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Papaconstantinou D, Kapetanakis EI, Mylonakis A, Davakis S, Kotidis E, Tagkalos E, Rouvelas I, Schizas D. Current aspects in the management of esophageal trauma: a systematic review and proportional meta-analysis. Dis Esophagus 2024; 37:doae007. [PMID: 38366609 DOI: 10.1093/dote/doae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Third Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Adam Mylonakis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Spyridon Davakis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Efstathios Kotidis
- Fourth Department of Surgery, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ioannis Rouvelas
- Center for Digestive Diseases, Karolinska University Hospital and the Division of Surgery and Oncology, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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2
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Evans BA, Craig WY, Cinelli CM, Siegel SG. CT esophagogram in the emergency setting: typical findings and suggested workflow. Emerg Radiol 2024; 31:33-44. [PMID: 38093143 DOI: 10.1007/s10140-023-02193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/27/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide. METHODS Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance. RESULTS EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP. CONCLUSION CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.
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Affiliation(s)
- Brad A Evans
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA.
- University of Wisconsin, 750 Highland Ave., Madison, WI, 53705, USA.
| | - Wendy Y Craig
- MaineHealth Institute for Research, 81 Research Drive, Scarborough, ME, 04074, USA
| | - Christina M Cinelli
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
| | - Sharon G Siegel
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
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Hinen SP, Griffith JP, Chamberlin J, Waltz J, Kocher M, Krull V, Young T, Litvin CB, Varga-Szemes A, Hardie AD. Dual-energy CT iodine overlay improves efficiency of oral contrast leak assessment. Acta Radiol 2023; 64:2357-2362. [PMID: 37157189 DOI: 10.1177/02841851231172771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Evaluation for gastrointestinal leak is a frequent imaging indication, and dual-energy computed tomography (DECT) with oral or rectally administered contrast can be used to improve efficiency and diagnostic confidence. PURPOSE To assess the value of the DECT iodine overlay (IO) reconstruction as a stand-alone image set compared to routine CT in assessing oral or rectal contrast leak from the gastrointestinal system. MATERIAL AND METHODS A blinded, retrospective audit study was performed by three readers who each interpreted 50 studies performed for assessment of oral or rectal contrast leak that were acquired using DECT. Each reader independently assessed both the routine CT images and the images of the reconstructed IO for contrast leak in random order with a six-week "wash-out period" between readings. Clinical follow-up provided the reference standard. Readers recorded the presence/absence of a leak, diagnostic confidence, image quality score, and interpretation time for each image set. RESULTS Pooled data for overall accuracy in identification of a leak increased from 0.81 (95% confidence interval [CI]=0.74-0.87) for routine CT to 0.91 (95% CI=0.85-0.95) with IO, and the area under the curve (AUC) was significantly higher for IO than routine CT (P = 0.015). Readers required significantly less time to interpret IO than routine CT (median improvement of 12.5 s per image using pooled data; P < 0.001) while maintaining diagnostic confidence and perceived image quality. CONCLUSION Use of DECT IO reconstructions for identification of oral or rectal contrast leak requires less time to interpret than routine CT with improved accuracy and maintained diagnostic confidence and perceived image quality.
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Affiliation(s)
- Shaun P Hinen
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Joseph P Griffith
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jordan Chamberlin
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey Waltz
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Madison Kocher
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Veronica Krull
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Tristan Young
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Cara B Litvin
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Andrew D Hardie
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
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Breeze J, Gensheimer WG, DuBose JJ. Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support. Mil Med 2020; 186:18-23. [PMID: 33007083 DOI: 10.1093/milmed/usaa252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/24/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
Introduction
Military trauma registries can identify broad epidemiological trends from neck wounds but cannot reliably demonstrate temporal casualty from clinical interventions or differentiate penetrating neck injuries (PNI) from those that do not breach platysma.
Materials and Methods
All casualties presenting with a neck wound to a Role 3 Medical Treatment Facility in Afghanistan between January 1, 2016 and September 15, 2019 were retrospectively identified using the Emergency Room database. These were matched to records from the Operating Room database, and computed tomography (CT) scans reviewed to determine damage to the neck region.
