Esophageal Disruption From Blunt and Penetrating External Trauma C. William
Spenler, MD,
John R.
Benfield, MD
\s=b\ Eleven patients suffered esophageal perforations from external trauma. This series includes the first report of esophageal perforation that resulted from a cervical flexion-hyperextension injury. The other ten patients had penetrating trauma. Early signs were subtle. Small amounts of mediastinal and cervical air tended to be overlooked or erroneously attributed to other causes, such as associated pneumothorax. Once suspected, the possibility of esophageal disruption was not always pursued with optimum vigor. There was undue reliance on contrast media radiography. There were two patients with falsely normal esophagograms. All patients healed well when treated within 12 hours after injury by primary closure and drainage. All three patients treated after 12 hours of delay required secondary drainage for cervicomediastinal sepsis, and one of them died. Possible esophageal injury needs to be suspected after blunt as well as penetrating cervicothoracic trauma. When time permits, endoscopy, esophagogram, and bronchoscopy should be the minimum preoperative workup. Prompt primary closure of externally induced esophageal perforations is the treatment of choice.
(Arch Surg 111:663-667, 1976)
assert themselves. Necessary attention is therefore given to obvious injuries, and trauma to the esophagus may be
overlooked. While it is generally accepted that early diag¬ nosis predisposes to optimum results, delays in recognition nevertheless occur, and controversies in recommendations for management persist.7' Our purpose is to share the lessons we have learned in recent years concerning esoph¬ ageal trauma, and to report for the first time that flexionhyperextension injury of the neck without penetratinginjury can lacerate the esophagus. !
SUBJECTS AND METHODS Records of all patients who suffered perforation of the
esophagus secondary were
reviewed.
esophagus is a chal¬ problem. Perforation is a emergency that is usually lethal if untreated and commonly fatal if treatment is delayed.1 When injured, the esophagus initially responds quietly while most of the surrounding vital structures vociferously induced trauma to the
Accepted
uncommon
for publication Feb 12, 1976. From the Division of Thoracic Surgery, Harbor General Hospital Campus of the University of California at Los Angeles School of Medicine. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, Jan 17, 1976. Reprint requests to Division of Thoracic Surgery, Harbor General Hospital, 1000 W Carson St, Torrance, CA 90509 (Dr Benfield).
Injuries from foreign bodies,
RESULTS
During nine years there were 11 patients (ten men and girl) who suffered external injuries that resulted in perforation of the esophagus. Their mean age was 38 (range, 8 to 63) years. The cause of the injuries in eight patients was gunshot wounds, and in one it was a stab wound. One patient, whose case will be presented in detail, suffered perforation of the esophagus from a hypertrophie cervical vertebral bone spur during a flexion-hyperextension injury. The child's esopha¬ gus was lacerated during emergency tracheostomy. The site of injury was in the neck in six cases and in the thorax in five instances. Two of the injuries were in the upper third of the thoracic esophagus and three were in the lower third. None of the patients had more than one esophageal perforation. Diagnostic tests were used in various combinations. Four patients (36%) had no tests specifically relevant to the esophagus prior to operation. Two of them had open wounds of the neck that mandated operation based on one
Externally lenging, relatively surgical
to external trauma from June 1966 to June
caustic inges¬ tions, or endoscopy were not included. Particular attention was given to the interval between injury and therapy. The factors that influenced results were subjected to retrospective analysis. 1975
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inspection alone, and the third had immediately lifethreatening injuries that precluded delay for additional diagnosis prior to thoracotomy. The fourth patient had no tests involving the esophagus because they were judged unnecessary in that neck exploration was to be done. His case history follows. Case 1.—An 18-year-old man was transferred from another with stable vital signs and a chest tube on the right two hours after having sustained a pneumothorax from a gunshot wound to the anterior part of the chest and neck. There was also a gunshot wound of the right lower quadrant of the abdomen. Examination of the neck revealed cervical crepitus and an entrance wound near the midline at the level of the thyroid cartilage. Abdominal examination revealed a rigid abdomen without bowel sounds. No neurological abnormalities were
hospital
observed.
