Injuries to the Esophagus and Stomach

Niels D. Martin

Babak Sarani

ESOPHAGEAL TRAUMA

Introduction

Injury to the esophagus is very rare, with the overwhelming majority of trauma being caused by penetrating injury. Iatrogenic injuries from foreign bodies or forceful vomiting are far more common but will not be discussed in this chapter. Although infrequent, a complete understanding of the diagnosis and management of esophageal trauma is essential to minimize the morbidity and mortality associated with esophageal injuries. Time from injury to definitive management and the degree of soilage to surrounding tissues are the most important factors for morbidity. The most important difference between traumatic injury and other forms of esophageal perforation is the high incidence of concomitant injury. Often, the underlying cause of morbidity or mortality in trauma patients is not the esophageal injury itself, but rather the constellation of other injuries sustained. For these reasons, the trauma surgeon must be aware of how esophageal injuries can present and expedite their evaluation.¹

Anatomy and Mechanism of Injury

The esophagus can be divided into three anatomic regions: cervical, thoracic, and abdominal. These regions differ in the associated injury pattern and also in the approach to the diagnosis and management of the esophageal injury itself. The cervical esophagus borders the trachea anteriorly, the spine posteriorly, and the carotid sheaths laterally. Cervical esophageal injuries are the most common overall and are the least lethal. Thoracic esophageal injuries are the second most common and carry the highest morbidity and mortality due to their proximity to other vital structures and the risk of severe mediastinal sepsis. The abdominal esophagus is the least commonly injured. The Organ Injury Scaling Committee of the American Association for the Surgery of Trauma has created a standardized grading system for esophageal injuries based on the degree of injury ranging from contusion to laceration to segmental loss (see Table 1).²

Injury patterns in esophageal trauma vary based on mechanism. As already noted, most esophageal injuries involve penetrating trauma, but the specific cause of penetrating esophageal injury (gunshot vs. stab wound) may differ based on the common type of weapons used in a particular area. For example, gunshot wounds are more common in the United States whereas stab wounds are more prevalent in other areas of the world. Penetrating cervical esophageal injury is present in < 1% of all penetrating trauma, but is found in 5% to 12% of all penetrating trauma to the neck.³,⁴,⁵ Conversely, penetrating thoracic esophageal trauma has a reported incidence of <1% of all penetrating wounds to the chest.⁶

Depending on muzzle velocity, bullet characteristics, and the attitude of the projectile, gunshot wounds can cause significant shearing, stretch, and blast injury to surrounding tissues. Therefore, ischemia and full-thickness
necrosis may evolve with time resulting in a delay in presentation of significant injury. Stab wounds, on the other hand, generally cause minimal injury to surrounding tissues. As will be discussed further, using advanced imaging for trajectory determination, especially for the path of a bullet, is a key aid to help determine esophageal injury.⁷ However, it should be remembered that using imaging for this process is less reliable following stab injury because surrounding tissues are less disturbed or disrupted.

TABLE 1 THE ORGAN INJURY SCALING COMMITTEE OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA GRADING SCALE OF ESOPHAGEAL INJURY

Grade	Description
I	Contusion/hematoma
II	Laceration <50%
III	Laceration >50%
IV	<2 cm disruption of tissue or vasculature
V	>2 cm disruption of tissue or vasculature
Moore EE, Jurkovich GJ, Knudson MM, et al. Organ injury scaling. VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary. J Trauma-Injury Infect Crit Care. 1995;39(16):1069-1070.

Blunt esophageal injury most commonly affects the abdominal esophagus. Such injury results from the sudden application of a blunt force to the abdomen, usually with a full stomach. This causes the gastroesophageal (GE) junction to stretch against the hiatal crura, which in turn act as a guillotine.⁸ The lack of a serosal layer on the esophagus makes an injury more likely to result in perforation. Motor vehicle collisions are the most common cause.⁹

Esophageal injury can also result from trauma to other structures. For example, vertebral column injuries associated with bony fragmentation can injure the esophagus—especially where the esophagus lies in very close proximity to the spine at C5 and T3-T4.¹⁰ Mediastinal hematomas have also been described to cause external compression on the esophagus and become clinically symptomatic from compression.¹¹

It is crucial to understand that most traumatic esophageal injuries are not isolated injuries; therefore once noted, investigation of adjacent and associated structures should be undertaken to rule out concomitant injuries. In the largest study to date, Asensio et al. performed a multicenter retrospective review and reported 88% of patients with esophageal trauma had associated injuries. In this review, Asensio et al. found significant associations with tracheal, vascular, pulmonary, diaphragmatic, and spinal cord injuries.¹² In a similar study, Glatterer et al. reported on 26 patients with esophageal trauma, noting 24 had associated injuries, 14 of which involved the trachea.¹³ Table 2 summarizes the incidence of concomitant injuries in patients with esophageal injury.

