Joseph A. DuBose, James V. O’Connor, and Thomas M. Scalea
Injuries to the chest are common after both blunt and penetrating trauma. Blunt thoracic injuries are responsible for approximately 8% of all trauma admissions in the United States, with motor vehicle crashes being the most common mechanism.1,2 In one recent report from the Los Angeles County Hospital, penetrating chest trauma accounted for 7% of all trauma admissions and 16% of all penetrating trauma admissions overall.3 A 1961 study described a 28% mortality with blunt chest injuries as compared to a 7% mortality following penetrating injury.4 Associated injures were common and were associated with a 42% mortality. These figures have not changed, as a more recent study described approximately a 25% fatality rate as a direct result of thoracic injury with chest trauma playing a contributing role in 50% of nonpenetrating injuries overall.5
Despite the prevalence of thoracic injury following trauma, the majority of patients can be managed nonoperatively. Between 18% and 40% of patients sustaining thoracic trauma can be treated with tube thoracostomy alone. A thoracotomy will be required for between 3% and 9% of patients. Even among those with penetrating trauma, only 14% of stab wounds and between 15% and 20% of gunshot wounds to the chest require thoracotomy.3
Operative mortality varies between 5% and 45%, with approximately 30% of patients requiring lung resection at the time of thoracotomy.4,5 This wide variability is almost certainly related to differences in mechanism of injury, inclusion of cardiac and major thoracic injury in some of the datasets, the extent of pulmonary resection needed, and concomitant extrathoracic injuries.4–13 The influence of thoracic trauma on mortality is particularly striking among patients who die within 1 hour of arriving to a trauma center. In those patients, thoracic trauma, especially thoracic vascular injury, is second only to central nervous system injury as the most common cause of death after hospital admission.
The determination of the optimal treatment for patients with thoracic injuries remains a challenge. Technological advances, particularly the evolution of sophisticated imaging, have allowed clinicians to make the diagnosis of major thoracic injury more quickly. Advances in critical care have made postoperative management more sophisticated. Improved approaches for nonoperative management may make the need for operative exploration even less frequent. Despite these advances, however, a modest number of patients still require thoracotomy. Thus, clinicians caring for injury must adequately appreciate the indications for operation and understand the treatment options in the emergency department as well as in the operating room. Thoughtful decision making based on a comprehensive appreciation of the anatomic relationships of the thoracic cavity and the physiologic principles that govern trauma is necessary to insure the highest survival and optimize functional recovery.
INJURY TO THE LUNGS
The lungs sit in each hemithorax. While physiologically quite complicated, in fact, the lungs are anatomically simple, consisting of primarily alveoli and blood vessels. The lungs have a dual blood supply, with a relatively large pulmonary artery and vein delivering significant volumes of blood at low pressure. While the bronchial vascular bed is characterized by a more substantial systemic pressure, the vessels of this vascular tree are quite small. The intercostal vessels in the chest wall also have systemic pressure, but possess larger-diameter vessels than their bronchial counterparts.
The bony thorax protects the lungs from injury. Thus, in adults, injury to the chest wall is a good marker for pulmonary injury following blunt trauma. The greater elasticity to the chest wall in children means that pulmonary injury can occur without evidence of injury to the chest wall.
The anatomic simplicity of the lungs means that a response to injury is relatively limited regardless of the severity and mechanism. The alveoli can rupture, causing a pneumothorax, or the lungs and parenchyma can bleed causing a hemothorax. The chest wall also bleeds when injured. Any of these can range from relatively trivial to life-threatening.
Very large pneumothoraces produce tension by shifting the mediastinal structures toward the contralateral side. In these situations, the anatomic distortion combined with the increase in intrathoracic pressure decreases cardiac output. If untreated, this can cause cardiac arrest. In contrast, large hemothoraces generally produce symptoms through the effects of hypovolemia. Very large hemothoraces, however, can also cause some degree of mediastinal anatomic distortion.
Injury to the lung can also cause intraparenchymal damage, usually pulmonary contusions or lacerations. These often cause symptoms such as shortness of breath or hypoxia. Following blunt trauma, these are often associated with rib fractures. Penetrating injury causes direct parenchymal damage. Radiographic findings often lag behind the clinical presentation. The increased use of CT scanning following most penetrating trauma allows the clinician to make the diagnosis earlier. As with many other entities, CT scanning may be overly sensitive and identify pulmonary pathology that is clinically unimportant.
Systemic air embolization, while rare, can also occur following direct pulmonary injury. This most often happens when patients are placed on positive pressure ventilation. If there is an injured bronchus adjacent to an injured blood vessel, air can be forced into the systemic circulation. This should be suspected when patients have sudden decompensation immediately after intubation.
Presentation and Evaluation
Any patient with blunt chest trauma or penetrating injury around the thoracic cavity is at risk for injury to the lung. The history may be provided by the patient, but often it is given by prehospital personnel. The mechanism of injury, time from injury, vital signs, and neurologic status at the scene and any changes during transport are critical components of an adequate history. With blunt injury specifics such as prolonged extrication, the location and degree of occupant compartment vehicle deformation may also provide useful information. With penetrating trauma, the specific details are usually vague and often unreliable.
Physical exam can often help make the diagnosis of intrathoracic injury. The presence of distended neck veins, tracheal deviation, subcutaneous emphysema, chest wall instability, absent breath sounds, or muffled heart sounds may all provide crucial information. Likewise, the absence of an upper extremity pulse suggests a proximal arterial injury. Vital signs should be frequently monitored with careful observation of the work of breathing and arterial saturation. Findings of subcutaneous air or decreased breath sounds should alert the clinician to the possibility of pneumothorax and/or hemothorax. Prompt placement of a tube thoracostomy in an unstable patient is wise, particularly as radiographic confirmation takes too long.
Penetrating thoracic trauma in a hemodynamically unstable patient warrants operative exploration. The decision regarding surgical exposure may be problematic especially if there is concomitant abdominal injury. The hemodynamically stable patient with penetrating thoracic injury may benefit from additional imaging, especially chest computed tomography which provides more detailed and organ-specific information as well as information about vascular anatomy.14–17
Following blunt trauma, stable patients require timely determination of the studies required to identify and characterize potential thoracic injuries. An arterial blood gas should be sent with the initial laboratory studies, and an electrocardiogram performed as indicated. A Focused Abdominal Sonography for Trauma (FAST) including the precordium should be performed. A portable chest radiograph (CXR) is routinely obtained, although some authors question the utility of this study in stable patients with a normal chest examination.16 We believe a CXR can rapidly yield critical information such as the identification of pleural space abnormalities including pneumothorax and hemothorax. If indicated, additional imaging studies such as thoracic ultrasound, a CT scan, esophagoscopy, bronchoscopy, and echocardiography should be obtained.
A CXR should make the diagnosis of any large hemothorax or pneumothorax. Since screening CXRs are usually performed supine, a hemothorax can be somewhat difficult to adequately diagnose. Haziness of one hemithorax when compared to the other may be the only real radiographic sign of blood in the pleural space. If this is of any substance, a chest tube should be placed. In addition, pure anterior or posterior pneumothoraces, even if they are large, may not be well seen on a CXR (Fig. 25-1). The CXR should be examined for a deep sulcus sign, displacement of the diaphragm inferiorly, which may be the only radiographic sign of a pneumothorax. A CXR will also allow the clinician to evaluate the mediastinum for the possibility of a traumatic aortic injury.