Roentgenograms at the time of admission revealed retropharyngeal and upper mediastinal interstitial air from a bullet in the right of the chest. There was a pneumothorax on the right and some clues regarding the presence of esophageal perforation, Which are illustrated in Fig 1. There was also a bullet in the right lower quadrant of the abdomen and free air was present under the left diaphragm. An intravenous urogram was normal. Esophagogram was not done. Bronchoscopy was normal. Esophagoscopy was not done. A cervical
exploration was performed because of the bullet wound. No esophageal perforation was found, and the neck was not drained. Laparotomy revealed a large retroperitoneal hema¬ toma extending from the aortic bifurcation to the duodenum. The postoperative course was complicated by spiking tempera¬ tures between 38.9 C to 40.0 C with leukocytosis. Blood cultures drawn on the second postoperative day grew /3-hemolytic strepto¬ coccus, group D. Despite intravenous administration of penicillin G potassium and methicillin sodium, the fever persisted. Seven days postoperatively, the mediastinum was widened on chest x-ray film. An esophagogram demonstrated an esophageal perforation with a retropharyngeal mass. An anterior superior mediastinal abscess cavity was drained through a transcervical approach. A feeding gastrostomy was inserted. Gentamicin sulfate was added to the antibiotic regimen. The patient made an uneventful recov¬ ery. Comment.—Reliance on planned neck exploration erroneously was believed to obviate the need for preoperative evaluation of the esophagus. Neck exploration failed to reveal esophageal injury, which esophagogram and esophagoscopy would almost certainly have shown. Four patients had a single test for esophageal injury, including three who had esophagoscopy only and two who had solely esophagograms. Three patients had esophagograms and bronchoscopies without'esophagoscopies. Two of them had esophagograms done twice. Only one man had esophagoscopy, esophagogram, and bronchoscopy. Four patients had great vessel angiography prompted by mediastinal widening on chest x-ray films. The diagnostic yield among the eight patients who had tests other than immediate exploration was as follows. All esophagoscopies were abnormal, and all bronchoscopies and great vessel angiograms were normal. Four of the six esophagograms were abnormal. In two cases, this study needed to be repeated in order to provide definitive two instances in which barium
information. There
were
esophagogram
falsely normal, including
was
one case
in
Fig 1.—Esophageal injury discovered too late. Admission chest x-ray film contains clues that were not optimally pursued. There is air in neck, and on the original x-ray film, one can see tiny metallic fragments (arrow) near esophagus, the location of which Is shown by nasogastric tube. Note pneumothorax on right that was erroneously believed adequate to explain cervical air. which a subsequent study with water-soluble contrast medium was abnormal. There was one false normal esopha¬ gogram with water-soluble contrast medium in a patient whose perforation was proved by esophagoscopy. The interval between injury and treatment was less than 12 hours in eight patients. We shall henceforth refer to this group as having had prompt recognition of the esophageal injury. Three patients in whom the esophageal injury was not found until more than 12 hours had elapsed will be referred to as having had delayed recognition. These delays were the result of falsely normal esophagograms in two cases. In one instance, esophageal injury was not suspected when the patient was initially seen in the emergency room of another hospital. His case history follows. Case 2.-A 63-year-old man suffered a cervical flexion-hyperextension injury when his car was struck from behind. The patient was unconscious after the accident. He was taken to another hospital, where his main complaint was pain and stiffness in the neck and pain in the superior anterior part of the chest. Roentgen¬ ograms of the chest and cervical vertebrae demonstrated severe hypertrophie osteoarthritis of the cervical spine without acute injury. Approximately 18 hours after discharge, the patient returned to the same hospital complaining of more neck pain and dysphagia. Repeat roentgenograms demonstrated a perforation of the posterior aspect of the cervical esophagus, and the osteoarthritic spurs of the cervical vertebrae were again noted. These findings are illustrated in Fig 2.
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An exploration of the right side of the patient's neck with closure of esophageal laceration and drainage was performed 24 hours after injury. Three days later he began to have spiking fevers to 40.0 C. These fevers, accompanied by progressive partial upper airway obstruction, persisted until five days postoperative¬ ly, when a transcervical exploration of the superior mediastinum was performed by one of us (J.R.B.) to drain a retropharyngeal mediastinal abscess. The patient was transferred to Harbor General Hospital and his sepsis gradually resolved during the next several days. His esophageal fistula gradually closed. Comment.-This patient illustrates the need to consider the possibility of esophageal perforation after severe cervical flexion-
hyperextension injuries.
