Injuries of the esophagus

Mechanical injuries of the esophagus are one of the most serious injuries, often resulting in death, even though timely and fully-fledged treatment activities. Anatomical damages of the esophagus (injuries, ruptures, perforations of foreign bodies) belong to the competence of thoracic surgeons, but by tradition uncomplicated foreign bodies, chemical burns of the esophagus, some types of strictures that do not require surgical treatment, otorhinolaryngologists continue to be engaged all over the world, although the remaining surgical diseases esophagus are in the hands of general and thoracic surgeons, and therapeutic diseases are in the competence of therapists-gastroenterologists.

For otorhinolaryngologists, knowledge and skills concerning the damage to the esophagus that occur in their daily practice are of undoubted practical importance. However, the issue of direct and differential diagnosis and those damages of the esophagus, which are in the care of thoracic surgeons, is also of the same practical importance, since often these patients first get to the ENT specialist, and how competently this expert puts the presumptive diagnosis and purposefully determines the tactics treatment can depend on the life of the patient. Therefore, in our opinion, all practical ENT doctors should be familiar with the list of possible traumatic injuries of the esophagus and at least in general terms to know the symptoms manifested under these conditions.

This classification is based on a large amount of factual material (from 1968 to 1979, the authors observed 489 patients with various injuries of the esophagus, during the same period 56 595 patients with complaints of stucking foreign bodies in the esophagus addressed to the Sklifosovsky Institute of Emergency Care , in 5959 the presence of foreign bodies was confirmed) and is given with some abbreviations and textual additions and changes.

[1], [2], [3], [4], [5]

Cause of esophagus injury

On this basis, all mechanical damage to the esophagus is divided into damage by foreign bodies, tools, spontaneous, hydraulic and pneumatic ruptures, injuries to compressed air, gunshot and stab wounds, blunt injuries; neck, chest and abdomen.

The above classification answers many questions facing the problem of the clinical description of mechanical damage to the esophagus. On the basis of the origin of the injury, all lesions of the esophagus are divided into external and internal. External injuries include injuries of the esophagus, which can occur in its cervical, thoracic and abdominal parts. As follows from the above classification, these wounds are divided into isolated and combined.

[6], [7], [8]

Wounds of the esophagus

Isolated wounds of the esophagus (chipped, cut) are rare; they are often combined with damage to neighboring tissues and organs. Especially severe are the gunshot wounds of the esophagus.

Damage to the cervical region of the esophagus

If the cervical region of the esophagus is damaged, trachea, thyroid gland, large vessels, recurrent nerve, spinal cord may be injured at the same time.

[9], [10], [11], [12], [13]

Symptoms of an esophagus injury

Symptoms of an esophagus injury are as follows: pain when swallowing, excreting saliva, blood and food from eating. Often, subcutaneous emphysema may occur when the wound channel is communicated with the larynx or cervical trachea. Any injury to the esophagus poses a serious risk of infectious-purulent complications, which are usually caused by anaerobic infection. Often, 24 hours after injury, esophagitis develops, on the 2nd day - periesophagitis, and on the third - mediastinitis. The latter often develops as a result of purulent swelling. These complications are accompanied by swelling in the neck and smoothness of its relief, serous-bloody, then purulent discharge from the wound, sharp pain in the throat and neck with head rotations, which is amplified by tilting the head. This causes the forced position of flexion in the cervical spine. Body temperature reaches 39 ° C, the emerging septic state is manifested by severe chills, pallor of the skin, and impaired cardiac activity. The general condition of the patient progressively worsens.

If the thoracic esophagus is injured, injuries to the heart, lungs, large vessels of the mediastinum, trachea and bronchi can occur, which in most cases lead either to the immediate death of the victim or to severe delayed complications with the same fatal outcome. If the patient is conscious, he complains of chest pain when swallowing, flexing and especially when extending into the thoracic spine. In a co-ordinate state, bloody vomiting can occur. With damage to the esophagus, combined with damage to the trachea or bronchi, a severe mediastinal emphysema syndrome develops with compression of the lungs, the heart and the aorta. Mediastinitis, pleurisy, and pericarditis are rapidly developing, usually ending in death.