FIGURE 25-1 Sizeable anterior pneumothorax not visible on initial trauma chest x-ray. A substantial amount of air can be present either anterior or posterior to the lung and not be appreciated by initial plain film.
In the days of liberal CT scanning, particularly in patients with blunt trauma, many more patients are undergoing either CT scan of the chest or a total-body CT screening. This allows for more precise evaluation of the aorta and also gives a three-dimensional evaluation of the thorax.14,16,17 Pneumothoraces or hemothoraces not seen on chest x-ray are often seen on CT. If they are small and patients are asymptomatic, prudent practice is to simply observe these patients. Even if they require operations for an associated injury or intubation for positive pressure ventilation, the chances that these very small pneumothoraces will become clinically significant is relatively small. A follow-up CXR may be useful, particularly in patients with small pneumothoraces.
In general, patients found to have large pneumothoraces not seen on CXR are treated with tube thoracotomy, particularly in patients who are multiply injured. While it is possible that these can be treated without drainage, our belief has been that these patients may well become symptomatic and we prefer to treat these patients preemptively.
In general, hemothoraces are treated similarly to pneumothoraces. If they are small, observation is generally successful. However, any moderate-sized or large hemothorax should be drained with a tube thoracostomy. Blood left within the pleural cavity will clot and will not be able to be evacuated with a chest tube. The lung will become trapped and this will produce a fibrothorax. Small hemothoraces should be followed with serial exams and a repeat CXR as they occasionally slowly expand. Early recognition and triage is the best idea in these cases. When placed, tube thoracotomies are generally connected to a pleurevac and the pleurevac is connected to suction. Repeat chest x-rays should be obtained to demonstrate good tube placement and to evaluate the possibility of either retained blood or air.
Patients with significant lacerations to the lung will often have large air leaks or hemoptysis. Bronchoscopy can be helpful in such patients to evaluate the possibility of major airway injury, as well as to attempt to localize the injured lobe or segment; this can be especially important if there is significant injury to both hemithoraces. In these cases, bronchoscopy should be performed by a senior clinician. Blood within the airway must be suctioned clear to allow for good visualization of all of the lobar airway structures. Patients with large volumes of hemoptysis or significant air leaks who do not have major airway injury should be considered for thoracotomy and lung repair or lung resection.
If the patient is stable, CT scanning can also be quite helpful in patients with hemoptysis (Fig. 25-2). CT scanning should be able to demonstrate the anatomy of the lung injury and help localize the lobe or lobes most likely to be producing the air leak or hemoptysis. CT may also be able to demonstrate intraparenchymal vascular injuries. The pulmonary vascular tree is a low-pressure system and radiographic vascular injuries do not carry the same prognosis as do arterial vascular injuries identified within solid viscera in the abdomen. If symptomatic, operative exploration is generally the best idea. In a very selective group of patients who are a poor operative risk, transcatheter embolization offers an alternative to thoracotomy.
FIGURE 25-2 CXR and corresponding CT demonstrating right-sided pulmonary contusion. This patient had some minimal associate hemoptysis on presentation, which resolved.
The majority of patients with injury to the lung can be managed nonoperatively. Simple tube thoracostomy evacuates accumulated air and blood, and the lung should be reexpanded up against the chest wall. Peripheral lung injuries generally seal once the lung is reexpanded. As pressures in pulmonary circulation are relatively low, coapting the lung up against the chest wall generally stops bleeding as well.
A number of patients, however, will require thoracotomy for pulmonary and/or chest wall injury. Intercostal hemorrhage, particularly after penetrating trauma, usually continues even after evacuation of the associated hemothorax and/or pneumothorax. This may also be true for major chest wall injuries after blunt trauma where a number of intercostal vessels may be injured. Bleeding can be impressive from injured chest wall musculature as well. Major lung lacerations can produce symptoms by either a continued air leak or hemorrhage.
Indications for Operation
While indications for thoracotomy will be covered in a different chapter, some brief comments here may be helpful. Massive hemothorax, generally defined as 1,500 cm3 of blood in the chest cavity or persistent chest tube output of 200–250 cm3/h for 3 consecutive hours, is generally considered an indication for thoracotomy. In addition, a 24-hour chest tube output >1,500 cm3 is generally considered an indication for thoracic exploration. Hemodynamic instability that is thought to be referable to thoracic injury should virtually always prompt emergent thoracic exploration. As there is a linear relationship between total amount of thoracic hemorrhage and mortality, the surgeon should not delay thoracotomy when indicated.
Care must be exercised when measuring chest tube output. Chest tubes routinely become clotted and if poorly positioned, may not completely evacuate blood or air. Blood will then continue to accumulate within the thoracic cavity. A repeat CXR can be helpful in detecting a retained hemothorax. While a second chest tube may be helpful, patients with a large retained hemothorax should generally be explored and drained.
A number of patients may not need emergent thoracotomy, but may require thoracic operation at a later date. Examples of this include retained hemothorax, persistent air leak, missed injury, and pleural space infections. Many of these nonemergent procedures can be performed using a thorascopic technique.18,19 In general, air leak >7 days should be treated with an operation. Early evacuation of retained hemothorax prevents the clot from becoming fibrotic and trapping the lungs. Proven empyema is almost always best treated with operation.
There are a number of ways to approach thoracic injury, each with advantages and disadvantages. It is imperative that the trauma surgeon be familiar with all of them. The clinical situation generally dictates which incision will be the best. Many patients have thoracotomy for a diagnosed condition such as a nonsealing air leak or a diagnosed tracheal or esophageal injury. In those cases, the incisions can be tailored to provide optimal exposure of the anatomic injury. However, many patients have true explorations for undiagnosed injuries such as in patients with a massive hemothorax or a large lung laceration that has not been localized. In those cases, the thoracic incision must be versatile and allow extension to provide greater exposure if that is necessary.
Hemodynamically unstable patients may not tolerate being put up in the lateral position, as it will exacerbate hypotension. In addition, patients with significant hemoptysis often do not tolerate being up in the lateral position. This puts them at risk for aspirating blood into the uninjured lung, which is now in the dependent position. In addition, there is sometimes the possibility of injury to an adjacent body cavity such as the abdomen and neck that requires operative care. This is especially true with penetrating thoracic trauma. The incision should be able to be modified in order to provide adequate exposure.
Commonly employed approaches are anterolateral, posterolateral, bilateral anterior thoracotomies (“clamshell”), and median sternotomy. The anterolateral approach is rapid and extending it across the midline affords excellent exposure to both pleural spaces and the anterior mediastinum. Likewise, the incision can be continued as a celiotomy for abdominal exploration, and is preferred over the posterolateral approach in the patient in shock. The main disadvantage of the anterolateral approach is the inability to provide optimal exposure of posterior thoracic structures. By extending the ipsilateral arm and placing a bump to elevate the thorax approximately 20°, the incision can be carried to the axilla improving posterior exposure (Fig. 25-3).
FIGURE 25-3 Anterolateral thoracotomy incision. Placing a bump to elevate the chest and extending the arm provides improved thoracic exposure.
