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Ann Thorac Surg 1995;59:845-849
© 1995 The Society of Thoracic Surgeons

Noniatrogenic Esophageal Trauma

Department of Surgery, University of Tennessee College of Medicine, Memphis, Tennessee

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 849.

Esophageal injuries can present uncommon technical problems. The complexity of the injury increases greatly if there is a concomitant injury of the trachea. If the trachea and esophagus are injured simultaneously, repair of the airway is jeopardized when it becomes infected by the salivary stream coming from an unrecognized esophageal injury or a leaking esophageal repair. Because the consequences of a failed tracheal repair are so devastating, the recognition of a simultaneous esophageal injury must be made and management must be successful.

In an effort to better define how to deal with noniatrogenic injuries of the esophagus, we reviewed our most recent 5-year experience at a regional trauma center.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients and Treatment
From July 1988 to June 1993, nineteen patients with noniatrogenic esophageal injury were identified by the registry at the Elvis Presley Trauma Center at the University of Tennessee. Medical records were reviewed to assess mechanism of injury, types of repair, associated injuries, postoperative complications, and management. Eighteen of these injuries were from gunshot wounds and one was from blunt trauma when the neck struck a steering wheel in an automobile accident. All injuries from gunshot wounds were repaired urgently. The one blunt injury was managed by stopping oral intake and administering antibiotics. All patients had nasogastric tubes placed. Ages ranged from 17 years to 55 years with a median of 22 years. There were 15 male and 4 female patients.

Nine patients had combined tracheal and esophageal injury. All of these combined injuries were from gunshot wounds and all were repaired. Three of these patients with combined injury were explored through transverse cervical incisions (collar incisions) and 6 were explored through oblique cervical incisions (one bilateral). Tracheal repairs were done in a single layer with polypropylene or polyglycolic acid sutures. Esophageal repairs were done in two layers with polyglycolic acid on the mucosal layer and silk suture on the muscular layers. When feasible, viable muscle was placed between the two repairs (Fig 1). Drains were not used except in 1 case where the hypopharynx was injured. Five patients had tracheostomies. In 1 patient a tracheoesophageal fistula that developed later was repaired with a pectoralis muscle flap.

View larger version (283K): [in this window] [in a new window]   Fig 1. . Repair of a combined tracheal and esophageal injury. Stenocleidomastoid muscle is placed between the repairs.

Seven esophageal perforations were in the thoracic (2) and abdominal (5) portions of the esophagus. These injuries were repaired and four were reinforced with a fundal wrap. Postoperative dye studies confirmed that all repairs were intact.

Associated injuries were to the spinal cord (3), lung (7), thyroid gland (1), thumb (1), shoulder (1), brachial artery (1), larynx (1), stomach (4), diaphragm (4), spleen (2), liver (4), arm (2), aorta (1), ankle (1), small bowel (2), colon (1), kidney (1), carotid artery (1), and thoracic duct (1).

Representative Case Histories
TRACHEAL AND ESOPHAGEAL INJURY.
There were 9 cases in which both the trachea and esophagus were injured (Table 1).

Patient 5, a 19-year-old woman, had a gunshot wound of the esophagus and trachea. The trachea was repaired and a tracheostomy was done. The esophagus was repaired in two layers and a strap muscle was placed between the repairs. Two weeks later, a tracheoesophageal fistula measuring 3 cm in length was repaired by placing the sternal head of the sternocleidomastoid muscle between the trachea and esophagus. The fistula recurred. A tracheostomy was placed distal to the fistula and a mushroom catheter esophagostomy was placed. Two months later, a pectoralis major muscle flap with a split-thickness skin graft was used to close the fistula. This patient was paralyzed at the T2 level (from the gunshot wound). She finally was discharged to a nursing care facility 5 months after the initial injury.

Patient 8, a 35-year-old woman, had a gunshot wound that injured the larynx and hypopharynx. A tracheostomy was placed and the larynx was repaired and stented. The hypopharynx was repaired in two layers and a drain was placed. A barium swallow showed no leak, but there was a delay in triggering a swallow. This patient learned to do a supraglottic swallow and was discharged on the twelfth postoperative day.

ESOPHAGEAL NECK INJURY.
Three patients had esophageal wounds in the neck that did not involve the trachea (Table 2).