Treatment consisted of primary closure of the perfora¬ tion with drainage of the operative site in seven of the eight patients in the prompt recognition group and in one of the three patients in the delayed recognition group. One patient with a cervical esophageal disruption was nonoper-
Fig 2.—Cervical esophageal perforation from flexion-hyperextension injury. Top left, Lateral view of cervical vertebrae shows severe anterior osteoarthritis spurs. Bottom left, Esophagogram showing perforation at level of most prominent arthritic protru¬ sions (C5-6). Bottom right, Level of bone spur and perforation.
LEVEL OF BONE SPUR AND PERFORATION
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atively treated. The two remaining patients in the delayed recognition group were treated by drainage and secondary closure of the esophageal fistula. Five patients (45%) in the series had gastrostomies. Secondary drainage of abscesses adjacent to the esophagus were required in all three patients whose esophageal perforations were not promptly identified, including one whose suture line leaked after attempted primary closure. The possible consequences of delayed recognition and inability to close an esophageal perforation primarily are illustrated by the following patient. Case 3.—A 20-year-old man sustained a 38-caliber gunshot wound to the left arm and the left hemithorax. The vital signs were stable. Physical examination revealed that the bullet had transversed the left arm and entered the chest at the level of the fourth intercostal space in the posterior axillary line. Bilateral hemopneumothoraxes were noted on chest x-ray film. Electrocar¬ diogram demonstrated no acute changes. Bilateral chest tubes were placed and thereafter the lungs reexpanded. Barium esopha¬ gogram and aortic arch studies were within normal limits. The findings (Fig 3, left) were erroneously explained on the basis of the pneumothorax and contusion injury, since the esophagogram was normal.
Esophageal Perforations Group Prompt diagnosis Delayed diagnosis Total
No. of Patients
From Blunt and
patient began spiking fevers of 38.9 C to despite antibiotics. Three days after the injury, repeat esophagograms demonstrated a perforation of the distal part of the esophagus (Fig 3, right). Chest x-ray film revealed bilateral effusions that proved to be empyemas. A thoracotomy on the right for optimum placement of drainage tubes and a laparotomy for gastrostomy and a tracheostomy were immediately performed. The cultures from operation grew Clostridium perfringens. Postoperatively, the patient underwent progressive deterioration with a septic course complicated by respiratory failure that required assisted mechanical ventilation. Despite aggressive treatment that included hyperbaric oxygen, the patient continued to deteriorate and he died on the 15th hospital day of complications of sepsis. Comment.—Falsely normal esophagograms are not rare. The initial false normal esophagogram in this case delayed treatment to the point at which primary closure of the perforation was no longer possible. This delay greatly enhanced the likelihood of the Within 24 hours the 40.0 C that persisted
disastrous consequence that ensued. Death occurred in two patients (18%) in the series. One of the deaths was a consequence of sepsis after delayed
recognition of a thoracic esophageal injury. The second occurred despite prompt recognition and treatment after the esophageal repair had already healed and without
Penetrating External Trauma, 1966 to Complications
Associated Injuries
No.
Rate/Patient
No.
Rate/Patient 1.4 3.0
16 1.3 11
20
20
3.—Late recognition of esophageal perforation. Left, Chest x-ray film shows mediastinal windening with air believed to be related to previous pneumothorax now expanded by chest tubes. Concomitant aortogram was normal. Right, Esophageal perfora¬ tion with extravasated barium three days after injury, and previous false normal esophagogram.
Fig
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1975
Hospitalization, Days (Range) 21 (13-37) 46 (44-51)
No. (%) of Deaths
(12) (33) 2(18) 1 1
relation to the
Morbidity
esophageal injury.