Wounds of the abdominal part of the esophagus can be combined with injuries of the stomach, parenchymal organs of the abdominal cavity, large vessels. In such wounds, in addition to the general pain syndrome, signs of peritonitis, internal bleeding, intestinal obstruction develop .

Morphological changes in esophagus perforations

The dynamics of these changes go through several stages.

The stage of serous inflammation is characterized by rapidly accruing traumatic edema of loose near-esophageal cellulitis, emphysema of neck tissue and mediastinum. Complication of the emphysema of the mediastinum can be a rupture of the mediastinal pleura.

The stage of fibrotic purulent inflammation occurs 6-8 hours after injury: the edges of the esophagus are covered with fibrin plaque and infiltrated by leukocytes. A pleural effusion of a hemorrhagic character is formed in the pleural cavity corresponding to the side of the wound. Often the primary or secondary pneumothorax develops . The peptic factor, which occurs when gastric juice enters the mediastinum, intensifies necrotic and lytic processes in the mediastinal tissue and promotes a more rapid flow of mediastinitis. As for emphysema, with a favorable postoperative period, it usually resolves within 8-10 days and does not significantly affect the further course of the process.

The stage of purulent exhaustion and late complications is characterized, according to the authors cited, by the so-called purulent-resorptive fever and wound exhaustion. At this stage, after 7-8 days after perforation, the purulent swelling spreads, resulting in secondary pleural empyema, purulent pericarditis, abscessing of the lung tissue. Such patients die from the arrosive bleeding from the large vessels of the mediastinum, which results from the strong fibrinolytic effect of the purulent exudate. The late complications of the pathological condition in question include purulent-fibrinous pericarditis, which occurs when perforations of the lower third of the esophagus, and also in those cases where the channel of false travel passes in the immediate vicinity of the pericardium.

The stage of repair (healing) usually occurs after the opening of the abscess, emptying and draining it, especially if the purulent focus is limited or encysted.

Closed injuries of the esophagus

Closed injuries of the esophagus are very rare and occur with severe bruises and compression of the chest and abdominal cavity as a result of traffic accidents, falling from a height, in production if safety precautions are not taken among moving units. Closed injuries of the esophagus can be combined with ruptures of the liver, spleen, stomach, colon, abdominal aorta, which sharply worsens the general condition of the patient and often leads to death at the scene from massive internal bleeding and traumatic shock. The reparative stage lasts from 3 weeks to 3 months and depends not so much on the size of the cavity of the abscess in the near-esophageal tissue as on the size of the esophageal wall, since recovery of the contents of the esophagus into the mediastinum can lead to recovery.

Defect of the esophagus is closed by secondary tension. Unshielded defects larger than 1.5 cm are replaced by scar tissue, resulting in subsequent deformities of the esophagus, diverticula are formed with inherent disturbances of its function.

[14], [15], [16], [17]

Classification of mechanical injuries of the esophagus

[18], [19], [20], [21], [22]

Localization of trauma

By level: cervical, thoracic, abdominal parts of the esophagus and their combination.

Damage to the cervical esophagus is most frequent and occurs as a result of foreign body wedging or in case of an unsuccessful attempt to extract them. In the case of bougainage, the damage to the esophagus is localized in the thoracic esophagus, with cardiodilation - in the supra-diaphragmatic and abdominal parts. The most dangerous manipulation is the "blind" buzhirovanie esophagus, in which often there are multiple perforations due to loss of elasticity of its walls. By involvement in the pathological process of the walls: anterior, posterior, right, left, their combinations, circular damage. The front wall is damaged relatively rarely. Foreign bodies most often injure the side walls. Instrumental ruptures of the cervical esophagus are more often located on the back wall, the thoracic esophagus - on the right wall. Hydraulic ruptures are observed on the right wall of the middle third of the thoracic esophagus, spontaneous - in the lower third of this division and more often on the left. Circular injuries, characterized by esophageal ruptures, occur with a blunt trauma of the chest and abdomen.

