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 |
Количество 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 |
Количество 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.