Esophagus Trauma

Esophagus Trauma

David Ray Velez, MD

Table of Contents

Background
Diagnosis
Treatment

Background

The Majority are Due to Penetrating Trauma

Site

  • Cervical Esophagus – Most Common
  • Thoracic Esophagus – Less Common Due to Bony Protection
  • Abdominal Esophagus – Least Common

Nearly All (98%) Have Other Associated Injuries

AAST Esophagus Injury Scale

Diagnosis

Signs/Symptoms

  • Pain in the Neck, Chest, or Abdomen
  • Dysphagia – Pain with Swallowing
  • Nausea and Vomiting
  • Hematemesis
  • Dyspnea
  • Cough
  • Subcutaneous Emphysema
  • Presentation is Generally Nonspecific

Delay in Diagnosis is Common and Requires a High Index of Suspicion

Diagnosis

  • Start with a Water-Soluble Contrast Esophagram
    • Can Pull NG Back to the Proximal Esophagus Before Contrast Instillation if Intubated
  • If Negative but High-Suspicion of Injury: Repeat Esophagram with Dilute-Barium
  • If Negative Again: Esophagoscopy

Specificity/Sensitivity

  • Contrast Studies Alone Have High False-Negative Rates (25%)
  • Esophagoscopy Has a High Negative Predictive Value (100%) but Low Positive Predictive Value (33%)
  • A Negative Esophagram AND Esophagoscopy Have a Near 100% Specificity

Traumatic Esophagus Perforation with Oral Contrast Extravasation 1

Treatment

The Primary Treatment is Surgical Repair Reinforced with Buttress and Drainage

Surgical Approach to the Esophagus

  • Cervical Esophagus: Left Cervical Incision Along the Anterior Border of the Sternocleidomastoid (SCM) Muscle
  • Thoracic Esophagus (Upper 2/3): Right Posterolateral Thoracotomy – Avoids the Aorta on the Left
  • Thoracic Esophagus (Lower 1/3): Left Posterolateral Thoracotomy – The Aorta Transitions to the Right Distally
    • May Be Able to Repair Through a Laparotomy Alone for Distal Injuries at the Esophagogastric Junction

Surgical Repair

  • The First Step is to Extend the Myotomy to See the Full Length of Mucosal Injury
    • The Muscular Defect is Almost Always Smaller than the Mucosal Defect
  • Close the Defect in Two Layers without Tension
    • Inner Absorbable Suture and Outer Permanent Suture
    • The Submucosa is the Strength Layer – There is No Serosa in the Esophagus
    • Transverse Repair is Preferred for Small Defects, but Large Injuries May Require Longitudinal Repair
  • The Blood Supply is Longitudinal Through the Submucosa – Allows Full Mobilization
  • Explore Circumferentially in Penetrating Injury to Verify No Back-Wall Injury

Buttress

  • Esophageal Repairs Should Be Buttressed to Strengthen and Enhance Healing Given No Serosal Layer Which Increases the Risk of Postoperative Leak
  • Neck: Strap Muscles or Sternocleidomastoid (SCM) Muscle
  • Proximal Thorax: Intercostals or Rhomboid Muscle
    • Muscle Flaps are Preferred – Less Friable and Provide More Bulky Coverage
    • Other Less Desirable Options: Pericardium or Pleura
  • Distal Thorax or Abdomen: Stomach (Nissen Fundoplication) or Diaphragm

Drainage

  • Neck: Penrose or JP Drain
  • Thoracic: Chest Tubes
  • Abdomen: JP Drain

Damage Control Options

  • Neck: Cervical Esophagostomy (Spit Fistula)
    • Loop Esophagostomy If Able – Allows Easier One-Stage Closure as an End Esophagostomy Requires Complex Closure
  • Thoracic: Large T-Tube (Creates a Controlled Fistula)

The Use of Endoluminal Esophageal Stents is Evolving but May Be an Appropriate Alternative for Damage Control

References

  1. Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights Imaging. 2011 Jun;2(3):281-295. (License: CC BY-4.0)