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Esophageal Trauma

Mohammad Vaziri MDThoracic Surgeon

Iran University of Medical SciencesMember of

European Society of Thoracic SurgeonsNew York Academy of Sciences

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Esophageal TraumaEsophageal TraumaII--Injuries to the Cervical EsophagusInjuries to the Cervical EsophagusIIII--Injuries to the Thoracic EsophagusInjuries to the Thoracic Esophagus

11--Intraluminal Penetrating TraumaIntraluminal Penetrating TraumaInstrumentalInstrumentalForeign body injuriesForeign body injuriesBarotraumaBarotraumaBoerhaave’sBoerhaave’s syndromesyndromeUnusual injuries Unusual injuries

22--Extraluminal Penetrating TraumaExtraluminal Penetrating TraumaGunshot/Stab wound Gunshot/Stab wound –– Thermal Thermal Operative trauma Operative trauma –– Blunt traumaBlunt trauma

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Esophageal TraumaEsophageal Trauma

IIIIII--Abdominal Esophageal PerforationAbdominal Esophageal Perforation

IVIV--Drug Induced Esophageal InjuriesDrug Induced Esophageal Injuries

VV--Chemical TraumaChemical Trauma

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INJURIES OF THE CERVICAL ESOPHAGUSMost injuries are iatrogenic:

Endoscopic procedures Endotracheal tube placementBougienageEmergent tracheostomyAirway stent placement

Impacted swallowed foreign body External trauma due to gunshot or stab wounds Chemical burns

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Symptoms and Signs of Cervical Esophageal Injury

Unusual difficulty or the occurrence of bleeding during the endoscopyPain and stiffness in the neck DysphagiaRespiratory distress FeverDysphonia Cervical tenderness. Crepitation

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Symptoms and signs of cervical esophageal injury

Radiographic examination of the neck may reveal ØAir in the fascial planesØ Widening of the retroesophageal spaceØObliteration of the normal cervical vertebral curvatureØMassive pneumomediastinumØRetroesophageal abscess with an air-fluid level

In most patients with instrumental perforation of the cervical esophagus, neither radiographic examinationwith the use of a contrast medium nor esophagoscopy is indicated because they frequently fail to identify thesite of perforation

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Management of Perforating Esophageal Injuries

Anterior cervical mediastinotomyRepair of the lacerationDrainage of the areaRepair of the perforation is best performed with

interrupted, non-absorbable,fine sutures.

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Extraluminal Injuries of the Cervical Esophagus

Cervical esophagus is injured in only about 0.5% of penetrating neck injuries.

Gunshot wounds are the most common cause of injury

Frequently are associated with an injury to the trachea, thelarge vessels of the neck, the spinal cord, or a

combination of these.

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Extraluminal Injuries of the Cervical Esophagus

Subcutaneous emphysema from an isolated injury of the esophagus occurs only in about one third of cases

When crepitus is palpable, a combined injury of the trachea and esophagus must be considered.

Occasionally, radiographs of the chest reveal a pneumomediastinum, but this finding almost always indicates concomitant airway injury.

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Extraluminal Injuries of the Cervical Esophagus (Repair)

Drains should be left in place until oral feedingshave been reinstituted (5 to 7 days) and there is no evidence of an esophagocutaneous fistula.

Aspiration of the oropharyngeal secretions, as well as appropriate antibiotics, should be used in all these injuries.

If the trachea and esophagus were injured simultaneously >>> rotation of a flap of viable muscle between the repair of the esophagus and that of the trachea.