measured in terms of complications and duration of hospitalization. There were 20 complications. Eleven complications occurred in eight patients who were in the prompt recognition group. These eight patients had 16 associated injuries. Stated another way, the prompt recognition group had two associated injuries per patient and 1.4 complications per patient. The average length of hospitalization of this group was 21 (13 to 37) days. The remaining nine complications occurred in the delayed recognition group, which consisted of three patients with four associated injuries. Thus, the delayed recognition group had 0.4 associated injuries per patient and three complications per patient. Their average hospitalization was 46 (44 to 51) days. These data are summarized in the Table. was
COMMENT
The most unique finding of our series is the patient whose esophageal laceration resulted from a "whiplash injury." This is a common form of trauma, and one must ask why the esophagus usually escapes injury. The answer undoubtedly lies in the fact that the esophagus is well protected in the neck and that it is a pliable structure. In our patient, the osteoarthritic bone spurs were responsible for lacerating the esophagus, and the rarity of this circum¬ stance makes the delay in recognition of his esophageal perforation when he was first seen at another hospital quite understandable. For the future, however, it is impor¬ tant that we remain aware of the possibility of esophageal perforation as a part of flexion-hyperextension injury of the neck and that each patient whose complaints suggest the possibility of esophageal injury after "whiplash" should have his esophagus fully evaluated. Perhaps the most striking feature of our data is the difference in morbidity between prompt and delayed treatment of esophageal trauma. In our series, the number and severity of associated injuries were no greater in the delayed recognition group than among patients who were promptly treated. Therefore, our data support the need for prompt diagnosis and therapy. That point has been stressed by others,4" and we wish to reemphasize it only in passing. Instead, we wish to focus on the reasons for delays in diagnosis and make a proposal for insuring prompt diagnosis of externally induced esophageal trauma in the future. Retrospective critical review of our patients identifies the following factors, which made recognition of esopha¬ geal injury suboptimum: (1) the index of suspicion was low because this is an uncommon injury; (2) associated injuries were usually more obvious than esophageal trauma, and the esophagus sometimes was assigned inappropriately low priority; (3) undue reliance was placed on esophago¬ grams (two false normal) and neck exploration (one false normal); and (4) esophagoscopy was not done often
enough.
Our recommendations concerning the diagnosis of esophageal injury after external trauma are as follows: (1) maintain a high index of suspicion after blunt as well as
after
penetrating injuries; (2) whenever possible, do not a single test to exclude the possibility of an rely esophageal tear; (3) should it be necessary to choose only one preoperative test, esophagoscopy rather than esopha¬ on
gogram should be chosen; and (4) time and circumstances permitting, the minimum evaluation for patients with suspected esophageal injury should include esophagoscopy, esophagogram with water-soluble contrast medium, and bronchoscopy. If repeat esophagogram is indicated, barium may be safely used. Therapy remains surprisingly controversial. There are advocates of nonoperative treatment as well as proponents for prompt operation.70 We are convinced that early diagnosis and prompt operation with primary closure of the esophagus and drainage of the operative site is the treatment of choice. When circumstances preclude the optimum, nonoperative treatment may be briefly tried. In most instances, however, it will be necessary to operate in order to provide drainage. In our opinion, antibiotic therapy should be considered adjunctive, and drainage should be considered the primary mode of treatment for esophageal perforations that come to the surgeon's atten¬ tion after delays greater than 12 hours. To suggest that the index of suspicion for esophageal injury be high without further discussion of that point would be incomplete. We believe any patient with hemop¬
tysis
or hematemesis after cervical or thoracic injury should be considered as having a potential esophageal perforation. Patients with mediastinal or cervical air are certainly at risk, even when there is a coexisting pneumo¬ thorax. When there is mediastinal widening, unexplained by vascular injury, esophageal trauma needs to be consid¬ ered. In general, the burden of proof to exclude esophageal injury rests with trauma surgeons, and the esophagus should not be given an opportunity to assert itself in a delayed fashion after injury.
We wish to gratefully acknowledge the contributions of Robert S. care of one of these patients.
MD, in the
Ozeran,
Nonproprietary Name and Trademark of Drug Gentamicin
auUate—Garamycin. References
Sealy WC: Rupture of the esophagus. Am J Surg 105:505-510, 1963. Sheely CH, Mattox KL, Reul GJ, et al: Current concepts in the management of penetrating neck trauma. J Trauma 15:895-900, 1975. 3. Jones RJ, Samson PC: Esophageal injury. Ann Thorac Surg 19:216-230, 1. 2.
1975. 4. Sawyers JL, Lane CE, Foster JH, et al: Esophageal perforation. Ann Thorac Surg 19:233-238, 1975. 5. Sheely CH, Mattox KL, Beall AC, et al: Penetrating wounds of the cervical esophagus. Am J Surg 130:707-711, 1975. 6. Berry BE, Ochsner JL: Perforation of the esophagus\p=m-\a30-year review. J Thorac Cardiovasc Surg 65:1-7, 1973. 7. Mengoli LR, Klassen KP: Conservative management of esophageal perforation. Arch Surg 91:238-240, 1965. 8. Stone HH, Callahan GS: Soft tissue injuries of the neck. Surg Gynecol Obstet 117:745-752, 1963. 9. Williams JW, Sherman RT: Penetrating wounds of the neck\p=m-\surgical management. J Trauma 13:435-442, 1973.
