Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma

Thoracic Trauma: Current Approach in Emergency Medicine

Chest trauma is the leading cause of death in people under 40. It is estimated to cause around 140,000 deaths each year. The key aims are to reduce mortality and the impact of associated complications to expedite recovery and to restore patient's conditions. The recognition of lesions through appropriate imaging and early treatment already in the emergency department are fundamental. The majority can be managed in a non-surgical way, but especially after traumatic cardiac arrest, a surgical approach is required. One of the most important surgical procedures is the Emergency Department Thoracotomy (EDT). The aim of this review is to provide a comprehensive synthesis about the management of thoracic trauma, the surgical procedures, accepted indications, and technical details adopted during the most important surgical procedures for different thoracic trauma injuries. Literature from 1990 to 2023 was retrieved from multiple databases and reviewed. It is also important to emphasize the medico-legal implications of this type of trauma, both from the point of view of collaboration with the judicial authority and in the prevention of any litigation.

Blunt esophageal injury in the setting of multitrauma: A case report

Blunt esophageal injury is an unusual organ injury that has unclear clinical symptoms due to the overlap of thoracoabdominal trauma in the setting of multiple traumas. The treatment options vary depending on the patient's clinical symptoms, the extent of esophageal damage, and the time from the onset of damage to diagnosis. This article presents a case of a young male patient receiving emergency treatment after a traffic accident. Esophageal perforation was diagnosed through chest computed tomography with contrast injection and oral contrast. The article focuses on imaging characteristics and suggestive signs of blunt esophageal injury in the setting of multitrauma.

Diagnostic approach to penetrating neck trauma: What you need to know

ABSTRACT

Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

The role of radiology in diagnosing gastrointestinal tract perforation

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study

BACKGROUND

Traumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP.

METHODS

Retrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome.

RESULTS

Patients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant.

CONCLUSION

E-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.

Operative Management of Aerodigestive Injuries: Improved Survival Over two Decades

INTRODUCTION

Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival.

METHODS

Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant.

RESULTS

95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury.

CONCLUSION

Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade.

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.

Esophageal Stab Wounds Repaired Endoscopically: A Case Report and Comprehensive Literature Review

Esophageal injuries are typically iatrogenic after endoscopic/surgical procedures, but they are rarely caused by penetrative or blunt trauma. We present a case of patient who suffered multiple stab wounds to the neck and underwent surgical repair for hemorrhagic shock but was ultimately diagnosed and treated successfully via endoscopy for a thoracic esophageal injury. Early detection is imperative and usually diagnosed via contrast studies but less commonly via direct visualization endoscopically. Moreover, endoscopic treatment is also less commonly utilized, even if diagnosed from that modality. Cervical injuries also confer a lower mortality than thoracic injuries.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Atypical Firearm Injury to the Anterior Triangle of the Neck With an Unusual Projectile Trajectory: A Rare Case Report

The use of firearms is increasing in our society, which increases the incidence of gunshot injuries in developing countries like India. Gunshot injuries in the neck regions are significantly associated with high mortality and morbidity because of the major vascular and other vital structures present in the neck. However, it's very rare that a bullet may have a trajectory that passes through the neck region and does not damage the vital structures. We present one such case of gunshot injury to the neck. A 20-year-old male reported to the emergency department after sustaining a gunshot wound to the left anterior cervical region of the neck. On examination, the right sternocleidomastoid muscle was taut and tender to the touch. It is very rare that a bullet injury in the neck without damage to even a single vital structure. The most critical steps in managing patients with high-velocity penetrating injuries to the head and neck region are securing an airway, controlling hemorrhage, and identifying and repairing residual traumatic deformities at the earliest possible key points for the best outcome.

Acute Pericarditis Hiding an Esophageal Perforation

Esophageal perforations due to foreign body ingestion are uncommon; however, they can be associated with extremely high mortality rate. The most dreadful complication of this entity is the infection of adjacent structures, namely, the mediastinum and the pericardium. A prompt diagnosis and a precocious start of treatment are essential to the prognosis. Thus, a high degree of suspicion is required, especially in older patients. Therapeutic options are highly variable, depend on several factors, and should be individualized to every patient and their clinical status. Surgical treatment with esophageal exclusion and diversion, in extreme circumstances, is mandatory to control the infection source site and prevent further contamination. We report a case of esophageal perforation, presenting 48 hours after onset, that led to multifactorial shock (septic and cardiogenic) due to pericarditis with pericardial and pleural effusion.