The posterolateral thoracotomy affords optimal exposure of the hemithorax, especially the posterior structures, and is the standard incision for most elective thorax operations. Its lack of versatility limits the usefulness in trauma but is the preferred approach to repair intrathoracic tracheal and esophageal injuries. Median sternotomy provides excellent access to the heart, great vessels, and anterior mediastinum. It is versatile and can be extended as an abdominal, periclavicular, or neck incision (Fig. 25-4). Opening the pleura after sternotomy provides good access to either hemithorax. Depending on the surgeon’s experience, a lung resection can be performed. The “trapdoor” incision is rarely used since left-sided thoracic vessels can be approached via sternotomy with extension.20
FIGURE 25-4 Tracheal intubation on the operative field. Partial sternotomy was chosen to obtain control of the great vessels.
Regardless of the incision choice, patients who undergo emergency thoracic operations should first have a complete exploration. Once entering the chest, blood should be evacuated to allow the surgeons good visualization of the entire contents of the thoracic cavity. The lung should be mobilized by taking down the inferior pulmonary ligament. In patients with serious injury to the lung, temporary inflow occlusion can be obtained by compressing the hilum.
There are a number of techniques for hilar compression. Simple finger occlusion will temporarily occlude both the pulmonary artery and vein. A vascular clamp can be placed across the hilum if a longer period of occlusion is necessary. In addition, the lung can simply be twisted on itself at the level of the hilum. This occludes both the pulmonary artery and vein as well as the main stem bronchus. Patients with very tenuous hemodynamics may decompensate when the hilum is occluded. This is associated with a rapid rise in pulmonary artery pressure, which can cause acute right heart dysfunction or failure.
While a double-lumen endotracheal tube is often used in elective thoracic operations, it is virtually never used in trauma, especially for emergency thoracotomies. Use of a single-lumen endotracheal tube can make visualizing the organs within the thorax more difficult and perpetuates any air leak that may be coming from the injured lung. Holding ventilation while localizing an air leak and/or repairing or resecting the lung can be a useful technique. However, if the patient’s respiratory status is tenuous, any extended interruption of ventilation will precipitate decompensation. Manual compression of the adjacent lung may sufficiently consolidate the tissue to facilitate surgery on the lung.
There are a number of techniques for lung repair. Pneumonorrhaphy is the simplest technique and is generally used to treat superficial pulmonary lacerations. The laceration is simply closed with a running simple suture or mattress sutures. Between 20% and 30% of patients requiring emergency thoracic exploration will need a pulmonary resection. This can range from simple wedge resection to major anatomic resections. The widespread adoption of a variety of surgical staplers has increased the options for lung surgery following trauma. Peripheral lacerations not amenable to simple repair can be treated with a small wedge resection using any of the commercially available staplers. The lung parenchyma is generally retracted up to view using a lung clamp and the stapler is fired to excise the injured lung tissue.
More significant lung injuries, particularly those from gunshot wounds, are often best treated with tractotomy21–24 (Fig. 25-5). This is performed by placing the jaws of the stapler through the tract of the injury and firing it. This opens the lung and exposes the bleeding vessels and injured airways. These can then be individually ligated. Tissue thickness will determine whether tractotomy is appropriate and the appropriate-sized staples to use. At times, the staple line may need to be oversewn with a running suture. In general, relatively peripheral tracts are best treated with tractotomy, if more simple maneuvers are not appropriate. Long central missile tracts are usually not amenable to tracheotomy.
FIGURE 25-5 Pulmonary tractotomy with ligation of exposed hemorrhage sources. (Reproduced with permission from Petrone P, Asensio JA. Surgical management of penetrating pulmonary injuries. Scand J Trauma Resusc Emerg Med. 2009 23;17(1):8.)
Serious lobar injuries that are not amenable to tractotomy are often best treated with formal lobectomy. The lungs should be fully mobilized and the extent of injury absolutely determined before making a decision to do a lobectomy. The hilar blood vessels must be dissected free and the blood supply to the injured lobe identified. These can then be stapled or ligated, generally using heavy nonabsorbable ties. The bronchus is generally divided using a stapler and the injured lobe then removed.
Hilar injuries are a special problem and pose significant challenges. There are usually injuries to the major blood vessels as well as the proximal airways. Hemorrhagic shock is almost always present. In very proximal hilar injuries, inflow occlusion is virtually always necessary in order to gauge the extent of injury. Opening the pericardium and controlling the pulmonary artery and vein within the pericardium can be quite helpful in some patients.
Often, after good exposure, and delineation of injuries, many hilar injuries can be treated with either lobectomy or bilobectomy. However, certain injuries require pneumonectomy. Mortality after pneumonectomy for patients in shock approaches 100%.25 Patients die of either uncontrolled hemorrhage or acute right heart failure. It is imperative to make the decision to proceed with pneumonectomy as early as possible. If a number of attempts are made at lung salvage, and the patient is in profound shock, survival after pneumonectomy is rare.
The postoperative care after pneumonectomy is as important as early decision making. Virtually all short-term survivors develop right heart dysfunction and/or acute respiratory failure. Liberal use of transesophageal echocardiography can be very helpful in estimating volume status as well as function of both ventricles. Selective pulmonary artery vasodilation such as nitric oxide26 and sildenafil also improves cardiac function. Virtually all short-term survivors require inotropic support. Finally, use of sophisticated modes of ventilation support such as prone positioning and extracorporeal membrane oxygenation (ECMO) is often needed in the postoperative period.
As bronchial stump leak is a devastating complication following either lobectomy or pneumonectomy, we prefer to cover the bronchial stump with some live tissue. Rotating an intercostal muscle preserving the blood supply to cover the bronchial stump is attractive. Other options include mobilizing a tongue of pericardium. If a bronchial stump leak occurs later in the postoperative period, covering the stump leak with a local muscle flap such as latissimus dorsi or the omentum is another option.
The concept of damage control was originally described for abdominal trauma but is applicable in the chest as well. As in any damage control operation, control of hemorrhage is the primary concern. Thoracic packing to control nonmechanical bleeding can be quite helpful.27–30 It is important to be sure that the packs do not interfere with cardiac or pulmonary function. The chest is then temporarily closed and the patient is brought to the intensive care unit. We generally employ a suction dressing similar to what we use in the abdomen when doing thoracic damage control. When the patient is physiologically improved, the chest can be reexplored and closed. Very rarely, the chest cannot be closed at the time of the first operation and the chest retractor is left in place until the patient is more stable. Thoracic damage control has a 17% mortality, which is admirable, as nearly 70% of patients are acidotic, hypothermic, or coagulopathic.29,30
Video-Assisted Thoracoscopic Surgery
Increasing experience with thoracoscopy has contributed to enthusiasm for the use of video-assisted thoracoscopic surgery (VATS) techniques for a variety of sequela of trauma.18,19 As a diagnostic tool, VATS remains an acceptable alternative to laparoscopy in the identification of isolated diaphragmatic injuries particularly after penetrating trauma. It can also potentially be utilized to diagnose other minor injuries of the thoracic cavity not well visualized with traditional imaging, although these indications have not been well elucidated.
Therapeutically, there are several promising potential applications for VATS. While significant thoracic hemorrhage, pulmonary trauma, and other more severe injuries of the thoracic cavity and mediastinum remain matters best addressed with traditional open techniques, described indications for VATS include: surgical resection of persistent pleural air leak sources in the peripheral lung, ligation of isolated intercostal artery injury, rib fracture reduction, and evacuation of empyema or persistent retained hemothoraces.