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Spenler, MD,
John R.
Benfield, MD
\s=b\ Eleven patients suffered esophageal perforations from external trauma. This series includes the first report of esophageal perforation that resulted from a cervical flexion-hyperextension injury. The other ten patients had penetrating trauma. Early signs were subtle. Small amounts of mediastinal and cervical air tended to be overlooked or erroneously attributed to other causes, such as associated pneumothorax. Once suspected, the possibility of esophageal disruption was not always pursued with optimum vigor. There was undue reliance on contrast media radiography. There were two patients with falsely normal esophagograms. All patients healed well when treated within 12 hours after injury by primary closure and drainage. All three patients treated after 12 hours of delay required secondary drainage for cervicomediastinal sepsis, and one of them died. Possible esophageal injury needs to be suspected after blunt as well as penetrating cervicothoracic trauma. When time permits, endoscopy, esophagogram, and bronchoscopy should be the minimum preoperative workup. Prompt primary closure of externally induced esophageal perforations is the treatment of choice.
(Arch Surg 111:663-667, 1976)
assert themselves. Necessary attention is therefore given to obvious injuries, and trauma to the esophagus may be
overlooked. While it is generally accepted that early diag¬ nosis predisposes to optimum results, delays in recognition nevertheless occur, and controversies in recommendations for management persist.7' Our purpose is to share the lessons we have learned in recent years concerning esoph¬ ageal trauma, and to report for the first time that flexionhyperextension injury of the neck without penetratinginjury can lacerate the esophagus. !
SUBJECTS AND METHODS Records of all patients who suffered perforation of the
esophagus secondary were
reviewed.
esophagus is a chal¬ problem. Perforation is a emergency that is usually lethal if untreated and commonly fatal if treatment is delayed.1 When injured, the esophagus initially responds quietly while most of the surrounding vital structures vociferously induced trauma to the
Accepted
uncommon
for publication Feb 12, 1976. From the Division of Thoracic Surgery, Harbor General Hospital Campus of the University of California at Los Angeles School of Medicine. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, Jan 17, 1976. Reprint requests to Division of Thoracic Surgery, Harbor General Hospital, 1000 W Carson St, Torrance, CA 90509 (Dr Benfield).
Injuries from foreign bodies,
RESULTS
During nine years there were 11 patients (ten men and girl) who suffered external injuries that resulted in perforation of the esophagus. Their mean age was 38 (range, 8 to 63) years. The cause of the injuries in eight patients was gunshot wounds, and in one it was a stab wound. One patient, whose case will be presented in detail, suffered perforation of the esophagus from a hypertrophie cervical vertebral bone spur during a flexion-hyperextension injury. The child's esopha¬ gus was lacerated during emergency tracheostomy. The site of injury was in the neck in six cases and in the thorax in five instances. Two of the injuries were in the upper third of the thoracic esophagus and three were in the lower third. None of the patients had more than one esophageal perforation. Diagnostic tests were used in various combinations. Four patients (36%) had no tests specifically relevant to the esophagus prior to operation. Two of them had open wounds of the neck that mandated operation based on one
Externally lenging, relatively surgical
to external trauma from June 1966 to June
caustic inges¬ tions, or endoscopy were not included. Particular attention was given to the interval between injury and therapy. The factors that influenced results were subjected to retrospective analysis. 1975
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/18/2015
inspection alone, and the third had immediately lifethreatening injuries that precluded delay for additional diagnosis prior to thoracotomy. The fourth patient had no tests involving the esophagus because they were judged unnecessary in that neck exploration was to be done. His case history follows. Case 1.—An 18-year-old man was transferred from another with stable vital signs and a chest tube on the right two hours after having sustained a pneumothorax from a gunshot wound to the anterior part of the chest and neck. There was also a gunshot wound of the right lower quadrant of the abdomen. Examination of the neck revealed cervical crepitus and an entrance wound near the midline at the level of the thyroid cartilage. Abdominal examination revealed a rigid abdomen without bowel sounds. No neurological abnormalities were
hospital
observed.
