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RESULTS
OF TREATMENT OF PATIENTS WITH ESOPHAGUS INJURIES IN LEVEL 1 TRAUMA CENTER
Dulaev A.K., Demko A.E., Taniya S.Sh., Babich A.I.
Saint Petersburg I.I. Dzhanelidze Institute of Emergency Medicine, Saint Petersburg, Russia
Esophageal injuries are rare - less than 1 % of patients admitted to hospital [1, 2]. As result, a physician who selects techniques of treatment, and an operating surgeon often do not have enough experience for management of this category of patients. Decisions are based on intuition and personal experience, but not on data of randomized clinical studies. However, there are not any studies for this problem [3]. A patient is involved in situation where he or she has no alternative option of treatment, and, from the second point of view, selected management can be inappropriate owing to absence of clear, standardized algorithms for management of such patients.
Objective – to analyze the results of treatment of patients with injuries (trauma, wounds) to the esophagus and to determine the objective signs of an unfavorable prognosis of the disease.
MATERIALS AND METHODS
The retrospective study included 76 patients with esophageal injuries for the period from 2003 to 2018. The inclusion criteria were esophageal injuries. There were more men than women (55 men and 21 women). The mean age was 37 ± 4. Stab and slash wounds of the esophagus were in 69 patients, gun-shot wounds - in 6, laceration of thoracic part of the esophagus with closed injury (after road traffic accident) - in 1. Most patients had injuries to cervical part of the esophagus (the table 1).
Table 1. Location of esophageal injuries
|
Region |
Amount |
% |
|
Cervical |
64 |
84 |
|
Thoracic |
8 |
11 |
|
Abdominal |
4 |
5 |
Single injuries to esophagus were identified in 20 patients, associated injuries - in 56 (the table 2).
Table 2. Injured structures found in concomitant injuries to esophagus
|
Injured organ/vessel |
Amount |
|
Descending aorta |
3 |
|
Carotid arteries |
18 |
|
Brachiocephalic trunk |
2 |
|
Diaphragm |
6 |
|
Heart |
3 |
|
Left main bronchus |
1 |
|
Internal jugular veins |
36 |
|
Spinal cord |
1 |
|
Trachea |
16 |
|
Thyroid gland |
24 |
|
Recurrent laryngeal nerve |
4 |
|
Thoracic duct flow |
1 |
Esophageal injuries in combination with two and more injured structures
were in 55 %.
After admission, AIS was determined. Arterial pressure was measured with
non-invasive technique with the cuff. Base excess (BE) in arterial blood was
measured. Hemodynamic stability was systolic arterial pressure > 90 mm Hg at
admission.
Diagnosis of esophageal injuries was based on clinical data, objective
examination, laboratory and instrumental data - X-ray examination, SCT,
esophagoscopy. The volume of diagnostic procedures for patients with esophageal
injuries depended on severity of condition and on possibilities for realization
of one or another examination.
Extended diagnostic algorithm was used for stable condition of patients.
It included radiological examination with water-soluble contrast media, SCT of
the neck and the abdomen with intravenous contrasting and oral administration
of water-soluble contrast media. Also 70 % and 50 % of patients received
fibroesophagoscopy and fibro-tracheo-bronchoscopy, correspondingly. In
conditions of the anti-shock surgical room, surgical intervention was conducted
for patients with unstable hemodynamics relating to injuries after X-ray
examination of the chest and FAST examination. The patients were distributed
into two groups to estimate the predictors of poor prognosis of the disease:
the group 1 (61 patients) - survived patients; the group 2 (15 patients)
- deceased patients. The patients of the group 2 died within the first 30 days
after trauma. All patients of the group 1 were discharged from the hospital.
The minimal follow-up was 3 months, the maximal one - 5 years. There were not
any lethal outcomes for the period of the study. The patients of both groups
were similar according to age and gender.
The statistical analysis of the data was conducted with Statistica 10.0
for Windows. Data distribution corresponded to normal distribution law.
Quantitative signs were presented as absolute and relative (%) values.