The latter two indications remain among the most commonly described, with early operation proving to have the greatest success among published case series. Early VATS for retained hemothorax has proven to be the most successful utilization of the modality. There is, however, a relative paucity of literature on the topic, with the definition of “early” varying between described experiences. However, beyond 72 hours the degree of fibrotic change occurring within the thoracic cavity may preclude the safe conduct of VATS for the evacuation of blood or infectious collections. When treating retained hemothorax and/or empyema, the procedure consists of evacuation of fluid collections and clot followed by decortication of the parietal pleura as necessary. Air leaks are repaired or treated with small wedge resections.
VATS is performed in the operating room under general anesthesia. Double-lumen endotracheal intubation or other lung isolation techniques should be utilized to collapse the lung in the operative hemithorax to permit better utilization of the chest and its contents. The procedure is ideally done with the patient in the full lateral decubitus position with the affected side up. The field should be appropriately draped to facilitate conversion to an open posteriolateral thoracotomy if VATS is not sufficient.
The first port is placed along the fourth or fifth intercostal space in the midaxillary or anterior axillary line. The tip of the scapula serves as a nice landmark to facilitate appropriate positioning (Fig. 25-6). The lung is desufflated by anesthesia as the chest is entered and port placement completed. An angled thoracoscope is preferred for initial use, as it improves visualization of the pleural space recesses. An aspiration catheter can be placed coaxially to the optical port to facilitate the lavage and evacuation required for initial visualization. Additional ports can then be developed under direct visualization to address the pathology encountered.
FIGURE 25-6 Port placement for video-assisted thoracoscopic surgery (VATS) of the left hemithorax. The scapula and edge of the latissimus dorsi anteriorly are marked for reference.
The instruments used for VATS are the same as used for laparoscopic procedures. Conventional open surgery forceps can also be used. Cautery, however, should be utilized cautiously and in close coordination with anesthesia, as oxygen-rich air leaks and cautery may interact to create a fire hazard within the patient’s thorax. On completion the chest is irrigated with normal saline or sterile water. Thoracostomy tubes can then be placed and positioned under direct visualization, utilizing the developed port sites, and the lung reexpanded prior to wound closure. Following the procedure a chest x-ray should be obtained and the thoracostomy tubes can be managed using the same principles utilized following open thoracic surgery.
There is wide variably in reported mortality after thoracic injury. Blunt trauma results in mortality as high as 68%.1,2 This is probably related to higher ISS, lower GSC, and more associated nonthoracic injuries than those with penetrating injuries.4,6 There is also variation in the reported mortality with penetrating trauma. Cardiac and major vascular injuries and the percentage of major pulmonary resections all contribute to poorer outcomes.4,8 In a high-risk group of patients with penetrating injury requiring urgent lobectomy or pneumonectomy, the mortality was 38% and 66%, respectively, with pulmonary complications occurring in over half of the survivors.31 The need for laparotomy has also been shown to increase mortality among those with penetrating trauma requiring thoracotomy.4,11
Several studies have demonstrated an increase in mortality with the magnitude of the pulmonary resection. Comparing nonanatomic with anatomic resection, the mortality was 4% and 77%, respectively.10This difference may not solely reflect the extent of resection since the severity of the lung trauma, the presence of a centrally located or hilar injury, more often requires an anatomic resection. The correlation of increased mortality with the extent of lung resection has been well documented.4,9 Again this finding may reflect the degree of the parenchymal injury that necessities a more extensive resection. Systolic blood pressure on arrival to the operating room is also associated with increased mortality.4,9
Complications of Injury to the Lung
Pneumonia is the most common complication of lung injury. The relative risk of developing pneumonia is closely linked to the need for subsequent mechanical ventilation. Patients requiring intubation are approximately seven times more likely to contract pneumonia than those who do not require mechanical ventilation after thoracic injury.1 Of all patients admitted with the diagnosis of pulmonary contusion (Fig. 25-5), nearly 50% will develop pneumonia, barotraumas, and/or major atelectasis, and one fourth will go on to develop acute respiratory distress syndrome (ARDS).1
For all patients with concomitant rib fractures, pain control remains of paramount importance to maintain good pulmonary mechanics unimpeded by splinting from pain. The resulting atelectasis and poor clearance of secretions creates a situation that increases the risk for subsequent pneumonia. For these patients, placement of a thoracic epidural should be strongly considered. A prospective, randomized trial by Bulger et al. found that epidural use for patients with pain due to multiple rib fractures resulted in significantly fewer ventilator days and decreased incidence of pneumonia.32
Intrapleural or extrapleural analgesic delivery systems also represent a promising potential pathway for pain control, but have been comparatively less well studied. For cases involving chest wall instability, it has also been suggested that operative chest wall stabilization may decrease ventilatory requirements and pain.
It has been estimated that tube thoracostomy fails to evacuate hemothorax completely in over 5% of cases.33 While the natural history of these collections of undrained blood in a violated space remains unknown, known sequela of retained hemothorax include fibrothorax and lung entrapment. The most common and worrisome complication of retained hemothorax, however, is empyema. A retained hemothorax is a known independent risk factor for the development of an empyema.34
The diagnosis of retained hemothorax requires computed tomography of the chest, as plain radiography has been shown to be insufficient for this purpose.35 Once identified, the optimal evacuation method for retained blood within the chest after initial chest tube placement remains a matter that has not been well investigated. Observation, placement of an additional thoracostomy tube, the use of intrapleural thrombolytics, and VATS have all been proposed.
VATS, particularly when utilized early in the course of retained hemothorax, has a high success rate and affords minimal risk to the patient.36 The initial choice of evacuation technique may prove important, as it has been shown that 17% of patients with retained hemothorax require subsequent thoracotomy after failure of less-invasive treatments.37 At present, a prospective, observational, multicenter trial on the management of retained hemothorax is being conducted by the American Association for the Surgery of Trauma. This study may provide considerable insight into the appropriate management of this sequela of thoracic trauma.
Empyema is diagnosed via documentation of an exudative effusion or from positive culture of intrapleural fluid. In approximately 25–30% of cases, cultures will be negative due to suppression, but not eradication, of bacterial growth by antibiotics.38 The optimal treatment of empyema has not been definitively studied, but trauma patients are at higher risk of gram-positive multiloculated empyema less amenable to simple drainage due to the presence of hemothorax. Additionally, the robust inflammatory response associated with infections of this type in trauma patients commonly means that patients require decortication and evacuation to ensure full lung reexpansion.
Empyema has been described as occurring in three “stages.” The first, typically within 1–7 days, is referred to as the “acute” or “serous” phase. During this phase, the likelihood of the process being treated successfully by tube thoracostomy is increased compared to more mature stages of infection. Vigorous inflammation in this early phase of infection, however, is sometimes associated with failure of simple drainage. Beyond the first 7 days, loculations and progressive pleural obliteration occur as the hallmarks of the second “subacute” and third “chronic” phases of empyema. In these latter stages of infection, effective drainage with a tube thoracostomy drainage alone is highly unlikely to effectively treat the process and thoracotomy with operative drainage and decortication is the mainstay of therapy.1,39
Persistent Air Leak and Bronchopleural Fistula
Individuals sustaining thoracic trauma may develop air leaks from both the proximal airways and the lung parenchyma due to a variety of reasons. A true bronchopleural fistula is a centrally located communication between the pleural cavity and the lobar or segmental bronchi. These types of communications are uncommon following trauma, unless the patient has required a pulmonary resection during his or her care and has developed a leak from a closure of a proximal airway conduit. Most post-traumatic leaks are actually communications with the distal airway conduits and can be more accurately termed parenchymal–pleural or alveolar–pleural fistula.