Roentgenograms at the time of admission revealed retropharyngeal and upper mediastinal interstitial air from a bullet in the right of the chest. There was a pneumothorax on the right and some clues regarding the presence of esophageal perforation, Which are illustrated in Fig 1. There was also a bullet in the right lower quadrant of the abdomen and free air was present under the left diaphragm. An intravenous urogram was normal. Esophagogram was not done. Bronchoscopy was normal. Esophagoscopy was not done. A cervical
exploration was performed because of the bullet wound. No esophageal perforation was found, and the neck was not drained. Laparotomy revealed a large retroperitoneal hema¬ toma extending from the aortic bifurcation to the duodenum. The postoperative course was complicated by spiking tempera¬ tures between 38.9 C to 40.0 C with leukocytosis. Blood cultures drawn on the second postoperative day grew /3-hemolytic strepto¬ coccus, group D. Despite intravenous administration of penicillin G potassium and methicillin sodium, the fever persisted. Seven days postoperatively, the mediastinum was widened on chest x-ray film. An esophagogram demonstrated an esophageal perforation with a retropharyngeal mass. An anterior superior mediastinal abscess cavity was drained through a transcervical approach. A feeding gastrostomy was inserted. Gentamicin sulfate was added to the antibiotic regimen. The patient made an uneventful recov¬ ery. Comment.—Reliance on planned neck exploration erroneously was believed to obviate the need for preoperative evaluation of the esophagus. Neck exploration failed to reveal esophageal injury, which esophagogram and esophagoscopy would almost certainly have shown. Four patients had a single test for esophageal injury, including three who had esophagoscopy only and two who had solely esophagograms. Three patients had esophagograms and bronchoscopies without'esophagoscopies. Two of them had esophagograms done twice. Only one man had esophagoscopy, esophagogram, and bronchoscopy. Four patients had great vessel angiography prompted by mediastinal widening on chest x-ray films. The diagnostic yield among the eight patients who had tests other than immediate exploration was as follows. All esophagoscopies were abnormal, and all bronchoscopies and great vessel angiograms were normal. Four of the six esophagograms were abnormal. In two cases, this study needed to be repeated in order to provide definitive two instances in which barium
information. There
were
esophagogram
falsely normal, including
was
one case
in
Fig 1.—Esophageal injury discovered too late. Admission chest x-ray film contains clues that were not optimally pursued. There is air in neck, and on the original x-ray film, one can see tiny metallic fragments (arrow) near esophagus, the location of which Is shown by nasogastric tube. Note pneumothorax on right that was erroneously believed adequate to explain cervical air. which a subsequent study with water-soluble contrast medium was abnormal. There was one false normal esopha¬ gogram with water-soluble contrast medium in a patient whose perforation was proved by esophagoscopy. The interval between injury and treatment was less than 12 hours in eight patients. We shall henceforth refer to this group as having had prompt recognition of the esophageal injury. Three patients in whom the esophageal injury was not found until more than 12 hours had elapsed will be referred to as having had delayed recognition. These delays were the result of falsely normal esophagograms in two cases. In one instance, esophageal injury was not suspected when the patient was initially seen in the emergency room of another hospital. His case history follows. Case 2.-A 63-year-old man suffered a cervical flexion-hyperextension injury when his car was struck from behind. The patient was unconscious after the accident. He was taken to another hospital, where his main complaint was pain and stiffness in the neck and pain in the superior anterior part of the chest. Roentgen¬ ograms of the chest and cervical vertebrae demonstrated severe hypertrophie osteoarthritis of the cervical spine without acute injury. Approximately 18 hours after discharge, the patient returned to the same hospital complaining of more neck pain and dysphagia. Repeat roentgenograms demonstrated a perforation of the posterior aspect of the cervical esophagus, and the osteoarthritic spurs of the cervical vertebrae were again noted. These findings are illustrated in Fig 2.
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An exploration of the right side of the patient's neck with closure of esophageal laceration and drainage was performed 24 hours after injury. Three days later he began to have spiking fevers to 40.0 C. These fevers, accompanied by progressive partial upper airway obstruction, persisted until five days postoperative¬ ly, when a transcervical exploration of the superior mediastinum was performed by one of us (J.R.B.) to drain a retropharyngeal mediastinal abscess. The patient was transferred to Harbor General Hospital and his sepsis gradually resolved during the next several days. His esophageal fistula gradually closed. Comment.-This patient illustrates the need to consider the possibility of esophageal perforation after severe cervical flexion-
hyperextension injuries.