Quantitative data is presented as the mean (M) and standard deviation (±σ). Non-parametrical
methods of statistical analysis were used. Student's test was used for
estimation of reliability of differences between the groups. When testing the
statistical hypotheses, the critical level of significance (α) was 0.05. Differences were considered as statistically
significant at p < 0.05. Relative values were compared with Pearson χ2-test, which was
used for analysis of four-fold contingency tables, depending on presence of
various factors. The expected values in each cell of contingency tables were
not less than 10. For cases with expected values of 5-9 in at least one of
cells, χ2 was calculated with
Yates correction. If the expected value was less than 5, Fisher's exact test
was used. P value < 0.05 was considered as the bordering criterion of
statistical significance for rejection of the null hypothesis.
RESULTS
At admission, stable hemodynamics was in 42
patients (67 %) in the group 1, and in 9 (60 %) patients in the group 2.
For 16 patients (26 %) in the group 1 and 3 (20
%) patients in the group 2, more than 24 hours passed from accident to hospital
admission, confirmation of diagnosis and initiation of treatment.
Injury severity in the groups 1 and 2 did not
show significant differences (average AIS - 4 points in both groups).
In patients with esophageal injuries, the
clinical picture depended on condition severity, presence or absence of
concurrent injuries, etiologic factors of esophageal injury, and age of injury
(the table 3).
Table 3. Clinical signs of suspected esophageal injury
|
Symptom |
group 1 |
group 2 |
|
Pain |
39 (59 %) |
10 (66 %) |
|
Subcutaneous emphysema |
32 (51 %) |
7 (46 %) |
|
Phonation disorder |
19 (31 %) |
4 (27 %) |
|
Impairment of consciousness |
11 (18 %) |
5 (33 %) |
|
External bleeding |
25 (41 %) |
7 (47 %) |
|
Affluxion of saliva from wound |
33 (54 %) |
8 (53 %) |
Our analysis of clinical manifestations in
patients with esophageal injuries testified the absence of statistically
significant differences in patients of the groups 1 and 2 (p > 0.05).
Presence of one or another symptom did not influence on disease course.
Plain X-ray examination of the chest, the
abdomen and the neck was used as the screening method. It allowed suspecting
the esophageal injury in 25 % of patients only. Esophageal injuries were
identified with indirect signs: neck soft tissue emphysema (30 %),
pneumomediastinum (25 %), left-sided (10 %) or right-sided pleuritis (5 %).
Multiple-position X-ray examination with uptake
of water-soluble contrast media was conducted for stable patients before
implementation of routine SCT and for
cases of impossibility of SCT. Distribution of the contrast media behind
the borders of the esophagus supposes the esophageal injury. Multi-position
X-ray examination is important, but impossible in some cases. Accuracy of X-ray
examination with oral contrasting is 75 % for esophageal injuries according to
our data.
SCT with oral administration of water-soluble
contrast shows higher sensitivity and specificity which allowed identification
of esophageal injuries in 97.5 % of patients. One patient with an injury to the
anterior wall of the esophagus showed the false-negative result after SCT with
administration of water-soluble contrast. This injury was identified with use
of other techniques of instrumental diagnostics. Distribution of contrast media
behind the limits of the esophagus is the sign of 100 % probability of the
esophageal injury. Other signs (mediastinum emphysema, inflammatory infiltrate
in the mediastinum, uni- or bilateral pleuritis, hydropericardium) were
non-specific and did not allow assessing the presence or absence of the
esophageal injury. Along with identification of signs of esophageal injuries,
SCT of the neck and the chest is the irreplaceable method for identification of
injuries, which are concurrent with the esophageal injury.
Esophagoscopy identifies the esophageal injury
on the basis of presence of esophageal mucosa defect. According to our data,
the accuracy of flexible endoscopy for identification of esophageal injuries in
its abdominal and intrathoracic segments is 95 %, for esophageal injuries in
the cervical region - not more than 80 %. It is associated with the fact that
the endoscope is guided into the proximal esophagus in blind manner, with
non-extended esophagus, and proximal 2-4 cm are not available for adequate
examination.
One should note that combination of SCT with
oral administration of contrast media and esophagoscopy does not allow 100 % of
accuracy for identification of esophageal injuries.