Persistent air leaks of this type can be challenging entities to manage, as large leaks occurring in a patient requiring mechanical ventilation can contribute to loss of effective tidal volume, resulting in increased ventilation–perfusion mismatch and respiratory acidosis. The diagnosis in these patients is usually not a subtle event, with persistent air bubbling through the water-seal chamber of the thoracostomy tube collection system.
For the most common peripheral leaks, care is primarily supportive. Methods that can be utilized to promote resolution of these leaks include minimizing transpulmonary pressures, especially end-inspiratory plateau pressure as tolerated if the patient is mechanically ventilated, as well as using the minimum chest tube suction necessary to keep the lung inflated. These measures will minimize the flow of gas across the fistula and promote healing. A few patients will still have a persistent air leak. We generally wait 5–7 days before considering operative exploration. In addition, we routinely obtain a CT before proceeding with operation. Some patients have residual pneumothorax that helps perpetuate the air leak. Inserting a pigtail catheter can be helpful to coapt the lung up against the chest wall to help seal the leak.
Pneumatocele and hematoma of the parenchyma are sequela of lung lacerations. Not surprisingly, these are often more visible on computed tomography imaging than traditional plain radiographic exams. These lesions usually resolve over several weeks, although this period may prove variable depending on size and location. Uncommonly, pneumatoceles may become infected and should then be treated in a similar fashion as a lung abscess.
Lung abscesses after trauma can occur as a result of aspiration, complications of severe or necrotizing pneumonia, retained foreign body, or infected traumatic injury. Initial therapy for these lesions consists of antibiotics, postural drainage, and bronchoscopy. Percutaneous drainage may be required in select cases, but can be associated with subsequent air leak and potential ventilation difficulties. This approach also liberates the infection into the pleural space, frequently necessitating the need for subsequent thoracotomy to relieve the resulting lung entrapment and to adequately clear infection.
Ruptured abscesses, likewise, commonly require operative treatment via thoracotomy with resection of the abscess cavity if this can be accomplished safely. At the time of operation, the lung tissue surrounding abscess cavity is frequently exceptionally friable, necessitating great care with resection. In critically ill or tenuous patients, drainage with thoracostomy or percutaneous techniques alone may prove the most prudent and effective course of action, even if thoracotomy is needed later.40
Primary traumatic chylothorax is an uncommon occurrence after traumatic injury. This condition can manifest in a delayed fashion with recurrent effusions of persistent, milky, chest tube output associated with oral diet. The diagnosis can be established by analyzing the content of the effusion and documenting the presence of fat (triglyceride levels greater than 110 mg/dL) with or without predominant lymphocytes in the effusion. The primary complication of chylothorax is nutritional deprivation and compromise of immune function.41
Treatment includes promotion of full lung expansion to promote tamponade and use of parenteral nutrition. The length of parenteral nutrition use that should be employed is not well established. Octreotide can also be utilized as an adjunct. If conservative treatment with pleural drainage, parenteral nutrition, and octreotide fails to promote resolution over several weeks, or if the patient continues to deteriorate nutritionally, interventional or operative occlusion should be undertaken.
Tracheobronchial injuries are infrequent, but potentially life-threatening consequences of trauma. These injuries are far more common in the neck, where the trachea does not have the protection of the bony thorax. Both mechanism and location are important factors to consider in managing these patients. The most common cause of blunt injuries is high-speed motor vehicle crashes.42 Penetrating injury, also more common in the neck, can occur after either stab or gunshot wounds. Iatrogenic injuries occurring during emergent airway procedures, while rare, represent another potential source of injury in the trauma population.43
The cervical trachea is more commonly injured from penetrating trauma and the distal trachea from blunt trauma.44–46 Most penetrating injury of the cervical trachea, while straightforward to repair, may be associated with injury to vessels, esophagus, thoracic duct, and nerves.47 Because of the large amount of energy needed to cause blunt tracheal injury, concomitant injuries in both the neck and other body regions are frequent.44
Laryngeal trauma is a specific subset that needs to be considered separately. The superficial location of the larynx increases its risk of injury from anterior blunt force trauma. The proximity of the laryngeal nerves places them in jeopardy as well. Minor injuries that will heal without complication can be managed nonoperatively. More severe laryngeal injuries will require surgical repair and a variety of techniques can be utilized including simple suture repair, external plate fixation, and internal stabilization with a T-tube.47–52
The operative management of the tracheobronchial tree, particularly within the thorax, requires expertise in a number of surgical approaches and various operative techniques that may be required for appropriate repair. Likewise, the perioperative management of these patients demands vigilance against the onset of pulmonary complications.
Presentation and Evaluation
Cervical tracheal injuries are often obvious on physical exam. In the case of penetrating injury, there may be large volume of subcutaneous air and/or air exiting within the missile tract. This often fluctuates with the patient’s respiratory status. In the case of blunt trauma, there is often massive subcutaneous emphysema in the neck. Patients often present with respiratory distress and require urgent airway stabilization.
Patients with major airway injury within the thorax may not have such obvious signs on physical exam. The classic patient with an injury to the distal trachea or proximal major bronchial structure will present with a very large pneumothorax. When a chest tube is inserted, it usually has a very large air leak and the lung may not completely reexpand. In the case of penetrating injury, these findings may not be as dramatic. Hemoptysis may be present but is not a reliable finding.
Patients with suspected tracheal or major airway injury should undergo emergent bronchoscopy (Fig. 25-7). Flexible fiber-optic bronchoscopy is the technique most often used. Common indications for bronchoscopy include a bullet trajectory in proximity to the airway or clinical signs raising the suspicion of an airway injury such as hemoptysis, hoarseness, subcutaneous emphysema, and/or suspicious findings on a CT scan. Flexible bronchoscopy has the advantages of being able to be performed in the emergency department. In the case of penetrating trauma, gunshot wounds are more likely to be associated with an abnormal bronchoscopy when compared to knife wounds.
FIGURE 25-7 Tracheal injury visualized with preoperative bronchoscopy.
In these patients, the bronchoscopy must be performed carefully to avoid missing any injury. While some patients have obvious injury at the time of bronchoscopy, more often the findings are far more subtle. The entire circumference of the trachea must be examined. Mucous and blood must be suctioned clear to be sure the endoscopist is able to get a clear look of the entire distal tracheal surface. Each main stem bronchus must be suctioned clear and examined.
If the cervical trachea is at risk and the patient is intubated, the endotracheal tube may well have been inserted distal to the area of suspected injury. In these cases, the endotracheal tube should be withdrawn using the bronchoscope as a guide. Ideally, the endotracheal tube should then be positioned at the level of the vocal cords. This allows the endoscopist to examine the proximal trachea. When the examination is complete, the endotracheal tube can be threaded distally over the bronchoscope and repositioned.
As the CT scanning has evolved, it is now sometimes used in the evaluation of potential trachea injuries. In the case of penetrating injury, a trajectory that is clearly away from the trachea should effectively rule out the possibility of a tracheal injury. Signs such as edema within the tracheal wall should prompt further investigation. Three-dimensional reformatting of the images can sometimes demonstrate a tracheal injury, though a negative study does not effectively rule out the presence of an injury.