Patient 11, a 17-year-old boy, was shot in the neck. Barium and Gastrografin (Squibb Diagnostic, Princeton, NJ) did not show a leak, but during exploration, bubbling was seen coming from the esophagus as air was injected down the nasogastric tube. The defect was found and closed. A barium swallow done a week later was normal, and he was discharged on the tenth postoperative day.

THORACIC ESOPHAGEAL INJURY.
Two patients had esophageal wounds in the thoracic portion of the esophagus (Table 3).

ABDOMINAL ESOPHAGEAL INJURY.
Five patients had injuries to the abdominal portion of the esophagus (Table 4).

Patient 18, a 31-year-old man shot in the epigastrium, had a through and through esophageal injury repaired in two layers. The fundus was mobilized and wrapped around the repair over a 50F bougie. Injuries to the liver and diaphragm also were repaired. Contrast studies (Gastrografin and barium) showed a narrowing at the gastroesophageal junction. A wound infection developed and this patient was treated as an outpatient. He went home on the twelfth hospital day.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The 9 patients who had both tracheal and esophageal injuries had unusual problems because of the airway involvement. All 9 had an obvious airway injury at their initial physical examination. All 9 were explored and repaired on an emergent basis. All tracheal injuries were repaired with an interrupted single layer of either polypropylene or polyglycolic acid sutures. Five of these patients had a tracheostomy placed. In this group, all of the esophageal injuries were repaired in two layers. A tracheoesophageal fistula developed in 1 patient. The other patients healed with no leaks.

Five of the patients with combined tracheal and esophageal injury had a muscle flap of either sternohyoid, sternothyroid, or sternocleidomastoid muscle placed between the repairs. The patient in whom a tracheoesophageal fistula developed had a muscle flap (sternohyoid) placed at the initial operation. This patient eventually was repaired with a pectoralis muscle flap after a previous attempt at closure (with sternocleidomastoid) had failed.

In 1 patient with a tracheal and esophageal injury, an esophageal stricture developed, which was dilated successfully.

Three patients had injuries to the cervical esophagus that did not involve the trachea. One patient was managed nonoperatively with antibiotics and cessation of oral intake. The other 2 patients in this group had the esophagus repaired in two layers. All of these patients did well. The repairs of the seven esophageal injuries in the chest and abdomen all healed.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Our series looks exclusively at patients with noniatrogenic esophageal injuries.

Most reports dealing with esophageal injuries include patients with Boerhaave's syndrome and patients with iatrogenic perforations. These patients often have other medical problems as well as underlying esophageal pathology, and clearly are different from the usual trauma patient who is generally younger and otherwise in good condition. The course of the esophagus puts it in contact with several other organs that also may be injured. Associated injuries have a detrimental effect on the final outcome.

The Neck
Twelve of our patients had injuries to the cervical esophagus and in 9 of these the injury involved the trachea. Respiratory distress, obvious air leak from the cervical perforation, and subcutaneous emphysema are the findings commonly seen from a major tracheal injury. At our institution, neck injuries with violation of the platysma are not always explored. In stable patients being observed, bronchoscopy, contrast study of the esophagus (barium or Gastrografin), and evaluation of the neck vessels are done. There are false negatives with all of the above studies, so all patients must be observed closely and the studies should be repeated or the neck should be explored if the clinical course suggests a missed injury [1].

In a combined tracheal and esophageal injury, the injured tracheal tissue should be debrided to viable tissue before the sutures are placed. The blood supply of the trachea is lateral and segmental, so care must be used in mobilizing and debriding so that the remaining trachea is not devascularized, which would result in tracheomalacia, tracheal stenosis, or breakdown of the repair [2].

A suture line leak of the cervical esophagus usually can be managed by opening the neck incision. However, with a tracheal repair, more aggressive treatment of an esophageal leak is warranted to protect the tracheal repair. In this situation, irrigation and repair of the esophagus with placement of a viable muscle flap may salvage the situation. If the esophageal leak is large and puts the tracheal repair in jeopardy, the salivary stream can be diverted with a ``spit fistula'' or a T tube. Reconstruction of the esophagus can be done after the tracheal repair has healed.

