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Hey, everyone. Welcome to another episode of Behind the Knives Clinical Challenge Series. We are the Miami Trauma Team, back with another episode from Jackson Memorial Hospital's Rider Trauma Center.
Do you remember being terrorized by one of your mentors in training walking you through a mock oral scenario featuring the dreaded esophageal injury? Think you remember right diagnostic tools and repair options for every location of esophageal injury? Well, today we're hoping to refresh your memory a little bit.
As always, we'd like to start with some introductions. I'm Mike Kobler-Lichter, PGY4, R2, and general surgery, and my second of two years of dedicated research with our trauma faculty here in Miami. Hi, everyone. My name is Dylan Tanzer. I'm a second-year trauma critical care fellow at Ryder Trauma Center here in Miami. I'm Eugenia Kwan, first year trauma and surgical critical care attending at Loma Linda University, having just graduated from fellowship at the Rider Trauma Center.
And I'm Jonathan Mesoso. I'm an attending trauma surgeon at the Reiter Trauma Center and an assistant professor of surgery at the University of Miami. Today, as Mike mentioned, we're going to be continuing our theme of discussing injuries that can be intimidating for surgeons and surgical trainees alike. We're going to be discussing the management of esophageal injuries using the Western Trauma Association's clinical decision algorithm as a guide, which will be included in the show notes.
We're going to be dividing this into two portions, the approach to diagnosing esophageal injuries and then the options for management. So Mike, in general, what are the first couple of questions you want to know the answer to when trying to diagnose an esophageal injury? So the major decision points in the algorithm focused around mechanism, meaning penetrating versus blunt. And blunt here would include iatrogenic or spontaneous injuries such as a Borhobs or perfon EGD.
and then the location of the injury, meaning in the neck or the chest, and of course the stability of the patient. I also think we'd be remiss if we didn't reiterate the fact that this is a trauma. So we always should also be starting with our ABCs, stabilizing any immediately life-threatening things that we find on our primary survey. But let's assume we've made it past that step. For purposes of this episode, we're only covering the things that pertain to esophageal injury.
but particularly for penetrating that trauma the injury could involve more than just the esophagus and all these injuries really go hand in hand but for purposes of this podcast about esophageal injuries we're not going to go into detail about that and kind of we'll just focus on the esophageal injury portion
Agreed. So let's talk about the penetrating side of the algorithm first. While there is a completely separate Western trauma algorithm for penetrating neck wounds, which will also be in the show notes. There are essentially two options for diagnosis that you're trying to decide between when you have a penetrating neck wound that violates the platysma. And what are those?
So basically the focus of that Western trauma penetrating neck algorithm is helping to decide whether the patient needs an operation right away or if the patient should get a CTA of the neck. Exactly. And when considering the indications for the OR, what are the most obvious indications in this context? So I think this would be the hard signs of vascular or aerodigestive injury or hemodynamic instability, of course.
Yep. So let's say we have a 26-year-old male patient who was stabbed in the right side of his neck. On arrival to the trauma bay, he has a thready pulse. He's tachycardic to 120. has a dressing completely saturated with blood. And when you remove it, you know, bubbling in the wound, which continues to bleed. So yeah, this guy's definitely not in a good place. He has multiple hard signs of vascular and aerodigestive injury.
Personally, I like to correlate these hard signs to the ABCs of the primary survey. So any airway compromise is a hard sign. Next, massive subcutaneous emphysema or bubbling through the wound or significant dyspnea is a hard sign. And then for circulation... It's basically like any hard vascular sign. Expanding or pulsatile hematoma. Active bleeding or shock.
Additionally, any hematemesis or hemoptysis would be a hard sign. And finally, neurodeficit or odontophagia are both concerning for aerodigestive injury as well. Note though, clinical findings of cervical esophageal injury are unreliable with a sensitivity of only 80%. This guy's in shock with active bleeding and bubbling from the wound, so he's going to the OR. Exactly. So penetrating neckwood with any of those hard signs goes directly to the OR for neck exploration.
But what if the patient doesn't have any heart signs? How do we make the decision between OR and CTA? What if this guy came in mildly agitated with a heart rate of 105, but when we removed the dressing, we saw no bleeding or bubbling? So this is kind of drilled down more again in that penetrating neck trauma algorithm, but this is where we have to further break down the location of the wound into which zone of the neck is involved.