The management of a tracheobronchial injury must begin with two critical procedures. First, a secure airway must be established. An emergency airway is required in 29% and 43% of patients presenting with airway injury. Compared to a distal tracheal injury, an emergent airway is more frequently required for laryngotracheal trauma.44–46 Endotracheal intubation, establishing a surgical airway, and directly intubating the tracheal laceration are all acceptable techniques.45,46 The risk of converting a partial tracheal laceration into a complete disruption during intubation can be minimized by intubating over a flexible bronchoscope. Second, the location and extent of the airway injury must be completely characterized. The patient must be evaluated for esophageal, vascular, and concomitant cavitary injuries.
The second issue is that of intraoperative management. Cooperation between the anesthesiologist and the surgeon cannot be overemphasized. A well-defined plan for intraoperative airway management and contingencies must be discussed between the surgeon and the anesthesiologist prior to the start of the operation. Most cases can be managed with a single-lumen endotracheal tube and a reinforced tube should be considered. If necessary, the airway can be intubated over the operative field (Fig. 25-4). Any potential advantage of a double-lumen tube is negated by possible complications in placing it, not the least of which is further airway trauma.
The surgical repair is facilitated by keeping the mean airway pressure as low as possible while consistent with adequate oxygenation and ventilation. In selected instances high-frequency ventilation may provide a quieter operative field and improved surgical exposure.49,50 Cardiopulmonary bypass and/or ECMO are rarely needed but in selected cases can be lifesaving. Examples are patients with severe pulmonary contusions and/or ARDS requiring high driving pressure ventilation, intrathoracic tracheal injuries with concomitant great vessel injury or cardiac injury, and complex carinal disruption.53
Although operative repair is the mainstay of treatment for tracheobronchial injuries, in highly selected patients there is limited role for both stent placement and nonoperative management.53 Conservative management is reserved for small (<2 cm), nontransmural tears, especially in those who are severely injured.54,55 There are limited data on the use of stents in the treatment of traumatic airway injuries; therefore, this modality must be individualized and considered on a case-by-case basis.53,56–58 Since most tracheobronchial injuries are amenable to primary repair, there must be compelling reasons to choose an alternative option.
Appropriate tracheal exposure is determined by the anatomic location of the airway injury. It is essential to precisely locate the injury and its extent by bronchoscopy. Arterial blood supply to the trachea is segmental in nature and arises from the inferior thyroid and bronchial vessels. The proximal half of the trachea can be exposed through a collar incision. Occasionally it is necessary to divide the manubrium to the level of the angle of Louis, which provides improved exposure of the mid-trachea and allows control of the great vessels. A full sternotomy offers no additional advantage unless there is a concomitant cardiac injury.
The distal half of the trachea, the right main stem, and proximal left main stem bronchus are best approached through a right posterolateral thoracotomy. Widely opening the mediastinal pleura, and doubly ligating and dividing the azygous vein will provide superior tracheal exposure (Fig. 25-8). If an esophageal injury has been excluded, placing an esophageal bougie will facilitate the dissection between the esophagus and trachea. The distal left main stem bronchus is best approached through a left posterolateral thoracotomy (Fig. 25-9). Mobilization of the aortic arch will improve exposure especially if the injury extends more proximally on the main stem bronchus.
FIGURE 25-8 Intraoperative photograph of a distal tracheal repair. The mediastinal pleura is widely opened and tacked with stay sutures. The endotracheal tube is visible through the tracheal defect.
FIGURE 25-9 Intraoperative airway management using a single-lumen endotracheal tube during repair of a ruptured main stem bronchus. (Reproduced with permission from Maurice Hood R, ed. Thoracic Surgery: Techniques in General Thoracic Surgery. Philadelphia: WB Saunders Company; 1985.)
The technical details of the tracheal repair, while straightforward, require attention to detail. Lacerations are repaired with interrupted absorbable sutures. If the injury is more severe but not a near or total transaction, debridement to healthy tissue is necessary. Following debridement the repair is performed as for a laceration. Extensive circumferential injures necessitate end-to-end anastomosis preserving the blood supply to avoid suture line ischemia (Fig. 25-6). Rarely does a significant length of trachea need to be resected. If necessary, additional length can be achieved by mobilizing the trachea by blunt dissection in the avascular pretracheal plane.
Other maneuvers such as laryngeal release are rarely needed. In extreme circumstances approximately half of the trachea can be resected and a primary repair performed. Whichever method is chosen, precise mucosa to mucosa apposition and an airtight, tension-free repair are mandatory. When placing the sutures, care must be taken to avoid the endotracheal tube balloon. When placing some sutures, it may be necessary to deflate the balloon and temporality interrupt ventilation to protect the balloon. If there is a concomitant vascular or esophageal injury, the possibility of postoperative fistula formation increases and vascularized muscle should be interposed between the suture lines.
The postoperative goal is early extubation except in complex repairs or in those with another reason for mechanical ventilation. If postoperative ventilation is required, the balloon cuff ideally should be positioned distal to the repair using the bronchoscope. Securing the endotracheal tube to the teeth with wire suture helps prevent migration. Early patient mobilization, aggressive chest physiotherapy, and humidified oxygen are all important in the postoperative period. Approximately 1 week after surgery flexible bronchoscopy should be preformed to assess the repair, and can also be used as needed to aid in clearing secretions.
Because of small sample size, mechanism, associated injuries, and need for emergent airway, the results among published reports vary. In a study of 57 patients with penetrating cervical airway injury, 81% had an isolated tracheal injury and the mortality was 3.5%.55 This compares favorably with a 5% operative mortality among 26 patients with penetrating trauma, half of whom had an associated esophageal injury.59 In a larger series of 71 patients, the mortality with a blunt mechanism was 63% and that for penetrating trauma was 13.5%.60 These authors concluded that blunt mechanism and the need for an emergency airway were independent predictors of mortality.
The influence of associated injuries on mortality is striking. In studies where over half of the patients had associated injuries, the mortality was as high as 21%, with almost all deaths secondary to the concomitant injury, especially vascular trauma.61–63 Morbidity can be as high as 19% and often results from an associated injury.62,63 Delay in diagnosis, missed esophageal injuries, and associated injuries all correlate with increased morbidity and mortality. Therefore, a thorough evaluation and expeditious exploration are imperative.
Complications of Tracheobronchial Injuries
Tracheal stenosis is an uncommon but potentially devastating complication of injury to the airway. Promoted by inflammation, scar, and injury characteristics, tracheal stenosis may manifest subtly and requires a high index of suspicion for detection in the earliest stages. Initial symptoms may be missed, or attributed to reactive airway diseases such as asthma or chronic obstructive pulmonary disease. The diagnosis can be made with high-resolution CT or even with appropriate flow-volume loop assessments. However, direct bronchoscopic visualization remains the gold standard of evaluation. Once identified, initial treatment consists of insuring a secure airway for patients with high-grade lesions. Subsequent therapy consists of rigid or balloon dilational techniques that should be performed under direct visualization. Airway stents have been utilized for cases of stenosis due to malignancy, but are not as well described for use due to post-traumatic stenosis.