TABLE 2 INCIDENCE OF CONCOMITANT INJURIES IN PATIENTS WITH ESOPHAGEAL INJURY

Injury	Incidence (%)
Vascular	5-40
Lung	5-35
Trachea	15-64
Spinal cord	8-16
Diaphragm	10-20
All injuries	88
Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma. J Trauma-Injury Infect Crit Care. 2001;50(2):289-296; Glatterer MS Jr, Toon RS, Ellestad C, et al. Management of blunt and penetrating external esophageal trauma. J Trauma-Injury Infect Crit Care. 1985;25(8):784-792; Armstrong WB, Detar TR, Stanley RB. Diagnosis and management of external penetrating cervical esophageal injuries. Ann Otol Rhinol Laryngol. 1994;103(11):863-871; Attar S, Hankins JR, Suter CM, et al. Esophageal perforation: A therapeutic challenge. Ann Thorac Surg. 1990;50(1):45-51; Ngakane H, Muckart DJ, Luvuno FM. Penetrating visceral injuries of the neck: Results of a conservative management policy. Br J Neurosurg. 1990;77(8):908-910; Richardson JD, Tobin GR. Closure of esophageal defects with muscle flaps. Arch Surg. 1994;129(5):541-548; Winter RP, Weigelt JA. Cervical esophageal trauma. Incidence and cause of esophageal fistulas. Arch Surg. 1990;125(7):849-852.

Presentation and Diagnosis

A high index of suspicion coupled with accurate, timely, and high-resolution imaging is necessary because injury to the esophagus commonly presents with nonspecific signs and symptoms or can be totally asymptomatic. Notably, Smakman et al. found that < 10% of patients presented with bloody nasogastric aspirate, hematemesis, or pneumomediastinum.¹⁴ Clinical examination was negative in 80% of all esophageal injuries.⁵ Signs and symptoms that are associated with esophageal injury can include pain, fever, dysphagia, odynophagia, hematemesis, hoarse voice, subcutaneous emphysema/crepitus, mediastinal crunch (Hamman sign), oropharyngeal blood, hemoptysis, and dyspnea (see Table 3).¹⁵,¹⁶,¹⁷,¹⁸ Most series of esophageal perforation have reported the most common symptoms to be chest pain (71% to 85%), followed by fever (51% to 90%) and dyspnea (24% to 40%).¹⁹,²⁰ However, these data generally include all esophageal injury modalities of which only 20% to 25% of the cohort is traumatically injured.

Various modalities, including chest x-ray (CXR), esophagography, esophagoscopy, and computed tomography (CT) scan can be used to image the esophagus. Chest x-ray and lateral C-spine films are usually the first images obtained in a trauma patient but are also the least specific. Air in the soft tissues of the neck or mediastinum mandates
further evaluation of the aerodigestive system, especially in the absence of pneumothorax.

TABLE 3 COMMON SIGNS AND SYMPTOMS OF ESOPHAGEAL PERFORATION (%)

Sign/Symptom	Smakman et al.	Goudy et al.
Prevertebral air	48	—
Fever	—	—
Pain/odynophagia	21	—
Blood in NG tube	10	—
Hoarseness	10	—
Hematemesis	6	—
Hemoptysis	6	—
Mediastinal air	—	—
Dysphagia	29	63
Hemothorax	33	—
Widened mediastinum	10	—
Crepitus/subcutaneous emphysema	46	21
Dyspnea	—	—
NG, nasogastric.
Smakman N, Nicol AJ, Walther G, et al. Factors affecting outcome in penetrating oesophageal trauma. Br J Neurosurg. 2004;91(11): 1513-1519; Goudy SL, Miller FB, Bumpous JM. Neck crepitance: Evaluation and management of suspected upper aerodigestive tract injury. Laryngoscope. 2002;112(5):791-795.

CT is much more sensitive than plain films in noting air and fluid collections around the esophagus. Although pneumomediastinum and/or pleural effusions are associated with esophageal injury, the lack of these findings does not adequately exclude injury and their presence does not definitively diagnose injury. CT is also helpful for determining bullet trajectory but less so for tracts created by stab wounds. Further invasive studies can often be eliminated from the diagnostic workup if CT scan demonstrates trajectories remote from the esophagus.²¹ Trajectory determination on CT is much more difficult for stab wounds because of the minimal blast effect, hemorrhage, and deposition of air along the wound tract.²²,²³ In conjunction with clinical examination, CT can help determine whether further directed workup is necessary. As stated previously, even small amounts of air within the mediastinum or neck, especially in the absence of pneumothorax, mandate full evaluation of the aerodigestive system.