Penetrating esophageal injury: A diagnostic challenge in resource-limited settings; a case report

Introduction

Penetrating injuries to the upper aerodigestive tract are potentially life-threatening, with significant morbidity and mortality. Although rare, the cervical esophagus is the most vulnerable part of the esophagus to penetrating injuries. Given the unique and condensed anatomy of the neck, penetrating injuries to the second zone of the neck pose a demanding challenge. Contention exists in diagnosing and managing penetrating esophageal injuries.

Case presentation

Herein is a case of a young male with a penetrating neck injury from the left lateral aspect with subsequent esophageal injury. An early primary repair with muscle buttress resulted in admirable results.

Discussion

Accurate diagnosis and timely management are critical in deflating morbidity and mortality. Flexible esophagoscopy and Computed tomography with water-soluble contrast are the ideal modalities for diagnosing penetrating neck injuries, as clinical evaluation alone can readily overlook cervical esophagus injury. The esophageal repair depends on the patient's clinical condition, the extent of damage, anatomical location, and duration of the injury. Management varies from a conservative approach to radical esophagectomies. Surgery remains a cornerstone in managing penetrating esophageal injuries. Primary repair with an external drain is advocated within 24 h of injury.

Conclusion

A high index of suspicion and timely diagnosis are critical in successfully managing penetrating esophageal injuries. Neck injuries demand a comprehensive evaluation for any aerodigestive or vascular leaks. Early primary repair with a muscle buttress improves the chance of an effective repair.

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Penetrating esophageal injuries are rare, with high morbidity and mortality.

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Appropriate investigations are critical in the evaluation of neck injuries.

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Early diagnosis and timely surgical management are crucial in outcomes of management.

Approaches to Repair of Penetrating Injuries of the Proximal, Mid, and Distal Esophagus

INTRODUCTION

Traumatic esophageal injuries represent less than 10% of traumatic injuries. Penetrating injuries represent an even smaller but more lethal percent. Esophageal injuries can be cervical, thoracic, or abdominal with decreasing frequency. Cervical and thoracic esophageal injuries represent >80% of these injuries and are more morbid. Morbidity and mortality are increased with delayed identification. Although diagnosis can be hard, management is similar despite location.

CASES

We present 3 cases of esophageal injuries to the cervical, thoracic, and abdominal esophageal segments with descriptions on diagnosis, repair, and management differences.

DISCUSSION

Despite low incidence of penetrating esophageal injuries, morbidity and mortality are extremely high, especially with associated injuries. Early identification and treatment is paramount. Anatomical knowledge is necessary for successful surgical management. Primary repair in 2 layers should be attempted whenever possible including musical closure with absorbable suture. Flaps, diversions, wide drainage, and feeding tube access should always be key surgical considerations. Flaps can include sternocleidomastoid muscle for cervical injuries, intercostal muscle, diaphragm, and pericardium for thoracic injuries and "Thal" gastric flaps for gastroesophageal junction and abdominal injuries. Successful identification and management can lead to increased survival.

Primary repair: damage control surgery in esophageal trauma

Esophageal trauma is a rare but life-threatening event associated with high morbidity and mortality. An inadvertent esophageal perforation can rapidly contaminate the neck, mediastinum, pleural space, or abdominal cavity, resulting in sepsis or septic shock. Higher complications and mortality rates are commonly associated with adjacent organ injuries and/or delays in diagnosis or definitive management. This article aims to delineate the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia, on the surgical management of esophageal trauma following damage control principles. Esophageal injuries should always be suspected in thoracoabdominal or cervical trauma when the trajectory or mechanism suggests so. Hemodynamically stable patients should be radiologically evaluated before a surgical correction, ideally with computed tomography of the neck, chest, and abdomen. While hemodynamically unstable patients should be immediately transferred to the operating room for direct surgical control. A primary repair is the surgical management of choice in all esophageal injuries, along with endoscopic nasogastric tube placement and immediate postoperative care in the intensive care unit. We propose an easy-to-follow surgical management algorithm that sticks to the philosophy of "Less is Better" by avoiding esophagostomas.