How do you define these zones? So zone one is most proximal from the level of the clavicles to the cricoid cartilage. Zone two is intermediate from the cricoid to the superior angle of the mandible. And then zone three is most distal from the angle of the mandible to the base of the skull. Yeah, exactly. And how does diagnosis differ between these three zones? So in zones one and three, if no indication for emergent neck exploration, you should probably just get the CTA. In zone two, though.
symptomatic patients should just go to the OR for exploration, while asymptomatic patients can also go down the CTA path. Dr. Mezzoso, in the penetrating neck algorithm, There's a branch point which states that patients without suspicion for injury can actually be managed with serial observation though. When would you take this pathway as opposed to just getting the CTA, especially with the knowledge that clinical signs of cervical esophageal injury are not very sensitive?
Yeah, I mean, I think that the major point here is your pretest probability of having an injury, or at least your suspicion that there is something going on. I think if you have any suspicion whatsoever, it's most prudent to just... get the CTA and rule out that there is an injury or at least begin to rule out that there's an injury. I would say that my suspicion for an injury would have to be pretty low to just be okay with serial exams.
So before we get too far down the rabbit hole here, let's bring it back to our esophageal trauma algorithm. We can summarize this portion of the algorithm by saying that if the patient has indications for neck exploration, do that. Otherwise, they should probably get a CTA.
Now, for penetrating chest injuries. Remember, this is the esophageal injury episode, so what is the main question we want to ask with a penetrating chest injury to determine if we should be concerned for an esophageal injury, Dylan? So this is going to be whether or not the trajectory is potentially transmediastinal. Yeah, good.
So let's change our scenario a bit and say that our 26-year-old guy came in with a single gunshot wound to the chest. You notice one aperture in the right anterolateral chest and another. on the left anterolateral chest around the level of T4. What are you thinking? Yeah, so this guy definitely sounds like he has a potential transmediastinal trajectory, but the first thing is to determine the stability of the patient.
Good. So remember, this is an episode about esophageal injuries. And if you have a penetrating thoracic injury without a transmediastinal trajectory, you basically cannot have an esophageal injury. and you're done, though you shouldn't forget about the other injuries, of course. Let's say this guy is tachycardic to 140 with a systolic blood pressure in the 90s.
Yeah, as you can imagine, patients with transmetastinal penetrating injuries are often unstable. And if they are like this guy, we shouldn't be going to the operating room. If the patient is stable, however, we should be getting a CTA in the chest. Good. That wraps up our penetrating diagnostic pathway. Let's change up the scenario again and imagine this time our patient came in after a high-energy motor vehicle accident.
Similarly to the penetrating side, what should our first branching point be like? So again, our first decision point is location of injury. Is this a neck or a chest injury? In both cases, we need to determine if there are indications for immediate expiration in terms of a neck injury or thoracotomy for a chest injury.
Yeah, exactly. And those would be similar to the hard signs instability we pointed out for penetrating neck injury. And while talking about indications for immediate thoracotomy and trauma is a topic worthy of a full second episode, we can abbreviate that.
to be any suspected surgical cause of instability related to a thoracic injury. So let's say our patient's neck impacted the steering wheel. You notice a lot of bruising, a suspected broken clavicle, and the patient is complaining of a lot of pain but is stable.
So it sounds like here we don't have an immediate indication for neck expiration, so we should probably be getting a CTA of the neck. And what if the patient had chest bruising and pain after their chest hit the steering wheel, but they're stable? so same thing no immediate need for thoracotomy so probably get a cta of the chest
So hopefully our listeners are picking up to a theme here that if you don't have a hard science to go to the OR, for purposes of an esophageal injury, you probably should get the CT, if that's an injury that you're concerned about. And just as an aside, I think it's important for listeners to...
recognize the rarity of a blunt esophageal injury. Data from 2009 to 2014 from Denver Health reported an incidence of penetrating esophageal injury of 0.6% in all trauma admissions compared to 0.06% in blunt admissions. So to summarize, any injury should go to the operating room if there's hemodynamic instability or hard signs of vascular or aerodigestive injury, as should symptomatic penetrating zone 2 neck injuries or penetrating transmediastidal injuries.