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INJURIES TO THE THORACIC ESOPHAGUSIntraluminal Penetrating Trauma

Intraluminal penetrating injuries are separated into four categories:

(a) Instrumental(b) Foreign body injuries(c) Non instrumental (barotrauma)(d) Rare causes

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Intraluminal Penetrating Injuries of the Thoracic EsophagusInstrumental injuries

Esophagoscopic proceduresBougienagePneumatic dilationBiopsy of esophageal massEndotracheal tube placementMalposition of a Sengstaken-Blakemore tubeTransesophageal echocardiographyErosion of an esophageal carcinomaSclerotherapy for esophageal varicesTransesophageal sclerosal therapy for bleeding Mallory-Weiss tear

Foreign body injuriesBarotrauma

Pneumatic from compressed air sourceBoerhaave's syndrome ("spontaneous rupture")Blunt trauma

Rupture of a Barrett's ulcer ..Necrotizing esophagitis in immunocomproimised patientsAssociated with a Zollinger-Ellison syndrome

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Intraluminal Penetrating Injuries of the Thoracic EsophagusInstrumental InjuriesMay occur during diagnostic or therapeutic proceduresThe incidence to be about 0.4% in routine diagnostic examination.The actual number of perforations might be increasingbecause of more frequent use of the flexible esophagoscope.The more common sites of perforation are at two of thenormal anatomic sites of narrowing : the distal end as it reaches the diaphragm to join the stomach, and the area of narrowing at the level of the aortic arch and left main stem bronchus.

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Clinical Presentation of Thoracic Esophageal Perforation

Contamination of the visceral mediastinum >>> Perforation of the mediastinal pleural layer >>> Contamination of the affected pleural space.

The left pleural space is usually involved when the injury isin the most distal portion of the esophagus

The right, when the perforation is more proximal in the esophagus.

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Clinical Presentation of Thoracic Esophageal Perforation

Pain, fever, dysphagia, respiratory distress.The pain may be thoracic, precordial, or even epigastric.Radiation of the pain may occur to the intrascapular

region.Tachycardia frequently is disproportionate to the degree of

temperature elevation.The degree of respiratory distress varies with the severity

of the pleural contamination, the amount of hydropneumothorax, and, at times, the presence of airway compression.

Excessive thirst may be present.

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Clinical Presentation of Thoracic Esophageal Perforation

The infection may spread and involve othermediastinal structures : the pericardium or even the

CNSA localized mediastinal abscess >>> esophageal-

subarachnoid fistula >>> spinal and cranial meningitis.

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Diagnostic Procedures in thoracic esophageal perforation

Radiographic examination of the chest may reveal Widened mediastinal shadow Mediastinal airAir or fluid, or both, in either pleural spacePneumopericardium Air in the spinal cord

The radiologic examination may be normal in 12% to 33% of the cases

Barium esophagographyChest CT scan

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Management of Thoracic Esophageal PerforationsThe management of these injuries is based on four

principles: (a) elimination of the source of soilage(b) provision of adequate drainage(c) antibiotics(d) adequate nutrition.

The time of institution of therapy is of less importance than formerly believed

At present immediate surgical intervention is recommended

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Management of Thoracic Esophageal Perforations

Nonoperative strategy - Cameron criteriaThe perforation is contained within the mediastinum - the

contrast material drains readily back into the esophageal lumen - no clinical signs of sepsis

Sawyer criteria(a) a recent perforation (within 24 hours), (b) no food

intake after the episode of perforation, (c) the perforation not proximal to a stenosis, (d) without clinical signs of sepsis (e) a contained perforation within the mediastinum, and (f) contrast studies showing good drainage from a small perforation

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Operative Management of Esophageal Perforations

Primary closurePrimary closure with buttressing of suture linesMuscle flap closure

Intercostal muscleLatissimus dosi muscleRhomboid muscleDiaphragmatic muscle

Exclusion and diversionT-tube drainageEsophagectomy

Primary reconstructionDelayed reconstruction

Intraluminal stentMinimally invasive repairs

Video-assisted thoracic surgeryLaparoscopic abdominal approach

Drainage only

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Operative Management of Esophageal Perforations

Primary closure, usually with buttressing of the suture line is recommended

Regardless of the amount of time that has elapsed since the occurrence of the esophageal perforation.