Depth of injury

• Non-penetrating lesions (abrasions, scalp ruptures of the mucosa and submucosal layer, submucosal hematomas) are the most common type of esophagus injury and are associated with foreign bodies or with coarse manipulation tools. Penetrating damage (perforations, through wounds) can be caused by the same mechanism as non-penetrating or gunshot wounds. Depending on the mechanism, injuries can be isolated or associated with damage to neighboring organs and anatomical formations. Mechanism of injury
• Crushed, cut, torn, gunshot wounds, bedsore with perforation, combined.
• Damage to foreign bodies most often is a stab wound and much less often - cut, resulting from the wedging in the esophagus double-edged sign. Instrumental lesions have the form of ragged wounds, and intraoperative lesions - linear wounds with even edges.

[23], [24], [25], [26], [27]

Condition of esophageal wall

• A scar-modified wall, affected by varicose veins, a deep chemical burn, a cancerous tumor.

The isolation of this classification feature is of great practical importance, since the course of the trauma and surgical tactics largely depend on: the previous state of the esophagus walls. In particular purulent complications in the rupture of the scar-altered esophagus develop later than when the unchanged wall is ruptured. In addition, the esophagus with sharply expressed cicatricial changes is a functionally inferior organ, which has lost its elasticity and compliance - so important qualities for the safe conduct of instrumental manipulations. With varicose veins of food, there is a danger of profuse bleeding, and when the esophageal wall is affected with a cancerous tumor, there is a significant probability of perforation during esophagoscopy by a rigid esophagoscope.

[28], [29], [30], [31]

Associated Damage

• Perforation of the esophagus wall with a complicated stroke without damage to adjacent organs.

These lesions concern only the esophagus and arise when it is perforated by foreign bodies, balloon probes, esophagoscope, buzz, biopsy cuff, endotracheal tube, gastric tube and are always accompanied by the occurrence of a so-called false stroke of various lengths with destruction of the near-esophageal tissue of the neck or mediastinum. Perforation of the esophagus wall with damage to the mediastinal pleura.

Such damage can be localized on the right, on the left or be two-sided. They can be combined with injuries of the tracheo-sacral tree, large vessels.

[32], [33],

Diagnosis of an esophagus injury

Diagnosis of an esophagus injury is an extremely important stage in measures to cure this trauma. An extremely important factor is the early diagnosis with the establishment of the cause, size and depth of the esophagus, since this determines the nature of the provision of medical care. The following sequence in carrying out diagnostic activities is common: a review of fluoroscopy of the neck and posterior mediastinum, x-ray methods of examination with contrast, diagnostic esophagoscopy, and pleural cavity puncture. The results of these studies, as well as anamnesis, an assessment of the circumstances that led to the esophageal injury syndrome and the nature of the clinical course allow differential diagnosis both between different types of esophageal injury and between the latter and other forms of esophageal diseases.

With an overview of the fluoroscopy in the near-esophageal tissue, air bubbles are seen; this phenomenon has received the name of a deep emphysema. The presence of pneumo- and hydrothorax indicates the damage to the pleura.

When carrying out X-ray methods of research with contrasting, some thoracic surgeons and radiologists prefer oil iodine-containing contrasting substances. However, with a narrow perforating stroke, the oil solution does not always penetrate into it due to its viscosity, which does not allow to diagnose the damage. In addition, these drugs on contact with the mediastinal fiber are firmly fixed on it, and it is much more difficult to wash them than a suspension of barium sulfate. The most widely accepted are two- and three-iodine-containing water-soluble compounds that are widely used in the diagnosis of gullet ruptures. They do not irritate the mediastinal tissue and, having a low viscosity, penetrate well even into small wound defects. As noted by BD Komarov et al. (1981), these contrasting substances are rapidly absorbed, which makes them indispensable in the obstruction of the esophagus and suspected of having esophageal-respiratory fistulas, have a bactericidal effect and can be repeatedly applied to the dynamic control of the healing process of the damage zone in the postoperative period.

With the use of X-ray examination methods with contrasting, it is possible to detect mucosal damage, the output of the contrast medium beyond the esophageal contour, the position, direction and size of the false path, its relation to the lumen of the esophagus, the mediastinal pleura, the diaphragm, the retroperitoneal space. All this is of decisive importance in the choice of therapeutic tactics.

