signs and symptoms of esophageal perforation. Cervical esophageal perforation typically is heralded by neck pain and subcutaneous emphysema involving the neck or upper thorax. Patients with abdominal and thoracic esophageal perforation typically complain of subxiphoid or epigastric pain as well as retrosternal pain occasionally radiating to the back. Tachycardia and dyspnea are uniformly present, leading inevitably to hypotension and shock if the condition is left undiagnosed and untreated.

The need for diagnostic studies depends on the degree of clinical suspicion. In cases of iatrogenic injury, especially those occurring during endoscopy, no further diagnostic studies are needed because the injury is directly visualized. When the presence or nature of esophageal injury is not known, various diagnostic studies can be helpful. In over 90% of patients, chest radiographs will suggest the presence of esophageal injury, with findings of pneumomediastinum, subcutaneous emphysema, and left-sided pleural effusion suggestive of perforation. These findings are nonspecific, however, and an upper gastrointestinal series or chest CT scan with oral contrast material can confirm the diagnosis in over 90% of patients. Water-soluble contrast material is recommended for the upper gastrointestinal because barium in the mediastinum can cause chemical mediastinitis. Of the two modalities, chest CT scanning is the more sensitive, having been reported to be over 95% sensitive for the diagnosis of esophageal perforation. Esophagogastroduodenoscopy is used more typically after the injury has been diagnosed by upper gastrointestinal series or chest CT scan.3,5 Esophagogastroduodenoscopy alone may miss small injuries and potentially can exacerbate the perforation as well as increase mediastinal contamination with air insufflation. Hence its use is limited to the operating room, where it serves as a diagnostic adjunct to precisely map out the area of injury immediately before definitive surgical repair.

Diagnosis of caustic injury rests on the history because it typically occurs after a suicide attempt or accidental ingestion by an infant. Oropharyngeal pain, emesis, and dysphagia are the predominant signs and symptoms. Diagnosis of perforation is made with an upper gastrointestinal series or chest CT scan. If no perforation is seen on upper gastrointestinal series or chest CT scan, esophagoscopy should be performed 12–24 hours after initial presentation to examine the extent of esophageal involvement and depth of injury.

MANAGEMENT AND TECHNIQUE

The management of esophageal perforation depends on multiple factors, but chief among these are the etiology, location, and time from injury to diagnosis. Progressive delay in diagnosis results in a worsened prognosis because of continued contamination, release of inflammatory mediators, and resulting septic physiology. As expected, iatrogenic perforation typically has the best prognosis because diagnosis is immediate, whereas spontaneous and trauma-related perforations carry the worst prognosis because the diagnosis is often missed and treatment delayed.

Management and survival are both influenced by the anatomic location of the perforation. Cervical esophageal perforations typically are better contained with less spillage and result in a mortality rate of less than 10%, especially when there is no contamination of the mediastinum. Thoracic and abdominal perforations with widespread contamination of the mediastinum, pleura, and peritoneum have a historical mortality rate of over 50% in most series.1,3,5,7–10 More recent series quote a mortality rate of 20–25%, probably resulting from improved surgical critical care and operative technique.1,3,5,7–9

Initial management of esophageal perforation involves resuscitation of the patient. The regimen includes administration of IV fluid, H2-blockers or proton pump inhibitors to reduce gastric acid secretion, broad-spectrum antibiotics to cover oral and gastrointestinal flora (including fungal organisms), and restriction of oral intake. Nasogastric tube placement is avoided initially to prevent worsening the injury, especially if an operative intervention is anticipated. If conservative measures are to be used, a nasogastric tube is carefully placed for gastric decompression.

Surgical treatment for esophageal perforation is the mainstay of therapy; however, nonoperative treatment can be substituted in some situations. Historically, nonoperative management alone with antibiotics and parental hyperalimentation carries a 20–40% mortality.1,3,5,7–13 In selected patients who have well-contained or internally drained perforations and are without septic physiology, nonoperative management may be attempted, especially in those who are poor operative candidates. Many cervical esophageal leaks can be managed this way. However, most thoracic and abdominal leaks require an operative intervention.