Treatment consisted of primary closure of the perfora¬ tion with drainage of the operative site in seven of the eight patients in the prompt recognition group and in one of the three patients in the delayed recognition group. One patient with a cervical esophageal disruption was nonoper-
Fig 2.—Cervical esophageal perforation from flexion-hyperextension injury. Top left, Lateral view of cervical vertebrae shows severe anterior osteoarthritis spurs. Bottom left, Esophagogram showing perforation at level of most prominent arthritic protru¬ sions (C5-6). Bottom right, Level of bone spur and perforation.
LEVEL OF BONE SPUR AND PERFORATION
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atively treated. The two remaining patients in the delayed recognition group were treated by drainage and secondary closure of the esophageal fistula. Five patients (45%) in the series had gastrostomies. Secondary drainage of abscesses adjacent to the esophagus were required in all three patients whose esophageal perforations were not promptly identified, including one whose suture line leaked after attempted primary closure. The possible consequences of delayed recognition and inability to close an esophageal perforation primarily are illustrated by the following patient. Case 3.—A 20-year-old man sustained a 38-caliber gunshot wound to the left arm and the left hemithorax. The vital signs were stable. Physical examination revealed that the bullet had transversed the left arm and entered the chest at the level of the fourth intercostal space in the posterior axillary line. Bilateral hemopneumothoraxes were noted on chest x-ray film. Electrocar¬ diogram demonstrated no acute changes. Bilateral chest tubes were placed and thereafter the lungs reexpanded. Barium esopha¬ gogram and aortic arch studies were within normal limits. The findings (Fig 3, left) were erroneously explained on the basis of the pneumothorax and contusion injury, since the esophagogram was normal.
Esophageal Perforations Group Prompt diagnosis Delayed diagnosis Total
No. of Patients
From Blunt and
patient began spiking fevers of 38.9 C to despite antibiotics. Three days after the injury, repeat esophagograms demonstrated a perforation of the distal part of the esophagus (Fig 3, right). Chest x-ray film revealed bilateral effusions that proved to be empyemas. A thoracotomy on the right for optimum placement of drainage tubes and a laparotomy for gastrostomy and a tracheostomy were immediately performed. The cultures from operation grew Clostridium perfringens. Postoperatively, the patient underwent progressive deterioration with a septic course complicated by respiratory failure that required assisted mechanical ventilation. Despite aggressive treatment that included hyperbaric oxygen, the patient continued to deteriorate and he died on the 15th hospital day of complications of sepsis. Comment.—Falsely normal esophagograms are not rare. The initial false normal esophagogram in this case delayed treatment to the point at which primary closure of the perforation was no longer possible. This delay greatly enhanced the likelihood of the Within 24 hours the 40.0 C that persisted
disastrous consequence that ensued. Death occurred in two patients (18%) in the series. One of the deaths was a consequence of sepsis after delayed
recognition of a thoracic esophageal injury. The second occurred despite prompt recognition and treatment after the esophageal repair had already healed and without
Penetrating External Trauma, 1966 to Complications
Associated Injuries
No.
Rate/Patient
No.
Rate/Patient 1.4 3.0
16 1.3 11
20
20
3.—Late recognition of esophageal perforation. Left, Chest x-ray film shows mediastinal windening with air believed to be related to previous pneumothorax now expanded by chest tubes. Concomitant aortogram was normal. Right, Esophageal perfora¬ tion with extravasated barium three days after injury, and previous false normal esophagogram.
Fig
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1975
Hospitalization, Days (Range) 21 (13-37) 46 (44-51)
No. (%) of Deaths
(12) (33) 2(18) 1 1
relation to the
Morbidity
esophageal injury.