Results
During this period, 78 casualties presented to the Emergency Room with a neck wound. Forty-one casualties underwent surgery for a neck wound, all of whom had a CT scan. Of these, 35/41 (85%) were deep to platysma (PNI). Casualties with PNI underwent neck exploration in 71% of casualties (25/35), with 8/25 (32%) having surgical exploration at Role 2 where CT is not present. Exploration was more likely in Zones 1 and 2 (8/10, 80% and 18/22, 82%, respectively) compared to Zone 3 (2/8, 25%).
Conclusion
Hemodynamically unstable patients in Zones 1 and 2 generally underwent surgery before CT, confirming that the low threshold for exploration in such patients remains. Only 25% (2/8) of Zone 3 PNI were explored, with the high negative predictive value of CT angiography providing confidence that it was capable of excluding major injury in the majority of cases. No deaths from PNI that survived to treatment at Role 3 were identified, lending evidence to the current management protocols being utilized in Afghanistan.
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Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD, 20762, USA
| | - Joseph J DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
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Madsen AS, Bruce JL, Oosthuizen GV, Bekker W, Smith M, Manchev V, Laing GL, Clarke DL. Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach. BJS Open 2020; 4:704-713. [PMID: 32525254 PMCID: PMC7397367 DOI: 10.1002/bjs5.50282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a ‘no‐zone’ approach to PNI is valid. Methods Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared. Results In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination. Conclusion An approach to PNI based on zones is questionable, and this study supports a no‐zone approach based on imaging guided by clinical examination.
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Affiliation(s)
- A S Madsen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - W Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - M Smith
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - V Manchev
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.
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Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med 2019; 56:499-511. [PMID: 30910368 DOI: 10.1016/j.jemermed.2019.01.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions. OBJECTIVE OF THE REVIEW This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions. DISCUSSION Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes. CONCLUSIONS This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Madsen A, Nair V, Loots E, Kong V, Clarke D. Penetrating Pharyngoesophageal Injuries. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0160-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Blunt Pharyngoesophageal Injury: an Overview of a Rare Entity. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0162-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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ACR Appropriateness Criteria ® Penetrating Neck Injury. J Am Coll Radiol 2018; 14:S500-S505. [PMID: 29101988 DOI: 10.1016/j.jacr.2017.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/31/2022]
Abstract
In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Acevedo E, Sjoholm LO, Santora T, Goldberg AJ. A Review of the Role and Utility of Chest Computed Tomography in Penetrating Chest Trauma. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Salamo RM, Moritz M, Parkar N. Bronchoesophageal fistula: a rare complication of aortic endograft infection. BJR Case Rep 2018; 4:20170061. [PMID: 30363195 PMCID: PMC6159143 DOI: 10.1259/bjrcr.20170061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/02/2017] [Accepted: 09/13/2017] [Indexed: 11/19/2022] Open
Abstract
Endovascular aortic aneurysm repair is an increasingly common approach for aortic aneurysm repair. Infection of the prosthetic is a rare, but devastating complication which may result in the well-known aortoenteric or aortobronchial fistulae. Bronchoesophageal fistula resulting from an infected aortic endograft has not yet been reported in the literature. Early recognition of the symptoms and prompt imaging confirmation are essential for treating an otherwise highly morbid diagnosis.
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Affiliation(s)
- Russell Mark Salamo
- Department of Radiology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Michael Moritz
- Department of Radiology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Nadeem Parkar
- Department of Radiology, Saint Louis University School of Medicine, St. Louis, MO, USA
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Abstract
Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms "non- iatrogenic", "esophageal", "trauma", "diagnosis", "management", and "prognosis". Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.
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Madsen AS, Oosthuizen G, Laing GL, Bruce JL, Clarke DL. The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury. J Surg Res 2016; 205:490-498. [DOI: 10.1016/j.jss.2016.06.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/11/2016] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
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