A Rare Outcome From a Self-Inflicted Gunshot Wound to the Neck

The incidence of self-inflicted gunshot wounds has increased significantly in the civilian population. In this case, we present a 25-year-old male with a self-inflicted gunshot wound to the neck exiting to the left shoulder. Penetrating injuries to the neck carry a high likelihood of severe injury and death. Exsanguination due to damage to the carotid or vertebral arteries is the most common cause of immediate death. Traumas caused by gunshot wounds can be complicated by an unusual path and can be devastating, depending on the extent of the injury. Our patient presents with a unique singular outcome of a spinal cord injury from anterior penetrating neck trauma. The aim of this case report is to raise awareness of a unique outcome from a self-inflicted gunshot wound, as it is vital to be aware of all possible outcomes because these injuries become more prevalent in our communities.

Transgastric repair of transfixing gastroesophageal junction gunshot wound: video case report

Managing traumatic injuries of the gastroesophageal junction (GEJ) is infrequent due to associated lesions of adjacent highly vascularized organs. Its anatomical localization in the upper abdomen makes the repair challenging to perform. A stable 23-year-old male was presented at the emergency department with two thorax gunshot wounds. Computed tomography revealed air in the periesophageal space and right hemopneumothorax with no injury of the major vessels. A chest tube was placed and the patient was transferred hemodynamically stable to the operating. Abdominal exploration identified injuries to the left diaphragm; liver lateral segment; 1-cm transfixing perforation of the GEJ and right diaphragmatic pillar. Primary repair of the GEJ was performed and patched with a partial fundoplication. The diaphragm was repaired and the liver bleeding controlled. Finally, drains and a feeding jejunostomy were placed. The patient had an uneventful early postoperative course and was discharged home on the 12th postoperative day.

CT Esophagography for Evaluation of Esophageal Perforation

Esophageal emergencies such as rupture or postoperative leak are uncommon but may be life threatening when they occur. Delay in their diagnosis and treatment may significantly increase morbidity and mortality. Causes of esophageal injury include iatrogenic (including esophagogastroduodenoscopy and stent placement), foreign body ingestion, blunt or penetrating trauma to the chest or abdomen, and forceful retching, also called Boerhaave syndrome. Although fluoroscopic esophagography remains the imaging study of choice according the American College of Radiology appropriateness criteria, CT esophagography has been shown to be at least equal to if not superior to fluoroscopic evaluation for esophageal injury. In addition, CT esophagography allows diagnosis of extraesophageal abnormalities, both as the cause of the patient's symptoms as well as incidental findings. CT esophagography also allows rapid diagnosis since the examination can be readily performed in most clinical settings and requires no direct radiologist supervision, requiring only properly trained technologists and a CT scanner. Multiple prior studies have shown the limited utility of fluoroscopic esophagography after a negative chest CT scan and the increase in accuracy after adding oral contrast agent to CT examinations, although there is considerable variability of CT esophagography protocols among institutions. Development of a CT esophagography program, utilizing a well-defined protocol with input from staff from the radiology, gastroenterology, emergency, and general surgery departments, can facilitate more rapid diagnosis and patient care, especially in overnight and emergency settings. The purpose of this article is to familiarize radiologists with CT esophagography techniques and imaging findings of emergent esophageal conditions. Online supplemental material is available for this article. ^©RSNA, 2021.

A Review of "Options in Management of Trauma to the Esophagus" (1982) "Submitted for the Literary Festschrift in Honor of J. David Richardson, MD"

This article is an update of a paper which Dave Richardson and I published in 1982, and serves as both an update of management of esophageal injuries and as a lasting tribute to my mentor and hero J. David Richardson.

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study

BACKGROUND

Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting.

METHODS

This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications.

RESULTS

Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management.

CONCLUSION

Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed.

LEVEL OF EVIDENCE

Therapeutic, level IV.

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.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

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.

Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series

Background

Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries.

Materials and methods

A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level.

Results

Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects.

Conclusion

Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome.

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Sixteen patients were treated for esophageal injuries at the PRTH.

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Two patients suffered blunt esophageal trauma and 14 patients had penetrating trauma to the esophagus.