Everyone else should probably be getting a CTA of the affected area. Great. So let's say our patient is unlucky and had neck and chest pain. and bruising and goes for a CTA of both. What are we looking for on these CTAs to diagnose an esophageal injury? So for any peri-esophageal air or fluid, this would be concerning for an esophageal injury.
If you don't have this, you're pretty much done with the algorithm and should focusing on managing other injuries. So let's say our patient does have some perisophageal air on this scan. What's the next question? Again, hopefully our listeners see a pattern here, but location is important. Hypopharyngeal injuries can generally be managed conservatively with observation, IV broad-spectrum antibiotics, and restricted oral intake.
However, lower hypopharyngeal injuries below the tips of the aretinoid cartilage or those with extensive tissue damage are very likely to fail this and likely require operative intervention. Okay, great. What about other possible locations? So for parasophageal air or fluids seen in the cervical area on CT scan, going to the operating room is probably most appropriate. It's easily surgically accessible with a low morbidity.
if despite these findings your suspicion for injury is very low you can consider getting further workup with esophagoscopy and esophagography Similarly, air fluid around the thoracic esophagus should prompt you to get further workup with the scope and swallow study as well. If these are the negatives, you're done. But if they're positive, you have your diagnosis and you should proceed to the operating room.
Great. So now that we know when to go to the OR, we have to talk about what to do when we actually get there. Mike, what do you think our first decision point is in the management portion of the algorithm? So given the first half of the episode, I'm going to say the location of injury. Yeah, exactly. It makes a big difference what we do with cervical perforations as compared to thoracic perforations.
So let's say the paraesophageal error noted on our patient's scan was in the cervical esophageal area. Mike, what is your general approach to a neck exploration for suspected esophageal injury? So a left anterior cervical incision along the anterior border of the SEM is best for esophageal exposure in the neck. But in general, for trauma, I would explore from whichever side has the penetrating injury, if that's what we are there for.
Once we have the injury exposed, have debris in any non-viable tissue, we should decide whether the injury is amenable to primary repair. And this is where that 24-hour rule comes into effect, right? Where you should avoid primary repair if the injury is greater than 24 hours old? Actually, this tenant has been disproven in multiple studies. If you can get closure of healthy tissue without tension, you should opt for primary repair. The esophagus should be debrided to healthy tissue.
and repaired with a single or double-layered closure and can be done with either absorbable or non-absorbable suture. Some people recommend non-absorbable suture and that not should be on the outside to avoid granuloma formation, but there is not good data for this. And what is the role for endoscopy in these cases? Do you routinely scope everyone intra-op with a cervical esophageal injury, Dr. Mezzoso?
No, I don't think that you need to scope every one of these. The purpose of you being in the operating room is you're looking at it with your eyes. So I think one of the important tenets of operating on these patients when you are staring at an injury.
is you want to make sure to completely expose the injury. So sometimes that requires enlarging the hole a bit so that you can see the entire extent of the injury in the mucosa. And once you're happy that you've seen everything and that you've debrided back to health. I think that's generally enough. And then the other kind of pearl that I would add for exploring these, particularly for...
penetrating trauma is that you always want to make sure to get a good circumferential look at the esophagus, especially for penetrating trauma. If there's a hole on one side, there's likely to be a hole on the other side. So we've repaired this guy's esophagus. Are we done now, Dylan? No, definitely not. We still need to ensure we buttress the repair with well vascularized tissue in the neck. The easiest thing is probably going to be the sternocleidomastoid muscle or one of the strap muscles.
Additionally, if there is significant contamination or in other niche cases, such as the presence of hardware during an iatrogenic injury in a cervical spine case, you should probably consider drain placement, but they aren't strictly necessary.
All right. This is especially important if you have a concomitant carotid or tracheal injury that's in close proximity as well. You want to minimize the chances of any kind of fistula. And just as a technical point, when using these muscles as a buttress, the strap muscle...
blood supply originates cranially. So you want to divide these muscles inferiorly, whereas the SCM has a much more robust blood supply and can be divided really from either end and rotated over pretty easily. Anything special to consider post-op? Yeah, for sure. So this patient should be NPO for a few days until there's evidence of healing, such as a normal swallow study, and should have some sort of enteral access feeding, such as a nasogastric tube or a DOPOP. Dr. Mezoso.