The 1 patient in our series who had a breakdown of the tracheal repair (patient 5) had a large tracheoesophageal fistula that was not recognized until it was 3 cm in length. Findings that act as clues to the development of a tracheoesophageal fistula include (1) increasing volume loss from the respirator, (2) need to increase the volume of the cuff on the endotracheal tube, (3) presence of a nasogastric tube along with a cuffed tube in the trachea, and (4) eructation with each breath from the respirator. The presence of a fistula can be confirmed by bronchoscopy or esophagoscopy. The presence of a tracheoesophageal fistula mandates surgical repair.

If an esophageal injury is suspected but not found, a nasogastric tube placed in the cervical esophagus can be used to insufflate air. Water placed in the wound will have bubbles coming through a small perforation. For extensive injuries, a stomach pull-up or a colon interposition or a jejeunal graft have been used to restore gastrointestinal continuity [3].

Other groups have described how difficult a combined injury to the trachea and esophagus can be. Feliciano and associates [1] reported 23 patients with combined tracheal and esophageal injury. Major complications occurred in 17 of these patients (74%) and there were four deaths. Shama and Odell [4] had 3 patients with combined tracheal and esophageal injury. In 1 an empyema developed from an esophageal leak.

Thoracic Esophagus
Two wounds of the thoracic esophagus were treated by primary closure and drainage.

Cohn and colleagues [5] described 23 wounds of the thoracic esophagus, about half of which were iatrogenic. Five of 10 patients treated with simple drainage died. These patients all had severe associated disease and were not considered to be suitable for an operation. Four of the 13 patients operated on died; all were more than 24 hours from the time of their injury.

Noniatrogenic injuries of the thoracic esophagus must be recognized early. The wound edges can be debrided and the esophagus repaired in one or two layers. If possible, the repair should be reinforced with pleura, viable muscle, or serosa from a fundal wrap [6–16].

Nonoperative management can be done for some esophageal perforations [17], but this may lead to complications because it may be difficult to distinguish a contained injury from one that can cause extensive mediastinitis.

Abdominal Esophagus
Because most penetrating injuries of the abdomen are explored early, prompt recognition of an esophageal injury is the usual scenario. This allows for early repair and reinforcement with a fundal wrap. All 5 of our patients with this injury did well with this management.

Conclusions
Injuries to the esophagus should be repaired as soon as possible. Injuries of the thoracic and abdominal esophagus usually can be debrided and closed primarily. Placement of a pleural patch, a muscle flap, or a serosal patch can reinforce the repair.

Patients who sustain a tracheal injury along with their esophageal wound are at risk for the development of major complications such as a tracheoesophageal fistula, breakdown of the tracheal or esophageal repairs, pneumonia, and mediastinal abscess. The risk of these complications can be lowered by early recognition of the injuries and appropriate repair of the trachea and esophagus with placement of a viable muscle between the repairs. Drainage is not always necessary.

With esophageal injuries, associated injuries seem to increase the incidence of complications. These patients should be observed closely for signs and symptoms that would allow early intervention to minimize the damage of these complications.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10--12, 1994.

Address reprint requests to Dr Weiman, Division of Cardiothoracic Surgery, Department of Surgery, University of Tennessee, 956 Court Ave, Suite G212, Memphis, TN 38163-2116.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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10. Campbell FC, Robbs JV. Penetrating injuries of the neck: a prospective study of 108 patients. Br J Surg 1980;67:582–6.[Medline]
11. Cheadle W, Richardson JD. Options in management of trauma to the esophagus. Surg Gynecol Obstet 1982;155:380–4.[Medline]
12. Popovsky J, Lee YC, Berk JL. Gunshot wounds of the esophagus. J Thorac Cardiovasc Surg 1976;72:609–12.[Abstract]
13. Sheely II CH, Mattox KL, Beall AC, et al. Penetrating wounds of the cervical esophagus. Am J Surg 1975;130:707–11.[Medline]
14. Pate JW. Tracheobronchial and esophageal injuries. Surg Clin North Am 1989;69:111–23.[Medline]
15. Defore Jr WW, Mattox KL, Hansen HA, et al. Surgical management of penetrating injuries of the esophagus. Am J Surg 1977;134:734–8.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Darryl S. Weiman William A. Walker James W. Pate Timothy C. Fabian Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weiman, D. S. Articles by Fabian, T. C. Search for Related Content PubMed PubMed Citation Articles by Weiman, D. S. Articles by Fabian, T. C. Related Collections Related Article