Esophageal Trauma Research Articles

Management of acute blunt and penetrating external laryngeal trauma

Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function.

An Unusual Complication of Bravo pH Capsule Dislodged into the Pyriform Sinus

Purpose: Wireless esophageal pH monitoring is an important diagnostic modality in patients with suspected gastroesophageal reflux disease (GERD) to confirm acid reflux and evaluate refractory symptoms. The device is commonly placed 6 cm above the endoscopically visualized gastroesophageal junction Z line. After deployment, the attachment and correct positioning on the esophageal wall is frequently confirmed with second look endoscopy. A 44-year-old man with history of GERD symptoms was non-adherent to anti-reflux therapy and developed worsening of his reflux symptoms. In addition to recommendations for antireflux diet and lifestyle modification, he was scheduled for esophagogastroduodenoscopy and Bravo pH testing off acid suppressing medications to confirm presence of acid reflux. The procedure was performed under monitored anesthesia care (MAC). The Z line was visualized at 40 cm from the incisors and the capsule was deployed at 34 cm. The procedure adhered to the manufacturer's protocol. The capsule was not visualized endoscopically attached to the esophageal wall at 34 cm and so the scope was advanced to see if it had migrated to the distal esophagus or into the stomach. The scope was withdrawn proximally after failure to see the capsule at either location. On withdrawal of the scope from upper esophageal sphincter, the capsule was visualized in the left pyriform sinus. It was presumed that the capsule either had been either dragged up by the side of the scope during withdrawal or that the patient had coughed it up. The options for safe removal of the capsule were reviewed in immediate consultation with ENT, and pulmonary physicians. The anesthesiologist provided additional sedation and endotracheal intubation after which the capsule was successfully retrieved by ENT. We report an unexpected, and so far unreported, complication of a Bravo capsule dislodgement. Bravo pH probe placement is generally a safe and well-tolerated procedure. Common complications include non-attachment, misplacement, early dislodgement, poor data reception and capsule removal in patients with intolerable chest pain. Other rare but more serious complications which have been described are esophageal wall trauma, severe bleeding, esophageal perforations, and capsule aspiration into the bronchus. Gastroenterologists performing this procedure should be aware of the low but non-negligible technical difficulties.

Esophageal rupture: a severe complication of transesophageal echocardiography

Since when the first transesophageal echocardiography (TEE) was undertaken in 1975, technological advances have made this diagnostic modality more reliable. TEE indications became widespread in cardiac and non-cardiac surgeries, intensive care units, and ambulatory clinics. The procedure is generally considered a safe diagnostic tool, but occasionally complications do occur. The insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Although rare, these complications may present a mortality rate of up to 56% depending on the treatment approach and the elapsed time to the diagnosis. The authors report a case of a 65-year-old woman submitted to attempt a TEE in order to better study or diagnose an inter-atrial communication. After 3 days of the procedure, the patient was admitted to the hospital with edema, hyperemia of the anterior face of the neck, accompanied by systemic symptoms. The imaging diagnostic work-up evidenced signs of esophageal rupture and upper mediastinal involvement, the former confirmed by upper gastrointestinal endoscopy. The patient was treated with antibiotics and cervical and mediastinal drainage, with a favorable outcome.

