Esophagogastric Trauma in Scotland

Current aspects in the management of esophageal trauma: a systematic review and proportional meta-analysis

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13-25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49-0.89, P = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32-73%), with 68% of patients having associated injuries (95% CI 43-94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1-6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14-8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases.

Could blunt trauma lead to a double lumen esophagus?

INTRODUCTION AND IMPORTANCE

Esophageal rupture and perforation are serious complications of blunt abdominal trauma. Early diagnosis and intervention is key for patient survival. Studies have reported that mortality of patients with esophageal perforation can be as high as 20-40 % (Schweigert et al., 2016; Deng et al., 2021 [1, 2]). We present a patient with suspected esophageal perforation after a blunt trauma identified by esophagogastroduodenoscopy (EGD) as the presence of a second gastroesophageal lumen concerning for esophagogastric fistula.

CASE PRESENTATION

Our patient is a 17-year-old male with no past medical history who was brought in from an outside facility status post electric bike accident. CT imaging from an outside hospital showed concern for possible esophageal rupture. On arrival, he was in no acute distress. Patient underwent a fluoroscopy upper GI series which showed extravasation of fluid outside the lumen, indicating an esophageal injury. Patient was evaluated by Gastroenterology and Cardiothoracic surgery, who agreed on an empiric course of piperacillin/tazobactam and fluconazole for prophylaxis in the setting of suspected esophageal rupture. Patient underwent an esophagram with EGD which demonstrated a 2nd false lumen from 40 to 45 cm. This appeared to be from incomplete avulsion of the submucosal space. No contrast extravasation was seen with the esophagram.

CLINICAL DISCUSSION

To date, there has been no published case of trauma induced formation of a double lumen esophagus. Our patient presented with no previous history to suggest chronic or congenital double lumen of the esophagus.

CONCLUSION

When considering esophageal rupture, the possibility of the formation of an esophago-gastric fistula should be considered via external traumatic insult.

Laparotomy for penetrating gastric trauma - A South African experience

INTRODUCTION

Penetrating gastric injury (PGI) is common and although primary repair is sufficient for most injuries, several areas surrounding the peri-operative management remain contentious. This study reviews our experience in the management of PGI and review the clinical outcome at a major trauma centre in South Africa.

MATERIALS AND METHODS

A retrospective study was conducted from January 2012 to April 2020 at a major trauma centre in South Africa.

RESULTS

210 cases were included (184 male, median age: 30 years). Mechanism of injury was 59% stab wounds (SWs) and 41% gunshot wounds (GSWs). The AAST grade was predominantly (92%) grade 2 for all cases. 20% (41/210) were isolated gastric injuries. All cases underwent primary repair and there were no cases of suture line failure. Eleven cases (5%) had one or more injuries not identified at the index laparotomy: 7 were unidentified gastric injuries and the remaining 4 were unidentified non gastric injuries. There was no association between unidentified injuries and mechanism of injury or outcome. Fifty-seven (27%) cases experienced one or more complications. Eighty-two cases (39%) required intensive care unit admission. The overall median length of hospital stay was 7 (IQR 4-11) days. The overall mortality was 14%. GSW injuries were more likely to have additional organ injury, higher ISS and PATI scores, longer length of hospitalization, higher likelihood of ICU stay, greater morbidity and mortality than SW injuries. There was a slight increase in the wound sepsis rate as number of associated extra gastric injuries increased but this was not statistically significant. There was no difference in wound overall sepsis rate between SW and GSW injuries (2% vs 8%, p=0.121).

CONCLUSIONS

Primary repair alone is sufficient for most PGI, but laparotomy is associated with high incidence of unidentified injury and surgeons must to be cognisant of the likelihood of these occult injuries.