The analysis of laboratory values showed that
patients of the group 2 had demonstrated lower BE at the moment of admission (p
< 0.05): -6 mmol/l in all patients of this group; -2.5 ± 2 mmol/l in the
group 1. All patients died in the group 2. They had the combination of low
level of systolic arterial pressure (< 90 mm Hg) at admission, and BE <
-6 mmol/l (p < 0.05). The analysis did not find any other laboratory values
of reliable differences in the groups 1 and 2 (p > 0.05).
After realization of one or other volume of
surgical interventions, all (100 %) patients with esophageal injuries were
operated. The table 4 shows the variants of surgical interventions.
Table 4. Variants of surgical interventions for patients with esophageal injuries
|
Surgery type |
group 1 |
group 2 |
|
Esophageal wound suturing |
30 |
24 |
|
Esophageal wound suturing and plasty with muscular flap |
8 |
6 |
|
Esophageal wound suturing and plasty with parietal pleura |
1 |
1 |
|
Esophageal wound suturing and suture covering with greater omentum |
1 |
1 |
|
Pleural cavity draining, gastrostomy, esophagostomy |
0 |
1 |
|
Gastrostomy, paraesophageal draining |
1 |
1 |
|
Pleural cavity draining |
1 |
0 |
Surgical approaches for injuries to cervical
part of the esophagus: left-sided cervicotomy along the anterior border of
sternocleidomastoid muscle from jugular notch of the sternum to the angle of
lower mandible to the left (according to Razumovsky). For superior thoracic
part of the esophagus, we used right-sided lateral thoracotomy in the 5th intercostal
space, or sternotomy - it depended on concurrent injuries. Esophagogastroplasty
was not performed for patients with acute traumatic disease. In the long term
period, esophagogastroplasty was conducted for two patients: the gastric stem
was directed before the sternum for one patient, and in posterior mediastinal
manner - for the second patient. For both cases, esophagogastroanastomosis was
made with end-to-end type with single interrupted sutures (vicryl 3/0) in two
ranks.
Surgical interventions lasted for 30-140 minutes
(60 ± 120 minutes on average). Long-lasting surgical intervention was usually
associated with severe concurrent injuries. All patients with surgical intervention
> 120 minutes died (p < 0.05).
The table 5 shows the postsurgical complications
in patients with esophageal injuries.
Table 5. Postsurgical complications in patients with esophageal injuries
|
Complication |
group 1 |
group 2 |
|
Purulence of postsurgical wounds |
20 (32 %) |
5 (33 %) |
|
Esophageal suture insufficiency |
8 (12,5 %) |
2 (13 %) |
|
Recurrent surgery |
5 (9 %) |
2 (13 %) |
|
Pneumonia |
24 (39 %) |
3 (20 %) |
|
Pleural empyema |
3 (5 %) |
1 (6 %) |
|
Sepsis + MODS |
11 (18 %) |
7 (46 %) |
Pneumonia was more often (p < 0.05) in patients
of the group 1, whereas septic complications in combination with multiple organ
dysfunction were more often in the group 2. The amount of recurrent surgical
interventions, the rate of failure of esophageal sutures, and incidence of
purulence of postsurgical wounds did not differ in the groups 1 and 2 and did
not influence on the disease outcome (p > 0.05).
The analysis of lethal outcomes in the group 2
showed that 8 patients had died on the first day after trauma due to multiple
organ dysfunction and acute massive blood loss. 7 patients died due to multiple
organ dysfunction at the background of sepsis.
DISCUSSION
We conducted the analysis of influence of time
from accident to hospital admission. It was found that this value did not
differ in the groups 1 and 2, and it did not influence on the disease outcome.
A lot of authors also note that time from injury moment to hospital admission
do not influence on disease outcome [2, 4].
When estimating the level of hemodynamics in
patients of the group 1 and 2, we did not find any reliable differences.