What is your practice to start these patients back on an oral diet or when to get a post-off esophagram? And do you always leave drains in these patients? Yeah, that's a good question. I generally tend to leave drains.
although I don't generally get a post-op study. This is one of those areas where there's not great evidence on either side, but there are very... animated opinions on either side but i you know i don't think that there's good data to support one or the other so i don't generally tend to get a post-op esophagram unless i'm really concerned about something
So now getting back to the scenario, say you got in there and there was significant tissue loss such that when you debride the unhealthy tissue, there's no way to bring the edges of the wound together. What now? Yeah, so basically anytime you can't get attention-free primary closure, you'll have to do something else such as an esophagostomy.
Okay, and important to note here, this should be a side esophagostomy where you bring the skin down to the level of the esophagostomy. You want to avoid entirely dividing the esophagus, as this makes for a more complicated reconstruction down the line. consider temporarily closing the distal lumen with the 3O absorbable suture if you think it's necessary, similar to a pyloric exclusion. The one case where you probably need an endosophagostomy is if...
The injury itself caused a transection, which again is pretty rare. And after this, you don't want to forget drains, enteral feeding access, and gastric decompression. So for penetrating cervical esophageal injury, primary repair when you can. Make sure you buttress it with well-vascularized tissue. Otherwise, perform a lateral esophagostomy and make sure you have good feeding access.
Now what about if that small amount of air we saw around the esophagus was down in the chest? What are the first things we need to consider if we are deciding whether or not to operate on someone with evidence of a thoracic esophageal perforation? Mike?
So again, we're looking for stability of the patient, and in this case, whether or not the perforation is contained. If the patient is stable, no signs of sepsis, with a small contained thoracic perforation, you can consider non-op management with antibiotics, a PPI. making the patient MPO, and re-imaging. But if any of these conditions are not met, you're looking at some type of intervention. Well, you can manage small contain leaks non-operatively.
Most of the data that describes this have not included traumatic preparation, so this approach should be pursued with caution if at all. It's important to realize that the traumatic event may have altered the tissue claims, which may prevent true containment of the leaf. Yeah, I think the other, you know, the other thing that you have to consider is timing in terms of when the patient presents to you, because that oftentimes will change the management. And I think with some experience.
you'll see that not all of these are managed the same way or the same way necessarily that's in the textbook. And some of that really just depends on the patient condition and, again, how far from injury they are to when they present to you. Because a lot of times these patients will come in as...
a transfer because there's a suspicion of an esophageal injury or something like that so that does play a role i think in what you're going to do the other thing that i'll mention is particularly if you're at a center where there are people who manage esophageal disease often I think it is helpful either to consult with a senior partner or with a senior trauma partner or with you know a thoracic surgeon or somebody who's got some more experience doing these because
Again, these injuries are rare and it's not something that you necessarily need to dive into doing at two o'clock in the morning if the patient's stable and you have a little bit of time to discuss and really plan what you're going to do. That being said, what if we change the scenario and say that there's air and fluid around the proximal thoracic esophagus and it's clearly not contained, but it has only been a few hours since the injury and it's small, about a centimeter and a half.
have. Yeah, so in this case, with a small free leak in a stable patient, you can consider endoscopic stenting or clipping if available at your institution. But again, a lot of the data on this has been the result of things other than external trauma. Stenting is probably safe, but at this point, there has been no direct comparison with surgical repair or non-operative management. And it's still probably why...
to debris the injury site thoracoscopically as well. Yeah, I think that there are a lot of things that are on the cutting edge, which is great. I also think that taking this patient to the operating room with an obvious free perforation.
is the safest thing to do and i don't think that there's any crime in doing that and taking this patient to the or for thoracotomy and a proper repair so i think that there's definitely promise in some of these endoscopic techniques And I have seen some of them work, but...
Without any real good, I think, head-to-head data, this is one of those things where patients don't tolerate this failing, so to speak. So you want to pick the thing that fails the best. And I think that taking the patient to the operating room, looking at the injury.
and really doing your best to get it fixed is probably the most prudent thing to do. So let's say you don't have the capability to stent at your institution, or let's say the perforation is a little bit bigger than two centimeters. What should we be doing now, Dylan? Yeah, well, we've kind of run out of options at this point. So this patient's getting a thoracotomy. Can you be a little more specific? How would you approach the injury in the stable patient with a proximal thoracic injury?