Diagnostic esophagoscopy for lesions of the esophagus is not as widespread as the X-ray examination. The reasons for this are as follows: esophagoscopy can not always be carried out because of the severity of the patient's condition; after this manipulation there is always a deterioration in the condition. These obstacles are eliminated with intratracheal anesthesia with muscle relaxation, in which a thorough and quiet examination of the esophagus is possible throughout its entire length and an accurate definition of the localization, size and depth of the lesion. Diagnostic esophagoscopy has not only diagnostic, but also therapeutic value, because with its help it is possible to remove from the false course of blood and other masses accumulated in the mediastinum, as well as the feeding into the stomach of the feeding probe.

Puncture of the pleural cavity is an integral part of preoperative preparation as a medical and diagnostic measure. Its role increases with late diagnosis of esophageal perforation. The detection of food particles and gastric juice in the puncture confirms the indicated diagnosis.

[34], [35], [36], [37]

Differential diagnosis of mechanical injuries of the esophagus

When differential diagnosis should be borne in mind that with open trauma to the neck and chest diagnosis of damage to the esophagus is established during primary surgical treatment: with intraoperative trauma, damage to the esophagus is detected, as a rule, during surgery (manipulation - probing, esophagoscopy by a rigid esophagoscope); damage to the esophagus with closed chest or abdominal trauma can only be diagnosed by roentgenology, since signs of traumatic shock prevail in the clinical picture.

With the rupture of the thoracic esophagus, the symptoms of esophagus injury can resemble many acute diseases of the cardiovascular system, respiratory organs and chest wall, the occurrence of which is accompanied by severe pain syndrome (myocardial infarction, exfoliating aortic aneurysm, pleuropneumonia, spontaneous pneumothorax, intercostal neuralgia).

Closed chest trauma with esophagus rupture in the clinical picture has some similarity with diaphragm rupture. Clinical practice shows that due to the fact that the data of the physical examination (tachycardia, hypotension, hydro- and pneumothorax), as well as the further course of the process (increased intoxication, fever, comorbid and coma) do not have specific signs of esophageal damage, Differential diagnosis in case of traumatic rupture can not be performed with a sufficiently high probability with most of the above diseases. However, as indicated by B.D. Komarov et al. (1981), a clear anamnesis (vomiting with spontaneous and hydraulic ruptures, foreign bodies or endoscopic manipulations) makes it possible to suspect damage to the esophagus. Confirm or refute this suspicion is possible only with the X-ray examination of the patient, but if this examination does not allow to give a clear answer to the state of the esophageal wall, then esophagoscopy is performed.

The rupture of the lower third of the thoracic esophagus and the abdominal section of the esophagus is manifested by symptoms very similar to those in perforation of the hollow organs of the abdominal cavity, in particular, the perforated ulcer of the stomach.

In the opinion of BD Komarov et al. (1981), differential diagnosis of esophagus ruptures should be carried out not only with diseases such as pulmonary embolism and strangulated diaphragmatic hernia, but also with acute diseases of the abdominal cavity organs (perforation of the hollow organ, acute pancreatitis and cholecystitis, thrombosis of mesenteric vessels).

In the differential diagnosis of esophageal injury, one should bear in mind some similarities with the hammen syndrome that occurs in the labor in time of labor: subcutaneous emphysema, pneumothorax, dyspnea, cyanosis, blood circulation disorders, pain, extracardiac murmurs synchronized with cardiac contractions. X-ray - air in the mediastinum.

Against the background of primary symptoms associated with rupture of the esophagus, significant difficulties arise in the differential diagnosis of acute mediastinitis due to esophageal injury from chronic sclerosing mediastinitis, which is a consequence of long-term inflammatory processes in the chest cavity and mediastinum (nonspecific pneumonia, bronchiectatic disease, pneumoconiosis, etc.). And is characterized by diffuse infiltration of the mediastinum, against which calcinous foci can be determined radhenologically. These foci can simulate the flow of contrast agent beyond the limits of the esophagus, unless you pay due attention to them in the review of the renal angiography of the mediastinum.