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Operative Management of Esophageal Perforations

The use of fibrin glue to obtain or to support aprimary repair of a perforated esophagus. It has been used to seal the suture line, to obtain

better adherence of a transposed muscle flap The use of an absorbable mesh-polyglactin mesh

(over the primary repair)

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Operative Management of Esophageal PerforationsWhen the perforation has occurred after a pneumatic

dilation for achalasia :1- mobilize the lower esophagus and to perform a modified

Heller esophagomyotomy opppsite the site of the perforation. If the integrity of the diaphragmatic hiatus has been compromised, an anti-reflux procedure should be done.

2- the esophageal wound is debried and the entire length of the mucosal tear is exposed and securely closed. An intercostal muscle flap is then sutured to the edges of the ruptured esoghageal muscle to ensure a tight closure. The approximation of the muscle flap to the ruptured edges of the esophageal muscle maintains the myotomy created b the balloon dilation.

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Operative Management of Esophageal Perforations

When the esophageal injury has occurred in or above an obstructing lesion, direct repair of the esophageal injury is contraindicated unless the obstructing lesion can be corrected at the same time.

If not >>> diversion of oropharyngeal and gastric secretions with adequate drainage of the mediastinal and pleural space.

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Operative Management of Esophageal Perforations

Another technique in the management of a patient with perforation that is difficult to close (a friable esophageal perforation or one in which the diagnosis has been markedly delayed) is the use of a T tube to establish a controlled fistula

First described by Abbott and associates in 1970,this technique may be considered as an acceptable alternative in a poor-risk patient.

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Operative Management of Esophageal Perforations

In patients with carcinoma or other serious accompanying esophageal disease (mega-esophagus, severe reflux with major strciture, severe lye burn) esophagectomy may be considered as the treatment of choice

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Minimally Invasive Techniques in Esophageal Perforations

Intraoperative endoscopy is performed to assist in identifying the site of perforation. The suspected region can be submerged under irrigation during endoscopic insufflation to pinpoint the precise location of perforation.

If the defect is small (< I cm) and surrounded by viable tissue, a primary closure can be performed with interrupted sutures.

Perforations involving an esophageal diverticulum can be managed by minimally invasive diverticulectomy and drainage

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Mortality and Morbidity

In 11 reports in the literature beginning in 1995 through early 2003, 327 patients with esophageal perforationswere reported, and an overall mortality rate of 11.9%was recorded.

Early morbidity in most series is mainly due to a leak from the suture line

Persistent empyemaLate dysphagia

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References

11--Shields TW. Esophageal trauma. In: Shields TW, Locicero J, Ponn Shields TW. Esophageal trauma. In: Shields TW, Locicero J, Ponn RB, Rusch VW,editors. General Thoracic Surgery. RB, Rusch VW,editors. General Thoracic Surgery. 66thed. thed. Lippincot; Lippincot; 20052005. P: . P: 21012101--21202120

22--Sung SW, Park JJ, Kim YT, Kim JH. Surgery in thoracic Sung SW, Park JJ, Kim YT, Kim JH. Surgery in thoracic esophageal perforation: primary repair is feasible. Dis Esophagus. esophageal perforation: primary repair is feasible. Dis Esophagus. 20022002; ; 1515((33): ): 204204--99

33--Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg. esophageal perforations: a decade of experience. Ann Thorac Surg. 2003 2003 Apr; Apr; 7575((44): ): 10711071--44

44--Rosiere A, Mulier S, Khoury A, Michel LA. Management of Rosiere A, Mulier S, Khoury A, Michel LA. Management of esophageal perforation after delayed diagnosis: the merit of tissue esophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement. Acta Chir Belg. flap reinforcement. Acta Chir Belg. 2003 2003 Oct; Oct; 103103((55): ): 497497--501501

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ReferencesReferences

55--Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. esophageal perforation. Ann Thorac Surg. 2004 2004 Apr; Apr; 7777((44): ): 14751475--8383

66--Jougon J, Mcbride T, Delcambre F, Minniti A, Velly JF. Primary Jougon J, Mcbride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave’s syndrome whatever the free esophageal repair for Boerhaave’s syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac interval between perforation and treatment. Eur J Cardiothorac Surg. Surg. 2004 2004 Apr; Apr; 2525((44): ): 475475--99

77--Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg. perforation. The merit of primary repair. J Thorac Cardiovasc Surg. 1995 1995 Jan; Jan; 109109((11): ): 140140--44

88--Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg. perforation. Ann Thorac Surg. 1995 1995 Aug; Aug; 6060((22): ): 245245--88..