Operative intervention consists of four modalities: (1) primary repair, (2) diversion and exclusion, (3) T-tube drainage, and (4) esophagectomy with immediate or staged reconstruction.3–5,7,12,14,15 The main principles of each of these operative interventions entail controlling the perforation and draining the area of contamination.

Primary repair of esophageal perforation is possible when the tissue quality of the esophagus and surrounding tissues lends itself to repair (see Chap. 40). Hence there is minimal edema and devitalized tissue in the area, permitting proper tissue approximation. Typically, primary repair is pursued in patients with minimal comorbidity who are diagnosed within 24 hours of injury. Usually, cervical esophageal injuries can be repaired primarily because the contamination tends to be minimal, it is contained within the surrounding neck tissues, and the repair can be well-drained.3,6,8,10 Primary repair for thoracic and abdominal perforations is considered in good surgical candidates who have minimal mediastinal and intraabdominal contamination or devitalized tissue and are stable hemodynamically. Primary repairs should be reinforced with viable tissues such as intercostal or platysmal muscle, pleura, pericardium, or adjacent stomach. When repairing thoracic esophageal injuries, it is prudent to debride and drain the entire mediastinum.

The esophagus is mobilized around the area of perforation. It is important to open the muscle layers over the perforation to identify the full extent of the injury, which can be subtle. A two-layer repair is recommended, with reapproximation of the mucosa with absorbable suture material (such as Vicryl or PDS [polydioxanone] suture; Ethicon, Somerville, NJ) and closure with the muscularis propria using either absorbable or nonabsorbable suture. The repair then is reinforced with intercostal muscle or other viable tissues3,8,10,12 (Fig. 41-1). The chest is thoroughly irrigated and extensively drained. In the case of very low intraabdominal esophageal perforations, a fundoplication or a Thal patch of stomach can be used to buttress the repair as well.3,5,7–9,12 If presented with extensive contamination and devitalized esophageal tissue, which can accompany late diagnosis or extensive injuries, surgical options include exclusion and diversion, T-tube drainage, and esophagectomy.3,5,7,9,12 Exclusion and diversion techniques involve a cervical esophageal fistula and a gastrostomy, one to divert the oral flow and the other to minimize reflux of gastric contents into the esophagus (see Chap. 43). A jejunostomy is placed for feeding. The mediastinum is also debrided before the repair. The perforation is repaired, and the flow of saliva and bile are diverted to protect the repair. Placement of gastrointestinal conduit is delayed 6 months to 1 year. A modification of this technique involves intrathoracic esophageal repair with drainage, followed by stapling of the esophagus (without division) below the injury and creation of a cervical loop esophagostomy to protect the repair. Esophageal peristalsis permits recanalization of the distal staple line, whereas only the proximal staple line needs to be reversed, which often can be performed under local anesthesia without the need for additional major recontruction.3,7,14

Figure 41-1.

 

The esophageal perforation is repaired and reinforced with intercostal muscle or other viable tissues.

 

Another technique to contain mediastinal contamination from a perforated esophagus uses a Silastic biliary T-tube positioned inside the perforation and brought out of the chest (Fig. 41-2). This form of drainage creates a controlled esophagocutaneous fistula. This technique is especially useful if the esophageal tissues are too edematous to hold sutures. The T-tube then is withdrawn slowly 6 months to 1 year later after resolution of the sepsis. The patient is reevaluated and the esophagus studied to see if any reconstructive options are needed.

Figure 41-2.

 

A Silastic biliary T-tube is positioned inside the perforation and brought out of the chest to control contamination from a severely perforated esophagus.