measured in terms of complications and duration of hospitalization. There were 20 complications. Eleven complications occurred in eight patients who were in the prompt recognition group. These eight patients had 16 associated injuries. Stated another way, the prompt recognition group had two associated injuries per patient and 1.4 complications per patient. The average length of hospitalization of this group was 21 (13 to 37) days. The remaining nine complications occurred in the delayed recognition group, which consisted of three patients with four associated injuries. Thus, the delayed recognition group had 0.4 associated injuries per patient and three complications per patient. Their average hospitalization was 46 (44 to 51) days. These data are summarized in the Table. was
COMMENT
The most unique finding of our series is the patient whose esophageal laceration resulted from a "whiplash injury." This is a common form of trauma, and one must ask why the esophagus usually escapes injury. The answer undoubtedly lies in the fact that the esophagus is well protected in the neck and that it is a pliable structure. In our patient, the osteoarthritic bone spurs were responsible for lacerating the esophagus, and the rarity of this circum¬ stance makes the delay in recognition of his esophageal perforation when he was first seen at another hospital quite understandable. For the future, however, it is impor¬ tant that we remain aware of the possibility of esophageal perforation as a part of flexion-hyperextension injury of the neck and that each patient whose complaints suggest the possibility of esophageal injury after "whiplash" should have his esophagus fully evaluated. Perhaps the most striking feature of our data is the difference in morbidity between prompt and delayed treatment of esophageal trauma. In our series, the number and severity of associated injuries were no greater in the delayed recognition group than among patients who were promptly treated. Therefore, our data support the need for prompt diagnosis and therapy. That point has been stressed by others,4" and we wish to reemphasize it only in passing. Instead, we wish to focus on the reasons for delays in diagnosis and make a proposal for insuring prompt diagnosis of externally induced esophageal trauma in the future. Retrospective critical review of our patients identifies the following factors, which made recognition of esopha¬ geal injury suboptimum: (1) the index of suspicion was low because this is an uncommon injury; (2) associated injuries were usually more obvious than esophageal trauma, and the esophagus sometimes was assigned inappropriately low priority; (3) undue reliance was placed on esophago¬ grams (two false normal) and neck exploration (one false normal); and (4) esophagoscopy was not done often
enough.
Our recommendations concerning the diagnosis of esophageal injury after external trauma are as follows: (1) maintain a high index of suspicion after blunt as well as
after
penetrating injuries; (2) whenever possible, do not a single test to exclude the possibility of an rely esophageal tear; (3) should it be necessary to choose only one preoperative test, esophagoscopy rather than esopha¬ on
gogram should be chosen; and (4) time and circumstances permitting, the minimum evaluation for patients with suspected esophageal injury should include esophagoscopy, esophagogram with water-soluble contrast medium, and bronchoscopy. If repeat esophagogram is indicated, barium may be safely used. Therapy remains surprisingly controversial. There are advocates of nonoperative treatment as well as proponents for prompt operation.70 We are convinced that early diagnosis and prompt operation with primary closure of the esophagus and drainage of the operative site is the treatment of choice. When circumstances preclude the optimum, nonoperative treatment may be briefly tried. In most instances, however, it will be necessary to operate in order to provide drainage. In our opinion, antibiotic therapy should be considered adjunctive, and drainage should be considered the primary mode of treatment for esophageal perforations that come to the surgeon's atten¬ tion after delays greater than 12 hours. To suggest that the index of suspicion for esophageal injury be high without further discussion of that point would be incomplete. We believe any patient with hemop¬
tysis
or hematemesis after cervical or thoracic injury should be considered as having a potential esophageal perforation. Patients with mediastinal or cervical air are certainly at risk, even when there is a coexisting pneumo¬ thorax. When there is mediastinal widening, unexplained by vascular injury, esophageal trauma needs to be consid¬ ered. In general, the burden of proof to exclude esophageal injury rests with trauma surgeons, and the esophagus should not be given an opportunity to assert itself in a delayed fashion after injury.
We wish to gratefully acknowledge the contributions of Robert S. care of one of these patients.
MD, in the
Ozeran,
Nonproprietary Name and Trademark of Drug Gentamicin
auUate—Garamycin. References
Sealy WC: Rupture of the esophagus. Am J Surg 105:505-510, 1963. Sheely CH, Mattox KL, Reul GJ, et al: Current concepts in the management of penetrating neck trauma. J Trauma 15:895-900, 1975. 3. Jones RJ, Samson PC: Esophageal injury. Ann Thorac Surg 19:216-230, 1. 2.
1975. 4. Sawyers JL, Lane CE, Foster JH, et al: Esophageal perforation. Ann Thorac Surg 19:233-238, 1975. 5. Sheely CH, Mattox KL, Beall AC, et al: Penetrating wounds of the cervical esophagus. Am J Surg 130:707-711, 1975. 6. Berry BE, Ochsner JL: Perforation of the esophagus\p=m-\a30-year review. J Thorac Cardiovasc Surg 65:1-7, 1973. 7. Mengoli LR, Klassen KP: Conservative management of esophageal perforation. Arch Surg 91:238-240, 1965. 8. Stone HH, Callahan GS: Soft tissue injuries of the neck. Surg Gynecol Obstet 117:745-752, 1963. 9. Williams JW, Sherman RT: Penetrating wounds of the neck\p=m-\surgical management. J Trauma 13:435-442, 1973.
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