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INJURIES TO THE THORACIC ESOPHAGUSIntraluminal Penetrating TraumaForeign Body Injuries

Sharp foreign bodies lacerate the wall partially or completely. Most commonly, such laceration occurs in the cervical esophagus, but any point of normal narrowing or at a diseased area may be the site of perforation.

Perforation of the wall may occur spontaneously or during the extraction of the foreign body.

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Foreign Body Injuries

Radiographic examinations may reveal the foreign body, but frequently they are negative,

The use of soft tissue techniques, permits visualization of about 75% of ingested bones, and further improvement may be noted with the use of xeroradiography.

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Foreign Body Injuries

Endoscopy with removal of the foreign body is indicated

Esophagotomy is necessary for removal of any foreign body that cannot be removed by endoscopic manipulation.

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INJURIES TO THE THORACIC ESOPHAGUSIntraluminal Penetrating TraumaBarotrauma (Noninstrumental lnjuries)

Rapid increase of the intraluminal pressure within the esophagus may result in partial or complete rupture of the esophageal wall.

Vomiting, defecation, convulsions, lifting, laborof childbirth, blunt abdominal trauma , deceleration injuries, exposure to compressed air, explosion of an inflated tire, carbonated beverages.

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Boerhaave's Syndrome (Spontaneous Rupture)Hermann Boerhaave described the first case of rupture of the

esophagus in 1724.

The etiology of Boerhaave's syndrome is thought to be a rapid increase of the intraluminal pressure of the esophagus that may occur with the act of vomiting

High pressure forced through a patent lower esophageal sphincter against a closed upper esophageal sphincter (the cricopharyngeus muscle)

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Boerhaave's Syndrome (Spontaneous Rupture)Most often, the rupture is located in the distal portion of the

intrathoracic esophagus (the terminal 6 to 8 cm).The injury extends through all layers of the posterolateral

wall on the left.

This is the result of the distribution of the smooth muscle at this location.

The longitudinal fibers taper out as they pass onto thestomach wall, resulting in a weakened area

Lack of support from adjacent structures, the esophagus being covered on its left lateral wall only by the parietal pleura.

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Boerhaave's Syndrome (Spontaneous Rupture)On occasion, a partial disruption occurs.Rarely, extensive dissection of the air within the intramural

layers of the esophagus occurs

A partial laceration of the wall may extend into theproximal stomach and cause major upper gastrointestinal bleeding, the Mallory-Weiss syndrome

In this situation, the problem is control of the bleeding. If bleeding does not stop with supportive management surgical intervention is required: gastrotomy, and suture ligation of the bleeding point.

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Clinical Features of Boerhaave's Syndrome

Varying amounts of bleeding Severe chest pain and dyspnea after an episode of vomiting.Shoulder painSome patients complain only of abdominal painMarked thirst is occasionally observed.

The physical findings: Subcutaneous emphysema is present in most patients

Epigastric tenderness Upper abdominal distentionDecreased Bowel sounds

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Diagnosis of Boerhaave's Syndrome.Radiographic examination:mediastinal emphysema, pleural effusion,

hydropneumothorax,and rarely pneumoperitoneum.

Patchy, irregular density may be visible behind the left cardiac silhouette: V sign

CT with contrast media opacification of the esophagus is especially helpful

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Treatment of Boerhaave 's Syndrome

Direct surgical repair, when there has been either an early diagnosis or a late one, with buttressing of the closure is the procedure of choice, and leads to the least morbidity and mortality.

In some recent cases Thoracoscopic/or/ laparoscopic approach

Most complications (development of an empyema, persistent fistulas, and late abscess formation) are related to leakage from the site of repair.