An esophagectomy, with or without immediate reconstruction, should be considered for esophageal perforations in the setting of cancer, severe stricture, or dilated megaesophagus from achalasia. These complex surgeries are presented in Chapters 10–23. Reconstruction should be delayed if the patient is unstable. However, if the patient is stable and the surrounding tissues of good viability with minimal edema, reconstructive options include creating a conduit from the stomach or colon. The jejunum is rarely used in this setting. The stomach is preferred but may not be possible if injured, as in cases of caustic ingestion. If reconstruction is to be delayed, a cervical esophageal fistula and gastrostomy and jejunostomy are created as in the diversion with exclusion technique.

Endoscopic repair of esophageal perforations has been described. Repairs include esophageal stenting of small perforations, endoscopic suturing of partial- and full-thickness injuries, and fibrin glue repair. However, no large studies have been conducted to date, and hence the efficacy of these approaches remains to be determined.

POSTOPERATIVE CARE

Postoperative management of patients with esophageal perforations is often precarious because the initial inflammatory insult leads to a septic physiology that is maintained 24–48 hours postoperatively and therefore requires attention to fluid resuscitation and vasopressor requirements. After this phase has passed, nutrition is paramount and typically is maintained enterally through feeding gastrostomies or jejunostomies or parenteral nutrition if there is an ileus. The primarily repaired or reconstructed neoesophagus is studied with a water-soluble upper gastrointestinal series. The exact timing of this contrast evaluation depends on the patient's clinical course, but typically the evaluation is performed a few days to 1 week after surgery.

Late complications of esophageal injury that result from primary repair and caustic injury include tracheoesophageal fistula and strictures. Esophageal strictures are treated symptomatically with dilation or occasionally stenting, but severe caustic strictures often require esophagectomy and reconstruction. Tracheoesophageal fistula also requires operative intervention, as outlined in Chapter 58.

PROCEDURE-SPECIFIC COMPLICATIONS

The incidence of complications after operative intervention for esophageal perforation depends on the quality of tissues repaired and the overall condition of the patient. If primary repair or T-tube drainage of the esophageal perforation fails and there is widespread contamination with septic physiology, the esophagus must be diverted and excluded, as described earlier.3–5,7,10,12,14,15 Often there are no physiologic signs of sepsis, but radiologic study (either an esophagram or chest CT scan) reveals a contained esophageal perforation with contrast material exiting and reentering into the esophagus. This scenario typically can be managed conservatively by restricting oral intake and starting IV antibiotics. The contrast study is repeated in 7 days to assess for healing. If there is clinical deterioration, the patient must be explored and the esophagus excluded or diverted and any abscess collection drained.

An intraabdominal or intrathoracic abscess can be seen with any of the four previously described surgical techniques, causing fever, an elevated white blood cell count, or failure to thrive. Any abscess must be drained, either surgically or with percutaneous CT-guided drainage, when feasible.3–5,7,10,12,14,15 If repair, T-tube drainage, or exclusion techniques along with drainage fail to contain the perforation and nidus for sepsis, or if the native esophagus is completely necrotic, esophagectomy with delayed reconstruction is the last surgical resort. If a necrotic esophagus is suspected, esophagectomy should not be delayed.

SUMMARY

Esophageal trauma may be caused by blunt or penetrating injury. Most injuries are iatrogenic and occur during endoscopic instrumentation of the esophagus. Untreated, esophageal trauma carries a high morbidity and mortality. Treatment can be conservative in selected patients with high operative risk, but typically a surgical intervention is required. Surgical intervention depends on the location and extent of injury, with options including (1) primary repair, (2) diversion and exclusion, (3) T-tube drainage, and (4) esophagectomy.

EDITOR'S COMMENT

There is little time for preparation when it comes to dealing with esophageal perforation or trauma. A thorough knowledge of the the fundamental principles and techniques cannot be overemphasized. It is paramount for the surgeon to endoscope the patient just prior to deciding the course of surgery. Often, the diagnostic imaging is not accurate as to the site of injury or perforation, nor to the state of the esophagus. Careful observation of the patient's injury and consideration of all possible therapeutic options and approaches is recommended prior to determining the final exposure, sequence, and method of surgical treatment.

–RB

REFERENCES

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