Trauma: Esophagus Trauma

Esophagus

General

  • Most Common in Penetrating Trauma
  • Most Common Site: Cervical #1, Thoracic #2 & Abdominal #3
  • Virtually All Have Other Concomitant Injuries

AAST Esophagus Injury Scale

Diagnosis

  • Delay in Diagnosis Common
  • Dx: Water-Soluble Esophagram
    • If Negative but High-Suspicion: Dilute-Barium Esophagram
    • If Again Negative: Esophagoscopy
  • Specificity:
    • Contrast Studies Have High False-Negative Rates (25%)
    • Negative Esophagram & Esophagoscopy Near 100% Specificity

Traumatic Esophagus Perforation with Contrast Extravasation 1

Treatment

  • Primary Tx: Surgical Repair, Buttress & Leave Drain
    • Repair
      • First Extend Myotomy – To See Full Length of Mucosal Injury
      • Close in Two Layers: Inner Absorbable, Outer Permanent
        • Strength Layer: Submucosa (No Serosa)
        • Direction:
          • Small: Transversely
          • Larger (> 2-3 cm): Longitudinally
      • If Penetrating Injury: Explore Circumference to Verify No Back-Wall Injury
    • Buttress
      • Strengthens & Enhance Healing Given no Serosal Layer
      • Neck: Strap Muscles or SCM
      • Proximal Thorax: Intercostals or Rhomboid Muscle
        • Muscle Flaps Preferred (Less Friable & More Bulky Coverage)
        • Other Less Desirable Options: Pericardium or Pleura
      • Distal Thorax or Abdomen: Stomach (Nissen Fundoplication)
        • If Unable to Perform Nissen: Diaphragm
    • Drains
      • Neck: Penrose or JP Drain
      • Thoracic: Chest Tubes
      • Abdomen: JP Drain
  • Devastating Injury (Repair Not Feasible):
    • Neck: Cervical Esophagostomy (Spit Fistula)
      • Loop Esophagostomy If Able – Allows One-Stage Closure
      • End Esophagostomy Requires Complex Closure
    • Thoracic: T-Tube (Creates a Controlled Fistula)

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)