Index of Suspicion

Index of Suspicion

Esophagogastric Trauma in Scotland

This study was designed to investigate the incidence of esophageal (ET) and gastric trauma (GT) in Scotland and to identify factors associated with adverse outcome. Population-based study of a prospective multicenter database of 52,887 trauma patients, admitted to 25 hospitals from 1992 to 2002. Thirty patients [0.06 %; median age, 32 year (range, 15-79); 86.7 % male] sustained ET [17 (56.7 %) blunt vs. 13 (43.3 %) penetrating]. The most common causes of injury were road traffic accidents (RTAs; n = 11; 36.7 %) and assaults (n = 10; 33.3 %). Most patients (n = 25; 83.3 %) had injury severity scores (ISS) >15, consistent with severe trauma. Fifteen patients (50 %) underwent surgery, of whom 8 (53.3 %) died. Another 13 patients died, yielding an overall mortality rate of 70 %. In contrast, 149 patients [0.29 %; median age, 28 year (range, 13-74); 90.6 % male] sustained GT [124 (83.2 %) penetrating vs. 25 (16.8 %) blunt]. The predominant cause was assault (n = 119; 79.9 %). Most patients (n = 134; 89.9 %) underwent surgery, of which 23 (17.2 %) died. Another 12 patients died, yielding an overall mortality rate of 23.5 %. Factors associated independently with GT mortality included higher ISS, lower Glasgow coma scale (GCS), and hemodynamic compromise. Esophagogastric trauma occurs predominantly in young males. The incidence of GT, although low, is five times that of ET. Predominant mechanisms of GT are penetrating compared with blunt for ET. Both ET and GT are commonly found in the presence of other multiple injuries, and are associated with high mortality. Operative management of GT is associated with reduced mortality, but outcome is worse for patients with hemodynamic compromise, low GCS, and high ISS.

Penetrating oesophageal injury: A contemporary analysis of the National Trauma Data Bank

BackgroundOesophageal trauma is uncommon. The aim of this study was to conduct a descriptive analysis of penetrating oesophageal trauma and determine risk factors for oesophageal related complications and mortality in the National Trauma Data Bank (NTDB). MethodsPatients with penetrating oesophageal trauma from Levels 1 and 2 trauma centres in the NTDB (2007 and 2008) that specified how complication and comorbidity data were recorded were selected. Data collected included age, injury severity score (ISS), abbreviated injury scores (AIS), lengths of stay (LOS) and ventilation days, systolic blood pressure (SBP) in the emergency department (ED), comorbidities, oesophageal related procedures, and oesophageal related complications. Univariate and multivariable analyses were conducted to identify significant predictors of oesophageal-related complications and mortality in patients with LOS>24h. Results227 patients from 107 centres were studied. The mean number of patients per centre was 2 (range 1–15). Overall mortality was found to be 44% with 92% of these deaths in less than 24h. In patients with LOS>24h, 62% had primary repair, 13% drainage, 4% resection, 1% diversion, and 20% unspecified. No significant difference in mortality was found in patients with oesophageal related complications. The time to first oesophageal related procedure was not significantly different in those with oesophageal related complications or those who died. Significant predictors of oesophageal related complications were age and AIS of the abdomen or pelvic contents ≥3 and the only significant predictor of mortality was ISS. ConclusionsMost deaths in penetrating oesophageal trauma occur in the first 24h due to severe associated injuries. Primary repair was the most common intervention, followed by drainage and resection. Oesophageal related complications were not found to significantly increase mortality and time to first oesophageal related procedure did not affect outcomes in this subset of patients from the NTDB.

Pus in the thorax: management of empyema and lung abscess

Pleural infection is a common clinical problem that is associated with a high mortality and morbidity. In the UK, the mortality is 20% with 20% requiring surgery. The development of an empyema associated with pneumonia is a progressive process classified in three stages. Initially, there is a free-flowing exudate with a normal pH termed a simple parapneumonic effusion. This progresses to a fibrinopurulent stage with increasing fluid and bacterial invasion causing a decrease in pH. If the fluid is clear but the pH ,7.2, this is termed a complicated parapneumonic effusion while frank pus is termed an empyema. The third stage is an organizing stage with the formation of a solid fibrous peel. Pleural infection can also occur after pleural interventions, thoracic or oesophageal surgery, trauma, or oesophageal rupture.

Surgical Management of Acquired Nonmalignant Tracheoesophageal and Bronchoesophageal Fistulae