Surgical treatment for airway obstruction is typically reserved for severe and relatively short lesions. The surgical treatment for post-traumatic stenosis varies by location of the stenosis, but most commonly consists of end-to-end anastomosis or tracheal sleeve resection. Even after resection, the anastomotic site is prone to recurrent stenosis and may necessitate multiple dilations, reoperation, or even permanent tracheostomy.64
INJURIES TO THE ESOPHAGUS
Injuries to the esophagus are serious, but rare, sequela of trauma. As with tracheal injuries, esophageal injuries are more common in the neck than within the thorax due to the protection of the bony thorax. Blunt injuries to the esophagus are very rare, but can occur due to a direct blow against a hyperextended neck or less commonly due to rupture secondary to overpressure of the esophagus.1 The majority of esophageal injuries occur due to penetrating injuries, but these injuries are not commonplace even among busy urban trauma centers. The largest multicenter study of penetrating esophageal injuries to date was conducted by the American Association for the Surgery of Trauma and involved 34 trauma centers in the United States. Only 405 penetrating esophageal injuries were identified over a span of 10.5 years. The majority of these (88%) had associated injuries.59
Esophageal injuries are associated with both high mortality and morbidity rates. The diagnosis of these injuries must be rapid, as delay in identification of these injuries is associated with increased risk of both esophageal-related and overall complications. Once identified, the definitive treatment of esophageal trauma requires a comprehensive understanding of appropriate surgical techniques and prompt intervention in order to optimize outcome.
Presentation and Evaluation
Any patient with a trajectory adjacent to the esophagus requires evaluation. Physical exam may be helpful in patients at risk for cervical esophageal injury. It is far less helpful in excluding thoracic esophageal injury. Saliva exiting an entrance would seem to make the diagnosis of esophageal injury. Other than that, there are really no hard signs of cervical esophageal injury on physical exam. However, signs that should alert the clinician for the possibility of esophageal injury include painful swallowing, subcutaneous emphysema, and hematemesis. Unfortunately, these findings are relatively nonspecific and occur in less than one quarter of patients with penetrating injury to the neck. In addition, only 18% of patients who have these findings will have an esophageal injury identified.65
Patients with thoracic esophageal injury may present with concomitant pneumothorax or hemothorax from associated injury to the lung and/or vascular structures. A tube thoracostomy should then be placed. Patients with pure esophageal injury may have a hydrothorax, which will appear identical to a hemothorax on chest x-ray. The drainage in the chest tube should be examined. If it is obviously saliva or has food substance in it, an esophageal injury should be high on the list of possibilities. Confirmatory testing should be performed immediately.
Contrast esophagography has traditionally been the test used to evaluate both the cervical and the thoracic esophagus. If performed with good technique, the entire esophagus should be able to be evaluated. In patients who are intubated, the contrast can be instilled via a nasogastric tube that is pulled back to the proximal esophagus. The ability to truly evaluate the proximal portion of the cervical esophagus using this technique is certainly not 100%. Other studies may be preferable. In one recent series, contrast esophagoscopy was used in 82% of patients with suspected esophageal injury, while esophagoscopy was used in the other 18%.66
Contrast studies may miss esophageal injuries. Even if films are performed in two planes, contrast studies do not provide a true three-dimensional evaluation of the esophagus. In one series, contrast esophagography missed one third of injuries in the esophagus later diagnosed with rigid esophagoscopy. Several techniques exist. Some advocate performing a flush study with water-soluble contrast. If no leak is identified, the study can be repeated using barium that should miss a smaller number of injuries. Others simply use barium. This should be safe as barium is relatively inert and extravasation into the mediastinum will not cause additional morbidity.
Obtaining high-quality contrast studies may be difficult, particularly in off-hours. Esophagoscopy is certainly an alternative. Acute care surgeons should be trained in esophagoscopy and therefore able to perform these studies at any time. Flexible esophagoscopy is most often used. However, rigid esophagoscopy may be superior to flexible esophagoscopy and has been advocated as the study of choice in some centers. Rigid esophagoscopy is no longer part of surgical training in most institutions. Flexible esophagoscopy does not require general anesthesia and can be done in the emergency department. It has a negative predictive value of 100% but a positive predictive value of only approximately 33%.67,68
It would seem reasonable that a combination of flexible esophagoscopy and a contrast study should be able to make the diagnosis of esophageal injury in virtually every patient. It is imperative that an esophagoscopy be done carefully. While a few patients will have obvious injury at the time of endoscopy, many patients will have much more subtle endoscopic findings such as hemorrhage in the mucosa. An esophageal wall defect may not necessarily be obvious. This may explain the relatively low positive predictive value that has been reported in literature. The entire circumference of the esophagus must be carefully evaluated. Those patients with concerning findings on esophagoscopy should undergo either an additional study or exploration.
CT scanning has become more popular in the evaluation of penetrating injury to the mediastinum, including the esophagus. Following penetrating injury, CT can often define the trajectory of the missile and determine whether the esophagus is at risk or not. If oral contrast has been administered, CT may well be able to identify contrast pooling outside of the esophagus. The ability to get a three-dimensional evaluation of the mediastinum potentially makes CT more attractive than a simple contrast study. Three-dimensional reformatted images may allow the clinician to obtain a relatively sophisticated look at the esophagus. However, CT is a static exam and one cannot see contrast moving through the esophagus, as is possible with the more dynamic esophagography.
The topic of esophageal injures often encompasses spontaneous rupture, iatrogenic and chemically induced perforations, and external trauma. Published reports frequently include most or all of these etiologies in their analysis and description of management, with external trauma usually the least frequently described.69–71 Because esophageal injury is uncommon, most studies are composed of small series,71 and this topic is further complicated by reports based on anatomic location or mechanism alone.70–72 Although many of the principles developed for the treatment of nontraumatic esophageal injury are applicable to the external esophageal trauma management, there are several important differences. Successful nonoperative treatment of specific iatrogenic injury has been described.69–71 While this approach may be appropriate in selected cervical injury, it must be utilized judiciously, as surgical repair remains the mainstay of treatment of esophageal injury resulting from external trauma.
A brief description of esophageal anatomy and vascular supply is important to fully appreciate surgical exposure, mobilization, and repair. The esophageal wall is composed of inner and outer muscular layers but lacks a serosa. The cervical esophagus is predominantly a left-sided structure and as it descends into the thorax it courses to the right. The largest angulation occurs at the esophagogastric junction as the esophagus passes through the diaphragm to lie left of the midline in the abdomen. Arterial supply to the cervical and a portion of proximal esophagus arises from the thyroidal vessels. The thoracic esophagus is supplied by multiple aortic branches and bronchial vessels, and blood supply to the distal esophagus is derived from the left gastric artery. The intramural vasculature courses longitudinally.