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Unusual Injuries of the EsophagusRupture of a Barrett's Ulcer

Most of the patients were men. the symptoms in the order of decreasing frequency were: (a) hematemesis (39%), (b) fever (35%), (c) abdominal pain (30%), (d) thoracic pain (30%), (e) melena (26%), and (f) nausea and vomiting (26%)

The preferred surgical procedure is an early esophagectomywith either an immediate or a delayed reconstruction

With non-surgical management only 22% of patients survived. With surgical intervention 77% survived. The overall mortality rate was 45%

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Unusual Injuries of the EsophagusEsophageal Perforation Associated with Gas Gangreneof the esophagus, mediastinum, and adjacent structuresfollowing the endoscopic ethanol injection of a bleeding

Mallory-Weiss tear.Emergency esophagectomy and local debridement were

carried out. Multiple broad-spectrum antibioticsSeven hyperbaric oxygen therapy sessions finally controlled

the infection. Multiple surgical procedures were required, and

gastrointestinal continuity was reestablished by a colon interposition with eventual full recovery.

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Rupture and Necrotizing Esophagitis in lmmunocompromised Patients

Overall, a 72.7% survival rate was noted in the surgicallymanaged patients (Esophagectomy)survival rate of only10% in patients manage conservatively.

Tuberculous (TB) infection of the esophagus is rare andis usually the result of extension from the lung or involvedmediastinal nodes. In the immunocompromised patient,however, the infection may be primary in natureUlceration, fistulization, or even perforation may occur.An adequate course of anti-tuberculosis medication and

subsequent surgical closure are indicated

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Esophageal Perforation Associated with Zollinger-Ellison Syndrome

Ng and colleagues (2001) recorded a nonbarometric spontaneous perforation of the distal portion of the thoracic esophagus.

Other than the presence of a Zollinger-Ellisonsyndrome, no other etiology could be discerned.

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Extraluminal Penetrating Esophageal Injuries

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Gunshot and Stab Wounds of the Chest and Upper Abdomen

Injuries of the esophagus represent less than I% of the intrathoracic injuries caused by penetrating trauma

The central anatomic location of the esophagus; the protection afforded by the vertebral bodies, heart, and aorta; and the relatively small, compact size of the esophagus all diminish its susceptibility to injury.

The diagnosis of penetrating injuries of the thoracicesophagus is difficult. Most often, these injuries occur as

part of a complex injury involving at the least the thoracic wall and lung

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Symptoms and findings in penetrating injuries of the esophagus

Dysphagia strongly suggests the possibility of esophageal injury, but it often is not present.

Pneumomediastinum is frequently present when the esophagus is injured, but it is caused more commonly by tracheal or bronchial injury.

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The treatment of penetrating injuries is based on earlyrecognition, primary repair, and adequate drainage

The associated injuries to other vital structures in the thorax lead to early exploration in many of these patients.

Most of the esophageal injuries are through-and-through perforations, in which there should always be an even number of rents in the esophagus. Occasionally, a lateral tear occurs, resulting in one large laceration.

when early diagnosis and exploration occur, the esophageal defect should be repaired primarily. At times, only a minimum of debridement is necessary

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Extraluminal Penetrating Esophageal Injuries

when significant esophageal tissue has been destroyed and primary closure is impossible without a stricture of the lumen, a muscle flap should be used to close the defect

The latissimus dorsi is the muscle of choice.

When this is not available,a flap from the rhomboid muscle brought into the chest by excising a portion of the fourth rib.

With distal wounds, a diaphragmatic flap has been used

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Thermal injury to the esophagus with subsequent perforation

First reported by Mohr and colleagues (2001) during intraoperative radiofrequency ablation of atrial fibrillation (IRAAF). The perforation occurred late in the postoperative period (postoperative day 10) and created a fistula between the esophagus and left atrium with the occurrence of air embolisms to the CNS

Surgical intervention was successful.The salient features are the development of neurologic

symptoms late in the postoperative period (10 to 12 days) after IRAAF.

Successful treatment is prompt diagnosis followed by closure of the atrial defect and esophagectomy.