Acquired nonmalignant fistulae between the airway and esophagus (tracheoesophageal fistulae [TEF]) are rare life-threatening conditions. Several management approaches have been proposed, while the optimal strategy remains controversial. This study is a retrospective review of all patients with TEF treated at our institution from 1978 through 2007. Thirty-five patients (22 men, 13 women) underwent surgical repair of acquired nonmalignant TEF. Median age was 55 years (range, 5 to 78). Most common causes were the following: complications of esophageal surgery (11), trauma (6), granulomatous infection (5), stent erosion (4), and prolonged mechanical ventilation (2). Location was proximal trachea in 7, mid-trachea in 5, and distal trachea or bronchus in 23. Fifty-six operations were performed. Six patients had staged repair, with 1 patient requiring 4 operations for recurrent TEF. TEF division and primary repair was performed in 18 patients, esophageal resection with reconstruction in 4, and esophageal diversion in 6. Four patients had suture closure of the esophageal or tracheal defect only, and 3 required segmental tracheal or bronchial resection. Four patients were ventilator dependent at the time of repair. Pedicled tissue flaps were used in 28 patients (80%). Operative mortality was 5.7% (2 of 35). Nineteen patients (54.3%) had complications. Median hospital stay was 14 days (range, 4 to 209). Median follow-up was 30.4 months (range, 0.5 to 233) and complete in 34 (97.1%). Three patients (8.6%) developed recurrent TEF. Twenty-nine patients resumed oral intake. One patient required a permanent tracheal T tube. Single-stage primary repair of both airway and esophageal defects with tissue flap interposition can safely be performed successfully in the majority of patients with acquired nonmalignant TEF.

Practice Guidelines for Perioperative Transesophageal Echocardiography

Practice Guidelines for Perioperative Transesophageal Echocardiography

Intravascular ultrasound catheter for transesophageal echocardiography in congenital heart surgery -A case report-

Transesophageal echocardiography (TEE) has an important role during congenital heart surgery. TEE in small infants is associated with complications, including an inability to pass the TEE probe, esophageal trauma, airway compression, aortic compression, and interference with ventilation. Recently, a monoplane intravascular ultrasound catheter (IVUC) has been developed for intracardiac echocardiography. The efficacy of IVUC for transesophageal use has been shown in numerous animal studies and several human studies, but there have been few reports involving small infants using an IVUC probe. We examined 15 pediatric patients undergoing congenital cardiac surgery using an 8-Fr AcuNav IVUC probe. We checked the cardiac anatomy, cardiac function pre-operatively and de-aeration before weaning from CPB; the surgical repairs were evaluated post-operatively. Although the IVUC probe has limitations associated with the monoplane, we found the IVUC probe to be useful in small infants and safer than the TEE.

Core Topics in Thoracic Anesthesia

This book is aimed primarily at trainees gaining experience in thoracic anaesthesia. Admirably, the authors are also motivated by the desire to convey and pass on their own experience to those they teach. The content is divided into broad sections dealing with pre-operative considerations, anaesthesia for specifi c procedures and identifi ed groups of patients (for example, by age, size and emergent/ elective status), and post-operative management. Of the 30 chapters, 15 are solely or partly authored by the editors, which adds to continuity of style. The target audience probably dictates (and even mandates) a rather dictatorial and unevidenced approach. Thus, the contents of each chapter are supported by key references rather than an exhaustive bibliography. Your Reviewer does not practice thoracic anaesthesia but spends a good deal of his clinical practice reviewing patients with problems covered by the pre-operative and post-operative periods. The chapters on thoracic anatomy and respiratory physiology are brief, concise and generally well written. Appropriate emphasis is placed upon chronic respiratory diseases likely to impact upon peri-operative care, particularly pulmonary arterial hypertension, pulmo nary fi brosis and occupational lung disease. Only occasion ally do the authors spill over into the self-evident, such as when advising the reader to employ an anaesthetic technique unlikely to provoke bronchospasm in asthmatics. Your Reviewer consulted colleagues who found the chapters on anaesthesia and the excellent illustrations contained therein of relevant equipment to be particularly robust. The use of decision trees and tables summarising the advantages and disadvantages of various techniques of anaesthesia and monitoring are a defi nite strength. Illustrations (such as those relating to video-assisted thoracoscopic surgery) were helpful but would have been enhanced by the (presumably expensive) use of colour. The division of the anaesthetic section into that dealing with oesophageal surgery, trauma, and pleural and chest wall procedures was helpful, as was the inclusion of a specifi c chapter on the (increasingly prevalent) morbidly obese patient. The section dealing with the management of postoperative respiratory problems was generally well written, although some epidemiology of those conditions most likely to confront the unwary anaesthetist would have been welcome. Acute lung injury/acute respiratory distress syndrome is the commonest cause of death in the postoperative period in patients undergoing lung resection, but the section dealing with mechanical ventilation and nonventilatory adjuncts is brief. By contrast, more than a full chapter is devoted to the use of extra corporeal membrane oxygenation and related technologies. This book should appeal to the trainee spending 6 months or so in a cardiothoracic unit but not planning to specialise in this area of practice. In a new edition, the editors should pay some attention to the rather opaque style that dogs one or two chapters, but the fact that this Reviewer thinks that a second edition is likely gives some indication of its probable appeal.