Formal evaluation of the esophagus is reserved for patients who are suspected of having an esophageal injury. This entails laryngoscopy for proximal injuries and esophagoscopy with or without esophagography for the remainder of the esophagus. The decision as to whether to use rigid or flexible endoscopy for trauma patient evaluation is controversial, although most centers now rely mainly on flexible endoscopy due to its ease of use at the bedside, lack of need for general anesthesia, and safety in patients who remain in cervical spine precautions.¹⁷,²⁴

Endoscopy is usually the first tool used after radiographic imaging. It is available, simple, and in trained hands, technically easy. However, flexible endoscopy alone must be used with caution. Flexible esophagoscopy has been shown to have a 40% to 100% sensitivity and 66% to 100% specificity with a positive predictive value of 33% and negative predictive value of 100%.⁵,²⁰,²⁴,²⁵ Flexible esophagoscopy has a lower sensitivity in the cervical esophagus as compared to the thoracic esophagus, and rigid esophagoscopy remains the preferred endoscopic modality for diagnosis of proximal esophageal injury.

Esophagography, utilizing water-soluble followed by barium contrast, was historically the gold standard in evaluating esophageal injury. Unfortunately, the patient’s clinical status may not allow for contrast imaging; for example, a patient with a decreased mental status at risk of aspiration or an intubated patient who cannot actively swallow contrast. Esophagography may be more sensitive than flexible endoscopy in evaluating the cervical esophagus, but the two modalities are equivalent in evaluating the thoracic esophagus.²⁰

The most recent literature suggests that the new gold standard is the combination of both flexible esophagoscopy and esophagography.⁵,²⁶,²⁷ Combining both modalities results in almost 100% sensitivity and specificity in detecting all esophageal injuries, although many trauma surgeons suggest this is needed only in cases where either study alone is technically limited.

Management Options

The management of esophageal injuries depends on location, time of diagnosis, associated injuries, and general medical condition. In general, the earlier esophageal injuries are addressed, the better. This is especially true in thoracic esophageal injuries where continued soilage of the mediastinum can cause severe sepsis and impede healing of a future repair. It should be remembered that the lack of a serosal layer makes esophageal repair far more tenuous than that of other parts of the gastrointestinal (GI) tract. Although attention to more life-threatening injuries or other pressing medical conditions may take precedence, the potential morbidity of waiting to repair an esophageal injury is significant. Definitive closure and drainage are best carried out as soon as possible.

Nonoperative Management

Nonoperative management is possible in patients who have contained leaks and few signs/symptoms or those who are moribund and unable to survive surgery. These patients generally have had a significant delay in diagnosis and have a high mortality rate. A contained leak is best described as extravasation of contrast on esophagography, but the contrast “goes-out and back-in” the esophagus.²⁸
This is usually a small area not associated with a standing fluid collection, mediastinal inflammation, or pleural effusion. If any of these criteria are violated, serious consideration should be given to invasive treatment.²⁸ Esophagography can be repeated in several days to document resolution before starting a soft diet. Patients not fit for operative intervention because of severe sepsis or pulmonary compromise should undergo wide chest drainage at the bedside using more than one large chest tube.

Operative Management

Although there are no prospective studies defining a safe period during which preoperative testing can be completed before operative intervention, there is general agreement that esophageal injury is a surgical emergency and preoperative testing must be expedited to facilitate a timely repair. Frequently, the severity of concomitant injuries necessitates delay of esophageal repair. Recently, it has been shown that morbidity is more accurately predicted by the degree of soilage. There is a preponderance of recent literature that states the degree of inflammation in surrounding tissues, and not time since injury per se, should dictate whether primary repair or simply drainage should be performed.⁸,¹³,¹⁴,²⁹,³⁰ Repairs can be accomplished, even at delayed time periods, in select patients with minimal soilage at time of surgery. It should be noted, however, that morbidity and mortality is mainly related to anastomotic failure, and breakdown of the esophageal repair is associated with at least 50% mortality.¹

Location of the injury is another factor that dictates the surgical approach and repair options (see Table 4). Cervical injuries are best approached from the left neck where the recurrent nerve can be more easily identified and preserved. The incision should be placed at the anterior border of the sternocleidomastoid muscle and carried down through the soft tissues between the trachea and the carotid sheath. The esophagus can be mobilized bluntly with a finger circumferentially with careful attention not to injure either recurrent nerve or the membranous portion of the trachea. Thoracic esophageal injuries are best approached from a right posterolateral thoracotomy. Appropriate positioning is imperative to optimize visualization, and therefore fashion a better technical repair. The intercostal muscle bundle should receive careful attention and be preserved when entering the chest, as it is a potential repairbuttressing flap. The distal third of the thoracic esophagus actually lies more to the left and can be accessible either from a left posterolateral thoracostomy or from the abdomen after appropriate mobilization. Lastly, the intra-abdominal esophagus is best accessed by an upper midline laparotomy. This should be carried up to the xiphoid process and down to at least just below the umbilicus.

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