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Operative TraumaLaceration of the cervical esophagus during

thyroidectomy or laryngectomy

The thoracic esophagus may be injured duringmediastinoscopy, vagotomy, hiatal hernia repair,antireflux procedure, removal of an adherent mediastinal tumor or cyst in the visceral compartment and pneumonectomy, most often for inflammatory disease.

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Blunt trauma to the esophagusDeceleration injuries to the chest, such as hitting the steering wheel

during high-speed collisions. The esophageal wall may be ruptured simultaneously with the adjacent membranous tracheal wall, or its blood supply may be compromised so that necrosis and subsequent perforation into the trachea occur. This injury may occur when the esophagus and trachea are compressed between the sternum and thoracic vertebral bodies.

Infrequently, an acute rupture results from a rapid increase inintraluminal pressure.

Esophageal rupture occurring with fractures of the cervical spine.

Rarely, a necrotizing injury of the esophageal wall occurs if theesophagus is torn away from its blood supply by severeblunt injury.

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In the compressive injury of the esophagus and trachea,The presence of the fistula is evidenced, usually sometime

after the third day, by spasms of coughing on eating or drinking or aspiration of oropharyngeal secretions into the lungs

The diagnosis should be confirmed by endoscopic and radiographic studies. When the condition of the patient

is stabilized, direct repair of the fistula is indicated through a right thoracotomy. Division of the azygos vein is done to permit wide exposure.The fistulous openings of each organ are closed.

A flap of adjacent tissue, usually pleura or, when this is unavailable, a vascularized pedicled flap of intercostalmuscle, should be interposed between the two closures.

A tracheostomy,has been suggested to protect the tracheal suture line.

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Migration of a Foreign Body into the Esophagus

Migration and erosion of an Angelchik prosthesis into the esophageal lumen. This prosthesis, introduced by Angelchik and Cohen in 1979, had a period of brief popularity in the treatmentof GERD but is no longer used because of its many complications.

Lucite plombage spheres also have eroded into the esophagus.

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Abdominal Esophageal PerforationsSigns and symptoms of an acute abdominal catastrophe.

One must remember that perforation of the distal thoracic esophagus may mimic such an event.

Radiographic examination of the chest and abdomen, as well as of the esophagus, with contrast material should resolve the actual site of the perforation.

At times, the injury may be confined to theretroperitoneal space, and a more indolent course may be observed.

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DRUG-INDUCED ESOPHAGEAL INJURIESFactors such as preexisting esophageal pathologic

conditions, ingestion of tablets or capsules unaccompanied by water, or recumbence at the time of or shortly after the ingestion of medication may predispose to retention of medication within the esophagus

Result in mild esophagitis or actual ulceration and, in rare instance, perforation of the esophagus.

The most commonly reported drugs associated with these injuries are tetracycline, emperonium,and potassium chloride.

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DRUG-INDUCED ESOPHAGEAL INJURIES

Diagnosis is usually established by esophagoscopy orbarium swallow in a patient with recent onset of retrosternal pain, odynophagia, or dysphagia.

Because of the frequently superficial changes in many of these injuries, esophagoscopy is the preferred diagnostic approach.

Treatment consists of withdrawal of the medication by the oral route, substitution of a liquid form if available.

As with any injury of the esophagus, patients must beobserved for stricture formation. If this occurs, esophageal dilations provide adequate treatment.

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CHEMICAL TRAUMA of the Esophagus

Result from the ingestion of caustic substances, either a strong acid or alkali. The latter is the more common offender

Most of the injuries occur from accidental ingestion by young children, usually under 5 years of age.

The site of caustic injury of the esophagus may be located almost equally in anyone of its anatomic subdivisions or may be widespread throughout.

Normally, the greater period of contact is in the lower esophagus; hence, more extensive injury usually occurs in this area.

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The burn injury to the esophagus has been divided into three phases.

Inflammation, edema, and necrosis occur during the initial few days after injury.

Sloughing of esophageal tissue with mucosal ulceration and moist granulation tissue occur in the second phase. The esophageal wall is weakest during this period, which may last 3 to 4 weeks.