Flexible Esophagoscopy as a Diagnostic Tool for Traumatic Esophageal Injuries

The management and clinical outcome of patients suffering esophageal trauma depends on a prompt diagnosis. The detection of esophageal injuries by clinical examination, esophagography, or computed tomography is limited. This study aimed to assess the yield and clinical utility of flexible esophagoscopy (FE) in the diagnosis of traumatic esophageal injuries. During 7 years, we conducted a retrospective (1998-2003) and prospective (2003-2005) study of 163 victims admitted to a trauma hospital, and submitted to FE because of suspected esophageal trauma. Esophageal injury was defined as laceration or perforation, hematoma, abrasion, hematin spots, or ecchymosis. The endoscopic diagnosis was compared with surgical findings or clinical follow-up. No traumatic lesion was observed in 139 patients (85.3%), esophageal injuries were detected in 23 (14.1%), and one examination was inconclusive (esophageal stricture, 0.6%). Lacerations were detected in 14 patients and confirmed surgically. Esophageal contusion was observed in nine patients and out of these, five patients underwent surgical exploration and four were managed nonoperatively. The assessment of esophageal injury by FE demonstrated 95.8% sensitivity, 100% specificity, 99.3% accuracy, 100% positive predictive value, and 99.2% negative predictive value. The likelihood ratio for a negative examination was 0.041 and the Youden J Index was 99.2%. FE appears to be an accurate diagnostic tool in the assessment of esophageal injuries. Two main lesions were noted: laceration and contusion. Laceration requires surgical repair. Contusion represents a nonperforative injury of the esophageal wall, requires correlation with computed tomography, and may be managed nonoperatively.

Ostomy-Product Selection and Innovations

TOPIC: An esophagectomy is an excision of part of the esophagus that is performed for esophageal cancer, swallowing disorders and trauma. One of several complications that can occur is an anastomotic leak. When a leak occurs an esophagostomy may be surgically created and require a pouching system to contain secretions. Sometimes these are referred to as a “spit fistula.” PURPOSE: The main purpose of this project is to demonstrate the use of ostomy pouches as a viable option when drainage control is necessary for a spit fistula. OBJECTIVES: A spit fistula is generally located in the left lower neck or clavicle area. If drainage is small, it may be managed with application of an absorptive dressing. Moderate or large amounts of drainage benefit from the application of a pouch to contain drainage, reduce skin irritation and improve the quality of life for patients. OUTCOMES: The creation of a spit fistula for an anastomotic leak following an esophagectomy may require the application of a pouch to contain moderate to large amounts of drainage. Patients may have the spit fistula for several months as infections are treated and incisions allowed to heal. A gastrostomy tube is inserted to provide for the patient's nutritional needs. Several attempts with different pouches may be necessary to find a correct fit. The pouching system generally requires changing every 3–5 days with the majority of patients receiving a four-day wear time. Containment of drainage prevents skin from becoming macerated and denuded. Drainage containment also keeps the patient's gown or clothing dry and may allow palliative food or fluid intake which can create a feeling of normalcy under very difficult circumstances.

Aortoesophageal Fistula: A Case Report

Patients with impacted foreign bodies in the upper aerodigestive tract present commonly to ENT clinics. This case report highlights two important issues in the management of these patients. First, if the evidence of esophageal perforation is strong and contrast swallow is negative, the physician must consider further imaging, such as contrast computed tomography. Second, ENT physicians must beware of the complications of esophageal trauma, including major vascular injury and aortoesophageal fistula, in patients with retained sharp foreign bodies in the mid-esophagus.