Blunt gastric rupture: a plural clinical presentation and literature review

Blunt trauma is still the leading mechanism of trauma found in patients admitted to trauma centres worldwide. In these patients, the gastric injury is a very rare lesion, occurring in less than 2% of all blunt traumas. Besides the low incidence, gastric rupture mortality is high, which makes the diagnosis an essential step. Thus, this study aims to report two blunt gastric injuries, with different clinical features, prompting the discussion about the main features of clinical suspicion and diagnosis, besides the main therapeutic approaches. Therefore, this study can alert the medical community to the quick diagnosis and assertive therapy, saving patients of unwelcome endpoints.

Esophageal Trauma: Analysis of Incidence, Morbidity, and Mortality

Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010–2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma ( P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.

Comparative analysis of traumatic esophageal injury in pediatric and adult populations

PURPOSE

Distribution and outcomes of traumatic injury of the esophagus (TIE) in pediatric versus adult populations are unknown. Our study sought to perform a descriptive analysis of TIE in children and adults.

METHODS

We reviewed the National Trauma Data Bank (NTDB) for the years 2010-2015. Demographics, characteristics, and outcomes of pediatric (age < 16 years) and adult TIE patients were described and compared.

RESULTS

Among 526,850 pediatric and 3,838,895 adult trauma patients, 90 pediatric (0.02%) and 1,411 (0.04%) adult TIE patients were identified. Demographics and esophageal injury severity did not differ. Children were more likely to sustain blunt trauma (63% versus 37%), with the most common mechanism being transportation-related accidents, were less-severely injured (median ISS 14 versus 22), and had fewer associated injuries (79% versus 95%) and complications (30% versus 51%) (all p < 0.001). Children had shorter hospitalizations (median 5 versus 10 days) and were more likely to be discharged home (84% versus 64%) (both p = 0.01). In-hospital mortality did not differ significantly between children and adults (10% versus 19%, p = 0.09).

CONCLUSION

TIE in the pediatric population has unique characteristics compared to adults: it is more likely to be a result of blunt trauma, has lower injury burden, and has more favorable clinical outcomes.

Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank

Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010–2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.

Epidemiology of penetrating injuries in the United Kingdom: A systematic review

INTRODUCTION

Penetrating injuries account for a significant number of deaths in the United Kingdom (UK) annually. Numerous articles have examined the epidemiology of penetrating trauma in various areas of the UK. This article aimed to systematically review the current literature and evaluate the incidence and mortality of penetrating injury according to region in the UK.

METHODS

A systematic literature search was performed using MEDLINE^® (1946 to June 2016), EMBASE^® (1974 to June 2016), and PsycINFO^® (1806 to June 2016) databases. The following keywords were used in combination with Boolean operators: "epidemiology", "incidence", "frequency", "pattern", "distribution"; "penetrating"; "injuries", "injury", "trauma"; "United Kingdom", "UK", "England", "Scotland", "Wales", "London".

RESULTS

Eleven relevant studies were identified across five regions of the UK. Study periods ranged from 3 months to 16 years and encompassed between 343 and 127,191 patients. Relative incidence within individual studies ranged from 0.3% (Midlands) to 21.0% (London) and mortality ranged from 0.5% (London) to 15.4% (Midlands). The majority of patients were young males.

DISCUSSION

An extensive range of incidence and mortality rates were observed between studies in all regions. This was largely dependent on the study population under review. London was found to have the highest incidence of penetrating injuries, however these studies tended to focus on populations of trauma patients. The high proportion of male victims may reflect the risk of becoming involved in gangs and violence.

CONCLUSIONS

Our ambiguous results indicate the need for further work directed towards the epidemiology of penetrating injuries within regional trauma networks.

Total esophageal avulsion at the esophagogastric junction after blunt trauma

Total avulsion and transection of the esophagus at the esophagogastric junction are very rare after blunt trauma, and their management is challenging. Here, we present the case of a boy with this injury. To date, only two cases have been reported in children. One was treated successfully and the other died. The initial emergency operation should aim to save the life and native esophagus. Therefore, a primary or early thoracal end esophagostomy with gastrostomy should be performed, while primary repair should not be.