In the third phase >>> cicatrization and stricture formation

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The signs and symptoms of the initial injury are related to the strength and amount of the substance swallowed.

Increased salivation and dysphagia are common. Bums of the mouth and pharynx

Respiratory distress occurs when the burn extends into the epiglottis or larynx.

When the offending agent happens to be in a very dilute solution, symptoms may be minimal

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CHEMICAL TRAUMA of the EsophagusTreatment is designed to minimize the extent of scarring

and subsequent stricture formation.

Early esophagoscopy, within the first 2 days, is recommended.

The esophagoscope is passed until the first area of burn is observed. No attempt is made to pass beyond this area

Further examination of the esophagus usually is not necessary for 3 to 4 weeks. At this time, the indicated examination is a barium esophagography to detect any strictures

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Use steroids in patients with severe grade II and grade III burns of the esophagus. steroid use is not indicated in grade I or mild grade II injuries.

Regardless of the use of steroids, strictures of varying degrees occur in almost all patients with severe injuries.

Subsequent bougienage is recommended in those patients with a definite stricture of the esophagus. This procedure is started during the early phase of cicatrix formation, which begins the third or fourth week after injury.

Danger of instrumental perforation, is present, and a string or wire guide is essential

The most important factor, is the ability of the patient to swallow. Recurrent or increasing dysphagia indicates the need for additional mechanical dilation.

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CHEMICAL TRAUMA of the Esophagus

Surgical intervention is seldom necessary in the acute phase of caustic injuries unless there is extension of the injury through the entire wall of the esophagus.

To determine such a situation >>> CT scan of the esophagus

Acute tracheoesophageal fistulas resulting from caustic ingestion in small children >>>tracheostomy,cervical esophagostomy, and gastrostomy with isolation (blind-ending) of the thoracic esophagus are required.

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Patients with second-degree burns >>> intraesophagealstenting through a celiotomy and the stent is left in place for at least 21 days. Antibiotics and steroids also are given.

In patients with third-degree burns without full-thickness involvement, a stent is likewise used

In those with extensive full-thickness necrosis, urgentradical total esophagogastrectomy is carried out along with

cervical esophagostomy and jejunostomy.

Reconstruction is performed at a later date. When an esophagectomy is indicated it is best done by the transhiatal route.

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CHEMICAL TRAUMA of the Esophagus

Surgical intervention may also be considered in longstanding lye strictures when it becomes difficult or impossible to maintain an adequate lumen despite repeated dilation.

Create a substitute esophagus using either the stomach, a reversed gastric tube, or a colon interposition

An increased risk for the development of carcinoma in residual, strictured esophagus has been suggested and the remaining esophagus should be excised.

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Reinforced Primary Repair in Delayed Thoracic Reinforced Primary Repair in Delayed Thoracic Esophageal PerforationEsophageal Perforation

Mohammad Mohammad VaziriVaziri MD*MD*

Thoracic Surgeon Thoracic Surgeon –– HazratHazrat RasoolRasool Hospital Hospital –– Iran Iran University of Medical SciencesUniversity of Medical Sciences

FaxFax: : 6650905666509056EE--mail: mail: [email protected][email protected]

Thoracic Surgery WardThoracic Surgery Ward-- HazratHazrat RasoolRasool HospitalHospitalNiayeshNiayesh AveAve-- ShahraraShahrara-- TehranTehran

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AbstractAbstractA A 5555--yearyear--old man with severe rightold man with severe right--sided empyema sided empyema

was admitted to our hospitalwas admitted to our hospital. Six days before this . Six days before this admission, he had undergone upper GI endoscopyadmission, he had undergone upper GI endoscopy in in another center to remove a retained chicken bone in lower another center to remove a retained chicken bone in lower esophagus and despite documented thoracic esophageal esophagus and despite documented thoracic esophageal perforationperforation, treatment was surprisingly delayed. The , treatment was surprisingly delayed. The perforation was closed with primary sutures and reinforced perforation was closed with primary sutures and reinforced with intercostal muscle flap wrap and pleural patch.with intercostal muscle flap wrap and pleural patch.Esophagography performed Esophagography performed 3 3 weeks after the operation weeks after the operation showed a wellshowed a well--healed esophagus without stenosis or healed esophagus without stenosis or leakage. leakage. We conclude that regardless of the time interval We conclude that regardless of the time interval between the injury and the operation, reinforced primary between the injury and the operation, reinforced primary repair is recommended for nonrepair is recommended for non--malignant thoracic malignant thoracic esophageal perforationesophageal perforation and provide a oneand provide a one--stage operation stage operation with preservation of the native esophaguswith preservation of the native esophagus