However, we found that the combination of SAP < 90 mm Hg and BE < -6
mmol/l was more often in the group 2 - 11 of 15 patients (73 %), in contrast to
the group 1 - 15 of 56 patients (26 %). We have to note that the combination of
SAP < 90 mm Hg and BE < -6 mmol/l was in 100 % of patients in the group 2
who died in the first day after admission. Therefore, this combination is the
predictor of poor outcome of the disease. Our data do not contradict to modern
studies, which show that these values correlate with blood loss degree and
severity of concurrent vascular injuries which determine poor prognosis of
diseases in this category of patients [3, 6, 7].
As for clinical diagnosis, most studies (and
our) show the absence of pathognomonic symptoms of the esophageal injury, and
the main clinical signs can be neck emphysema, and appearance of saliva and
gastric contents in the wound [1, 3, 4, 7]. There were not any statistically
significant differences in predominance of one or other symptom in patients in
the groups 1 and 2.
There is not any uniform opinion on surgical
interventions and surgical approaches for injuries to cervical, thoracic and
abdominal parts of the esophagus. The preference for one or other surgical
approach is given not due to simplification of approach to the esophagus, but
due to necessity for removal of a vascular injury [1, 2, 6]. It corresponds to our
point of view. However, some authors note that all cases with suturing of
cervical esophageal injury require for covering of the line of sutures with
sternocleidomastoid muscle [3, 5, 7]. We did not find any reliable differences
after comparison of selected surgical approaches and volumes of surgical
interventions in patients in the groups 1 and 2. Independent influence on
prognosis of the disease course is related only with surgery time > 120
minutes, which was in 8 of 15 patients in the group 1, and in 10 of 56 patients
in the group 2. It testified severe injuries or advanced infectious process.
One should note that incidence of lethal outcomes and the structure of
complications in our study does not contradict to studies of the modern authors
[1, 2, 3, 5, 7].
CONCLUSION
1. The combination of systolic arterial pressure
< 90 mm Hg and BE < -6 mmol/l at admission is the predictor of poor
prognosis of the disease course. Duration of surgical intervention > 120
minutes is the independent sign of poor prognosis of the disease course.
2. Time from injury to hospital admission,
presence or absence of recurrent surgery, insufficient esophageal sutures in
the postsurgical period, a surgical approach and the volume of surgical
intervention did not influence on the disease outcome.
PRACTICAL GUIDELINES:
1. At admission, all patients with suspected
esophageal injuries are divided into two groups: the group 1 - patients with
poor prognosis of the disease course (time from injury moment > 24 hours
and/or combination of systolic AP < 90 mm Hg and BE < -6 mmol/l). It is
necessary to create conditions for medical care performed by a specialist with
high experience in surgery of injuries. Unstable patients should receive
reduced examination in condition of the anti-shock surgical room: chest X-ray
examination and FAST; after this, surgery is carried out; it is desirable that
time from admission to surgery is to be minimized; stable patients receive the
whole range of examinations including SCT of the neck, the abdomen and the
chest, fibroesophagoscopy, fibrobronchoscopy.
2. The volume of surgical intervention for the
esophagus should be directed to maximally possible decrease in time of surgery:
it is appropriate to perform simple suturing of esophageal laceration with
single interrupted sutures in one rank or with continuous twisted suture, with
extensive draining of injury site. When suturing the esophagus, we always
capture the mucosa and use absorbable monofilament sutures (PDS 3/0 or PDS
4/0). If esophageal suturing is impossible with simple sutures, the esophagus
is completely ruptured or injury with more than 2/3 of diameter, one should
ligate it above or below the site of a defect (lineal suturing apparatus can be
used for acceleration of surgery); then, after stabilization of patient's
condition, esophagostoma is formed more proximal than the defect, and
gastrostoma - more distal; restoration of integrity of gastrointestinal tract
with use of various variants of reconstructive interventions is performed in
long term period after primary surgical intervention.
CONCLUSION
The use of the medical approach, which is based on identification of the predictors of poor prognosis in patients with esophageal injuries allows differentiation of diagnostic and curative strategies for this category of patients, improving the results of treatment of patients with esophageal injuries. However, considering the low amount of cases, it is necessary to conduct further studies in this direction.
Information on financing and conflict of interest
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of
interests relating to publication of this article.
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