Would that change if the patient were unstable or if the injury were more distal? Yeah, it definitely would. In our patient with a proximal injury, I would want to do a right posterior lateral thoracotomy. as the proximal esophagus is approached better from this side, as opposed to a left posterior lateral thoracotomy for a more distal injury. If, however, the patient were unstable, I'd want to do an anterior lateral thoracotomy.
particularly if other injuries are suspected. From there, just like with the neck exploration, I'd wanted to breed any unhealthy tissue, expose the full extent of the injury. using endoscopy to assist with this and assess if the perforation is amenable to primary repair. Okay, so let's say that our patient's perforation is not that large and the esophagus comes together without any tension. Now what?
So here we proceed very similarly to the way we did in the neck. Repair in the same way, one or two layers with either absorbable or non-absorbable suture and buttress it with a well-vascularized tissue. Since we're in the chest, we'll have different tissues available, but we can use any of the pleura, pericardium, intercostal muscles, which you should think about preparing on your way into the chest, diaphragm, or stomach for really distal injuries.
Again, if there's lots of contamination, you can lay drains and you should make sure to have some kind of enteral feeding access. So let's change it up again and say you can't get the esophagus to come together primarily. What should you do, Mike? So in this case, you have to assess the amount of tissue loss. There's a relatively small amount of tissue loss. You consider repairing over a T-tube. But if the tissue loss is more significant...
you should probably go the diversion route, and you would want to do something similar to what we described in the cervical injury example, with a lateral esophagostomy. In both cases, you should place enteral feeding access, preferably in the form of a jagenostomy, as well as a gastrostomy for drainage and consideration of extraluminal drainage in the case of massive contamination. Is there ever an indication for an upfront esophagectomy for truly devastating injuries?
So in cases of a perforated malignancy or severe stricture, this could definitely be considered, but I don't think I would really be considering this in a trauma setting. You'd probably be in a damage control setting at this point in the first place. and would probably want to do as little as possible in that first operation. Yeah, I agree. This is a damage control situation where really there's no role. I'll just say it like that. There is no role for an emergency esophagectomy.
So to summarize the surgical portion, primarily repair when you can, whether the injury is in the neck or the chest, and always buttress with a well vascularized tissue. If you can't repair primarily, you're probably looking at a cervical esophagostomy, though you can consider a T-tube repair in thoracic perforations with a small amount of tissue loss.
Non-operative therapy may be an option for stable patients with small contained weeks, but this should really be done with caution and is not really standard of care at this point. Stenting or clipping is another option for smaller injuries in stable patients. In all cases, you need to ensure that you have enteral feeding access, preferably with a jejunostomy tube in cases of esophagostomy as well as gastric decompression.
Anything that I missed, Dr. Mezoso? No, I don't think so. I would say that, again, these are very rare injuries. No one person has a vast experience in taking care of multiple of these. So I think it really is.
important when you have something like this to bounce your thoughts off of someone more senior than you especially when you're a junior attending to figure out what the best thing to do is again thankfully most of the time i would say This is not an injury that you need to race to the operating room with in the middle of the night, which is nice because it gives you some time to look at images, get a little more information and and have a well-planned out operation.
Because a lot of times these aren't really super easy to do. The other thing, again, to kind of remind everyone is that timing does matter. These patients are different. If they arrive straight from the scene versus if they arrive a week later, and that should be taken into account and how you take care of them. And then the last thing I will say is that the safest.
place for patients with a real esophageal injury, right? One that's not contained a real injury. The safest place for them is to be in the operating room and non-operative and endoscopic management should. really be, I think, scrutinized a little bit. And operative management is probably the safest thing for the patient. Okay. Good work, everyone.
hopefully people are a little less intimidated for their next esophageal injury after that review i think it's time to summarize some key points with a few quick hits one don't forget the primary survey Unstable patients should be in the operating room, as should patients with hard signs of vascular or neurodigestive injury.
If there is concern for esophageal injury but no immediate indication for the operating room, this should be further investigated with a CTA of the affected area. Clinical exam has poor sensitivity. The esophagus should be primarily repaired if the defect is able to come together without tension after debridement. Don't forget a well-vascularized buttress.
If you cannot perform a primary repair, your procedure of choice should be a lateral esophagostomy with a feeding jejunostomy and gastrostomy for decompression. Repair over T-tubes can be considered for injuries with small amounts of tissue loss. So that wraps up our episode on esophageal injury management. And until next time, dominate the day.
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