Flexible Endoscopy As a Diagnostic Tool for Esophageal Injuries: Large Experience from a Trauma Center

Abstract

Background: The successful management and clinical outcome of patients suffering esophageal trauma depends on a prompt diagnosis. The detection of esophageal injuries by clinical suspicion, esophagography or CT is far from perfect. There is scarce retrospective data on the role of flexible endoscopy (FE) in esophageal trauma. Aims: To assess the yield, safety and clinical utility of FE on the diagnosis of suspected esophageal injuries in trauma victims. Methods: Over a seven year period, we conducted a retrospective (1998 to 2003) and prospective (2003 to 2005) study of patients (pts) submitted to an urgent FE, requested by the attending traumatologist, due to suspected esophageal trauma. Exclusion criteria: death or transferal before 72 hours of clinical follow-up, and esophageal strictures precluding complete examination. Esophageal injury was defined as laceration (full-thickness wound with perforation) and contusion (mucosal abrasion with localized hyperemia and hematin spots or clots, without perforation, in a site close to the bullet path, attributed to a thermal energy from the gunshot). The endoscopic diagnosis was compared to surgical findings or clinical follow-up. Results: 163 pts were enrolled, 153 males (93.9%) and 10 females (6.1%), mean age 27 years (7-78 years). Mechanism of injury: 131 gunshot wounds (80.4%), 27 stab wounds (16.6%) and 5 blunt trauma (3.1%). Time for FE from admission: 12 hours - 70.5%, 12 to 24 hours - 11.6%, after 24 hours - 17.9%. FE findings: no traumatic lesion in 139 pts (85.3%), esophageal injuries in 23 pts (14.1%), inconclusive in one case (esophageal stricture, 0.6%). Lacerations were detected in 14 pts, all confirmed surgically. Contusions were observed in 10 pts. The first six cases were operated, and esophageal wall damage from the bullet path without perforation was noted. The past four cases with esophageal contusion without signs of perforation were managed conservatively. True-positive procedures occurred for 23 pts, true-negative results for 119 pts, false-negative exam for one case, and no false-positive examination. Overall FE showed 95.8% sensitivity, 100% specificity, 100% positive predictive value, 99.2% negative predictive value, and 99.3% accuracy. One complication was registered (aspiration pneumonia). Conclusion: FE is a highly accurate and safe diagnostic tool in the assessment of esophageal injuries. Endoscopists should be alert on two main lesions: laceration or perforation and contusion. Laceration usually requires surgical repair. Esophageal contusion, in selected cases, may be managed in a more conservative manner.