Long-distance esophagogastric submucosal dissection after minimal esophageal trauma of a gastric tube

Spontaneous submucosal dissection of the esophagus is a rare disorder 1 Marks I.N. Keet A.D. Intramural rupture of the esophagus. Br Med J. 1968; 3: 536-537 Crossref PubMed Scopus (86) Google Scholar , 2 Shimada T. Kimura K. Higashi K. et al. Spontaneous submucosal dissection of the esophagus. Intern Med. 1993; 32: 795-797 Crossref PubMed Scopus (18) Google Scholar , 3 Gluck M. Jiranek G.C. Low D.E. et al. Spontaneous intramural rupture of the esophagus: clinical presentation and endoscopic findings. Gastrointest Endosc. 2002; 56: 134-136 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and usually occurs proximal to the esophagogastric junction, within the proper mucosal layer. 4 Steadman C. Kerlin P. Crimmins F. et al. Spontaneous intramural rupture of the oesophagus. Gut. 1990; 31: 845-849 Crossref PubMed Scopus (61) Google Scholar With proper management, most patients improve within 2 to 4 weeks, and few cases require endoscopic or surgical treatment. 5 Cho C.M. Ha S.S. Tak W.Y. et al. Endoscopic incision of a septum in a case of spontaneous intramural dissection of the esophagus. J Clin Gastroenterol. 2002; 35: 387-390 Crossref PubMed Scopus (21) Google Scholar , 6 Kim S.H. Lee S.O. Circumferential intramural esophageal dissection successfully treated by endoscopic procedure and metal stent insertion. J Gastroenterol. 2005; 40: 1065-1069 Crossref PubMed Scopus (26) Google Scholar We report a case of spontaneous esophagogastric submucosal dissection, which may start from the esophagus and extend to the stomach.

A state-of-the-art review of esophageal trauma: where do we stand?

The esophagus provides a diagnostic and therapeutic pathway not only for gastroenterologists but for surgeons, radiologists, cardiologists, and other specialists. Unfortunately, this procedural traffic occasionally leads to iatrogenic injury. As well, though reasonably well protected anatomically, frank esophageal injuries due to non-iatrogenic causes are not uncommon. We present a review of the literature on this subject covering anatomy, etiology, diagnostics, therapeutics, and management generally.

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

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.

Spent Bullet in the Bronchus

Penetrating tracheal trauma, although infrequent, varies from minor to life-threatening injuries. Serious injury often results from airway compromise or significant associated esophageal or vascular trauma. Tracheal injuries resulting in a retained ballistic fragment in the airway have been infrequently reported. We report the successful treatment of a patient with a gunshot wound to the anterior cervical trachea resulting in a spent bullet lodged in the left lower lobe bronchus.

Clinical Features of Complications From Transesophageal Echocardiography: A Single-Center Case Series of 10,000 Consecutive Examinations

Transesophageal echocardiography (TEE) is an essential diagnostic tool that has gained widespread use in clinical cardiology. It is considered reasonably noninvasive and safe; however, insertion and operation of the TEE probe may cause hypopharyngeal, esophageal, or gastric trauma. The current study reports a single-center experience of esophagogastric trauma in 10,000 consecutive TEE examinations. TEE examinations were performed by 9 attending physicians who were trained in endoscopic procedures and had been performing TEE studies for at least 1 year. One case of hypopharyngeal perforation (0.01%), 2 cases of cervical esophageal perforation (0.02%), and no cases of gastric perforation (0%) occurred after TEE examination. No fatalities (0%) occurred. We describe the clinical characteristics of individuals who experienced esophageal perforation during this 10-year period. This single-center study demonstrates that TEE examinations are associated with a very low risk of esophagogastric trauma when performed in a safe setting by experienced operators.

The course of the esophagus and its relevance to the ablation of atrial fibrillation

Left atrial (LA) ablation for AF may cause esophageal (Eso) trauma. Knowledge of the relationships of the Eso to potential LA ablation sites may reduce this risk.