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Case ReportCase ReportA A 5555--yearyear--old man with obvious rightold man with obvious right--

sidedsided empyema empyema and and clinical signs of sepsisclinical signs of sepsis was was admitted to our hospital. admitted to our hospital. Six days beforeSix days before this this admission admission he had undergone upper GIhe had undergone upper GIendoscopyendoscopy in another center to remove a in another center to remove a retained chicken bone in lower esophagus retained chicken bone in lower esophagus following which following which chest pain, fever and dyspneachest pain, fever and dyspneaappeared. A appeared. A chest radiographychest radiography had shown a had shown a significant right pleural effusion significant right pleural effusion (Fig (Fig 11)) and a and a chest tube had been inserted. Surprisingly no chest tube had been inserted. Surprisingly no definitive treatment had been performed and definitive treatment had been performed and worsening empyema ensuedworsening empyema ensued

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Vital signs at presentationVital signs at presentation include: include: PR=PR=110110/min/min, , RR=RR=2828/min, /min, T=T=3939ooCCandand BP=BP=110110//7575mmHg. The mmHg. The patient was a farmer and had no underlying patient was a farmer and had no underlying disease and physical examination revealed no disease and physical examination revealed no other significant finding. Laboratory tests were other significant finding. Laboratory tests were normal except for normal except for WBC=WBC=1300013000 and and PMN=PMN=9090%.%.Following resuscitation of the patient and Following resuscitation of the patient and insertion of CVP and Foley catheters and insertion of CVP and Foley catheters and administration of broadadministration of broad--spectrum antibiotics, an spectrum antibiotics, an emergency barium esophagographyemergency barium esophagography was was performed and esophageal perforation including performed and esophageal perforation including its site and extent was confirmed its site and extent was confirmed (Fig (Fig 22).).

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A A right posteroright postero--lateral thoracotomylateral thoracotomy was was performed and after performed and after evacuation of significant pusevacuation of significant pusand complete clearing of the operative site by and complete clearing of the operative site by irrigationirrigation, , the esophageal perforation was closedthe esophageal perforation was closedand reinforced with pleural patch and intercostaland reinforced with pleural patch and intercostalmuscle flap wrapmuscle flap wrap. A . A jejunostomy tubejejunostomy tube was also was also inserted. Postinserted. Post--operatively, operatively, 55--litre daily irrigationlitre daily irrigation(by a catheter within the chest tube) and (by a catheter within the chest tube) and antibioticsantibiotics were given until the drainage was were given until the drainage was clear and the patient became afebrile.clear and the patient became afebrile.

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Esophagography performed Esophagography performed 12 12 days afterdays after the the operationoperation (Fig.(Fig.33)) showed a showed a scant leakage.scant leakage.Thus, Thus, feeding via jejunostomy tube and antibiotics feeding via jejunostomy tube and antibiotics were continued while the patient remained were continued while the patient remained completely stable with no signs of sepsis. completely stable with no signs of sepsis. Esophagography performed Esophagography performed 3 3 weeks afterweeks after the the operationoperation showed showed a wella well--healed esophagushealed esophagus with with no leakage.The patient increasingly tolerated a no leakage.The patient increasingly tolerated a normal diet and normal diet and discharged after discharged after 35 35 daysdays of of hospital stay with no complication.hospital stay with no complication.FollowFollow--up of the patient since up of the patient since 6 6 months after the months after the operation has revealed no dysphagia or any other operation has revealed no dysphagia or any other difficulty in swallowing.difficulty in swallowing.

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