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Most patients had a prompt diagnosis of traumatic esophageal perforation, while 3 patients had a delayed diagnosis.

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Regarding esophageal location, of the 16 patients, 9 presented cervical, 6 thoracic, and 1 abdominal esophageal injury.

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Only 2 deaths occurred among our 16 patients, including 1 in delayed diagnosed subjects.

Esophageal emergencies: WSES guidelines

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Management of cervical tracheoesophageal injuries: A 2018 EAST Master Class Video Presentation

This video techniques article focuses on the choice of incision, and repair techniques, for cervical injuries to the trachea and esophagus.

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.

Management of traumatic esophageal injuries

Traumatic esophageal perforations are rare but difficult to treat injuries. We review the principles of work-up, anatomy and treatment of cervical, thoracic and abdominal traumatic esophageal perforations. Management is dictated by location of the perforation and any concurrent injuries. The majority of cases are amenable to primary repair with flap re-enforcement. Other principles include adequate drainage around the repair, decompression of the esophagus and stomach (via nasogastric tube or gastrostomy tube) and distal enteral nutrition (feeding jejunostomy).

Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.

Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma: A single-center review of 86 cases

BACKGROUND

This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM).

METHODS

This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation.

RESULTS

Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19-8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13-6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks.

CONCLUSION

Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration.

LEVEL OF EVIDENCE

Clinical Management Study, Level V evidence.

Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Defining the gastroesophageal junction in trauma: Epidemiology and management of a challenging injury

BACKGROUND

Injuries to the gastroesophageal (GE) junction are infrequently encountered because of the high mortality of associated injuries. Consequently, there is a paucity of literature on the patient demographics and treatment options. The aim of this study was to examine the epidemiology, surgical management, and outcomes of these rare injuries.

METHODS

Patients presenting to LAC + USC Medical Center (January 2008 to August 2016) with traumatic esophageal or gastric injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification and 10th Rev. codes) were extracted from the trauma registry. Patient charts were reviewed, and all patients who sustained an injury to the GE junction were enrolled. Patient demographics, injury characteristics, procedures, and outcomes were analyzed.

RESULTS

Of the 238 patients who sustained an injury to the esophagus or stomach during the study period, 28 (12%) were found to have a GE junction injury. Mean age was 26 years (range, 14-57 years), 89% male. Mechanism of injury was penetrating in 96% (n = 27), the majority of which were gunshot wounds (n = 22, 81%). Most patients (n = 18, 64%) were taken directly to the operating room. Ten (36%) underwent computed tomography scan before going to the operating room, all demonstrating a GE junction injury. All patients underwent repair via laparotomy. One (4%) also required thoracotomy to facilitate delayed reconstruction. GE junction injuries were typically managed with primary repair (n = 22, 79%). Associated injuries were frequent (n = 26, 93%), and injury severity was high (mean Injury Severity Score, 25 [9-75]). Mortality was 25% (n = 7), and all patients required intensive care unit admission. Most did not require total parenteral nutrition (n = 25, 89%) or a surgically placed feeding tube (n = 26, 93%). Of the 13 patients who presented for clinical follow-up, all but one (n = 12, 92%) were eating independently by the first clinic visit.

CONCLUSION

GE junction injuries are uncommon and occur almost exclusively after penetrating trauma. Patients are severely injured with a high mortality rate and frequently have associated intracavitary injuries. Most can be fixed through the abdomen alone and do not require thoracotomy for repair. Despite the severity of injuries, the majority of survivors are eating independently by the first clinic visit.

LEVEL OF EVIDENCE

Epidemiological, level V.

Evaluation of the use of tomography in penetrating neck trauma

OBJECTIVE

the study has the intention of evaluate the accuracy of computed tomography for the diagnosis of cervical lesions on penetrating neck trauma and also identify the most frequent mechanisms of trauma. Most injured structures, determine the age range and the most prevalent sex.

METHODS

observational descriptive retrospective study executed by the systematic retrospective review of medical records of all patients victims of penetrating neck trauma that went through surgery and CT scans, admitted into Hospital do Trabalhador, between January 2009 and December 2013.