Exposure of the cervical esophagus is achieved via the left neck. Mobilizing the cervical esophagus is accomplished by lateral retraction of the sternocleidomastoid and blunt dissection in the prevertebral plane. During this dissection care must be exercised to avoid injuring the recurrent laryngeal nerves that lie in the tracheoesophageal grove. If needed, a rubber drain can be passed around the esophagus to facilitate exposure. A fundamental principle in treating esophageal trauma is visualizing the entire extent of the mucosal injury. The defect in the muscular layer is almost always less extensive than that in the mucosa. The extent of the mucosal defect is exposed by incising the muscular layer until both ends of the mucosal tear are visualized. Esophageal repair is performed in two layers and must be tension free. The mucosa is approximated with interrupted sutures, either absorbable or nonabsorbable, and the muscular layer is closed with interrupted nonabsorbable sutures (Fig. 25-10). Some authors advocate use of a nasogastric tube or bougie to ensure a widely patent repair.69,70 Drains, while not uniformly used, are recommended. In the unusual circumstance where no injury is found at exploration, drainage and antibiotics usually suffice.71,72
FIGURE 25-10 (A) Necrotic mediastinal pleura has been excised, and esophageal tear has been debrided. (B) Elevation of the esophagus on a rubber drain allows for debridement of the right mediastinal pleura if indicated. (C) Debridement of the esophageal rupture. Muscularis is incised superiorly and inferiorly to allow visualization of the extent of mucosal defect before two-layer closure of the perforation if possible. (Reproduced with permission from Alexander Patterson GA, ed. Pearson’s Thoracic and Esophageal Surgery. Vol. 2. 3rd ed. Philadelphia: Elsevier; 2008. © Elsevier.)
Intrathoracic esophageal injuries present a more challenging problem due to the degree of initial mediastinal contamination and extent of the esophageal injury. In addition, an uncontrolled mediastinal leak is more serious than one arising from the cervical esophagus. Historically, time from injury to repair often influenced operative management. This concept has evolved and time, while important, is no longer the main factor. The degree of mediastinal contamination is the principal consideration in determining intraoperative management. The majority of intrathoracic esophageal injuries can be managed similar to those in the cervical region. The surgical approach is through a right thoracotomy. The azygous vein is divided and the lung is retracted. The mediastinal pleura widely opened to expose the esophagus. The esophagus is then mobilized by blunt dissection. Visualization is facilitated by placing a rubber drain around it. Care must be taken to avoid injury to the trachea or main stem bronchi. Devitalized mediastinal and esophageal tissues are debrided.
Following the repair, several tissues can be used as a buttress for the repair. A pedicled intercostal muscle is often used since it is robust and easily harvested.63,69,70–72 (Fig. 25-11). Wide mediastinal drainage is mandatory. A contrast study is performed approximately 1 week postoperatively, and if no leak is noted, oral feedings can be started.
FIGURE 25-11 Construction of intercostal musculopleural flap. (A) Periosteum of the rib inferior to thoracotomy incision is incised, and the subjacent pleura is mobilized. (B) The neurovascular bundle is divided anteriorly, and the flap is created. (Reproduced with permission from Alexander Patterson GA, ed. Pearson’s Thoracic and Esophageal Surgery. Vol. 2. 3rd ed. Philadelphia: Elsevier; 2008. © Elsevier.)
There are several surgical approaches to the distal esophagus or esophagogastric junction including a sixth or seventh interspace left posterolateral thoracotomy, laparotomy, or a thoracoabdominal incision. Injuries to the distal intrathoracic esophagus are best approached via thoracotomy. Widely opening the mediastinal pleura and freely mobilizing the esophagus will enhance exposure. The choice of incision to expose the esophagogastric junction is influenced by the exact location of the injury and associated injuries. If there are concomitant abdominal injuries, laparotomy alone may be sufficient, while associated intrathoracic injuries may be approached by thoracotomy or thoracoabdominal incision. The same principles and techniques are used as previously described. Distal esophageal injuries lend themselves to reinforcement with a fundal wrap.
Regardless of the location, a primary repair buttressed with muscle and adequate mediastinal drainage is the best solution. Esophageal excision and resection with diversion should be avoided, and every effort made to preserve esophageal length. In rare circumstances, the magnitude of the esophageal injury or the patient’s clinical condition precludes definitive repair. In these instances a damage control procedure may be lifesaving. Creating a controlled esophageal fistula by using a T-tube is an effective procedure.69,70,73 This technique, combined with wide drainage, controls mediastinal contamination and preserves esophageal length. Devastating injury to the stomach and esophagogastric junction presents a unique challenge. These are not amenable to T-tube drainage; however, retrograde esophageal drainage may prove useful. Continuity is reestablished by an esophagojejunostomy performed several months later.74
Esophageal trauma results in significant morbidity and mortality. Mortality ranges from 0% to 22%.62,71,75,76 In the large AAST series, the mortality was 19%.59 Complications are common and are often subdivided into those that are esophageal related ranging between 38% and 66%.59,75 With respect to cervical injuries the most common complication is an esophageal fistula, most of which close spontaneously.72 Esophageal-specific complications occur in 29–38% of patients with postoperative leak and infection predominating.59,75 The most important risk factors are delayed operation, magnitude of the esophageal injury, and resection and diversion.59,75 Prompt diagnosis, consideration of a damage control procedure in dire circumstances, and a precise technical repair are the essentials for a satisfactory outcome.
Complications of Esophageal Injury
The diagnosis of esophageal injury must be made rapidly after trauma, as any delay in diagnosis confers significant risk for morbidity and mortality. In the largest study to date of penetrating esophageal injuries, Asensio and colleagues found that patients subjected to lengthy evaluations had higher complication rates overall and esophageal-related complications specifically, compared to counterparts who proceeded directly to operation for diagnosis and received operative treatment in an expedited fashion.59 In another recent study of esophageal perforations due to trauma, iatrogenic injuries, and other causes, Eroglu et al.78 found that survival was significantly influenced by a delay of more than 24 hours in the initiation of treatment.
Suspicion for late esophageal injury must be high depending on the mechanism. In alert patients, pain will be the most common symptom.76,78–80 Other symptoms may include dyspnea, fever, or dysphagia. Subcutaneous emphysema, while not specific or particularly sensitive for injury, may develop early in the course of injury. Utilizing the principles and approaches outlined earlier in this chapter, every effort should be made to rule out definitively esophageal injury whenever it is suspected.
Tracheoesophageal fistula following trauma is, fortunately, exceptionally rare. Any appropriately located injury to the trachea and/or esophagus has the potential to lead to the formation of a fistulous connection between these two structures. In these clinical scenarios it is advisable, therefore, to complete initial tracheal or esophageal repairs with muscle flap coverage interposed between the repairs to protect them from subsequent compromise and fistulization.
The presentation of these patients may be initially subtle. Recurrent pneumonia and persistent cough with unidentified cause alone warrants evaluation in the appropriate patient. The diagnosis can be made with a combination of endoscopy, bronchoscopy, and/or esophageal swallow contrast study. Once diagnosed, treatment most commonly entails surgical intervention and ligation of the fistula with repair of the respective defects and muscle flap coverage. The use of covered tracheal or esophageal stents has been described for patients who are not operative candidates, as has diversion.
Given the anatomic proximity of these two structures, combined injury can occur. While tracheoesophageal injuries can happen anywhere along their course, they occur more frequently in the cervical region, as this is the site of most tracheal trauma. The management of combined tracheoesophageal trauma is essentially the management of each individual injury. Surgical exposure is identical to the approach described above. Technical details include tracheal repair with interrupted absorbable sutures, a two-layer esophageal closure, and muscle interposition.63,71,80 Two alternative techniques have been described, closing the esophagus through the tracheal laceration without interposing muscle and utilizing a tracheal flap to close the esophageal defect.78,81 Mortality has ranged from 0% to 21% and complications were common.63,71,81 While the benefit of muscle interposition had not been proven, it is prudent, adds little operating time, and is widely employed.59,63,71,81
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