RESULTS

the final sample was of 30 patients, 96.7% of the male sex, the median age was of 28 years old. Most patients suffered injuries by gun (56.7%) and 33,3% suffered stab wounds. The most stricken area of the neck was Zone II (77.8%) and the left side (55.2%). Regarding the structures injured, the CT showed 6.7% lesions on airways but the surgery showed 40% of damaged, with a value of p=0.002. As to damages of the esophagus and pharynx the CT detected 10% of lesions, while surgery found 30% of lesions, therefore with a significant value of p=0.013. As for the analysis the CT showed reliable. As for the analysis of vascular damage, the CT showed to be, in most cases, reliable to the findings during the surgical act.

CONCLUSION

besides the great use of CT for the diagnosis of penetrating neck injuries we can say that this is an exam with low accuracy for the diagnosis of lesions of aerodigestive tract, therefore it is important a clinical correlation for a good diagnosis.as for the vascular lesions and of other structures, the CT had high sensibility and specificity, thus a good exam to be used in overall.

Esophageal perforation due to blunt chest trauma: Difficult diagnosis because of coexisting severe disturbance of consciousness

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis.

Management of esophageal injuries secondary to trauma

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.

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

BACKGROUND

Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality.

METHODS

This National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications.

RESULTS

A total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p = 0.008), 30-day mortality (4.2 vs. 9.3%, p = 0.005), and overall mortality (7.9 vs. 13.5%, p = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV-V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148-0.546; p < 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06-2.53; p = 0.026).

CONCLUSIONS

Despite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival.

TRIAL REGISTRATION

iStar, HS-16-00883.

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

Thoracic trauma: principles of early management

Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.

Conservative management of gunshot oesophageal injuries: A report of two consecutive exceptional cases

INTRODUCTION

Oesophageal trauma carries high mortality and morbidity. For penetrating intrathoracic oesophageal injury, surgical repair has been the standard for decades to avoid its devastating consequences.

CASE REPORT

Both patients presented with a thoracoabdominal gunshot wound and retained intraabdominal missile. Although there were no visible signs of perforation on oesophagoscopy or contrast swallow, the presence of an intraluminal bullet highly suggested a thoracic oesophageal injury.

DISCUSSION

Non-operative management of intrathoracic oesophageal perforation is controversial. Small perforations or contained leaks diagnosed within 24-48 h in a stable patient with no mediastinitis or empyema can be managed non-operatively with antibiotics and nasogastric feeds. These two case reports support the notion of selective non-operative management of asymptomatic patients with penetrating injury to the oesophagus.

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.

An audit of penetrating neck injuries in a South African trauma service

INTRODUCTION

This study reviews and validates the practice of selective non-operative management (SNOM) of penetrating neck injury (PNI) in a South African trauma service and reviews the impact new imaging modalities have had on the management of this injury.

METHODOLOGY

This study was performed within the Pietermaritzburg Metropolitan Trauma Service, in the city of Pietermaritzburg, Kwazulu-Natal, South Africa. A prospectively maintained trauma registry was retrospectively interrogated. All patients with PNI treated over a 46-month period were included within the study.

RESULTS

A total of 510 patients were included in the study. There were 452 stab wounds (SW) and 58 gunshot wounds (GSW). A total of 202 (40%) patients sustained isolated PNI, the remaining 308 (60%) patients sustained trauma to at least one additional anatomical region. An airway injury was identified in 29 (6%) patients; a pharyngo-oesophageal injury in 41 (8%) patients and a vascular injury in 86 (17%) patients. Associated injuries included three penetrating cardiac injuries (PCI) and 146 patients with haemo-pneumothoraces. Of the total cohort, 387 patients (76%) underwent CT Angiography (CTA), of which 70 (18%) demonstrated a vascular injury. Formal catheter directed angiogram (CDA) was performed on 16 patients with positive CTA but confirmed injury in only half of these patients. Of 212 patients (42%) who underwent water-soluble contrast swallow (WS-swallow), an injury was demonstrated in 29 (14%) cases. A total of 401 (79%) patients were successfully managed conservatively for PNI and 109 (21%) surgically or by endovascular intervention. Only five (1.2%) patients failed a trial of SNOM and required surgery. The in-hospital mortality rate was 2%. No deaths could be attributed to a failure of SNOM.

CONCLUSION

SNOM of PNI is a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity, is associated with a low yield. CTA has a significant false positive rate and good clinical assessment remains the cornerstone of management.