[38], [39], [40], [41], [42], [43]

Treatment of esophagus injury

The treatment of an esophagus injury is divided into a nonoperative and a surgical one. When determining the tactics of treatment and choosing its method, the cause of the trauma, its mechanism, the morphological features of the damaged tissues, localization, the state of the perisophageal tissue and the period that has passed since the damage to the esophagus are taken into account.

As a rule, nonoperative treatment of the esophagus injury is indicated for patients with non-penetrating injuries of the esophagus, with perforations of the esophagus with a foreign body and with instrumental damages of the esophagus.

With non-penetrating damage to the esophagus, the need for hospitalization and non-operative treatment arises when multiple and deep abrasions of the mucous membrane and the submucosal layer are detected during esophagoscopy and X-ray examination, accompanied by swelling of the near-esophageal cellulose of the neck and mediastinal tissue. In the opinion of BD Komarov et al. (1981), with superficial abrasions of the mucous membrane without pronounced edema of the perisophageal tissue, patients may be on outpatient treatment, which in most cases leads to recovery. They are recommended sparing food in a warm form, mucous broths, intake of whipped raw egg whites, drinking small portions of St. John's wort, medical chamomile and other herbs that have antiseptic properties that are not capable of irritating the mucous membrane. With this form of treatment at home, the patient should be informed of the possible appearance of signs of complication of the existing trauma (increased pain, difficulty swallowing, chills, body temperature rise). If they occur, immediately consult a doctor. As noted above, but their observations, in 1.8-2% of patients with non-penetrating damage to the esophagus from 372 after 5-6 days in the near-esophageal tissue, immediately adjacent to the zone of non-penetrating damage, abscesses were formed.

When the esophagus is perforated by a foreign body penetrating into the esophagus, the inflammatory process always occurs in this region, which is limited to a small area adjacent to the site of the damaged esophageal wall on the 1st day after the injury. The use in this period of massive doses of antibiotics leads in most cases to limiting inflammation, and then to recovery. Indications for drainage of a limited abscess, formed against the background of antibiotic therapy, occurred only in 5-8% of cases. Adequate drainage of the abscess also leads to recovery.

The stay of a foreign body in the lumen of the damaged esophagus causes a massive infection of the esophagus tissues and the development of phlegmonous (often putrefactive) inflammation. Attempts for non-surgical treatment of such patients are erroneous, as when delayed with surgical intervention diffuse mediastinitis develops with unpredictable consequences.

With instrumental damages of the esophagus, nonoperative treatment of the esophagus injury is possible only if there is an effective outflow of purulent discharge from the zone of injury into the lumen of the esophagus, when the rupture of its wall is no more than 1-1.5 cm and is not accompanied by damage to surrounding organs and the mediastinal pleura, the fiber of the neck or mediastinum does not exceed 2 cm. With instrumental ruptures of the scar-altered wall of the esophagus, in which the false course does not exceed 3 cm, it is also possible for non-operative treatment, rhotic changes in tissue periesophageal accompanying sclerosis of the esophagus, prevents the spread of inflammation.

Usually, nonoperative treatment of the esophagus injury and the corresponding indications is performed either in the surgical thoracic or in the ENT, especially if the uncomplicated foreign body has been removed in the latter, leaving behind injuries requiring only non-operative treatment.

Methodologically, non-operative treatment of esophageal injury, performed according to the appropriate indications in hospital, consists in massive antibiotic therapy and restriction or exclusion of oral nutrition for a certain period.

With non-intrusive oesophageal lesions that do not require the complete elimination of oral nutrition, along with antibiotics, a penicillin solution (1 million units in 200 ml of water) or a solution of furacilin 1: 5000 is prescribed per os, the purpose of which is to wash deep abrasions and scalp wounds from fibrin, pus and food residues.

With penetrating damage to the esophagus, the dose of antibiotics is brought to the maximum possible, oral nutrition is excluded until the defect of the esophagus wall is healed. The tactics of administering a patient with such damage to the esophagus, according to the recommendations of BD Komarov et al., Should be as follows. If it is expected that the healing will occur within a week, which usually occurs with crushed injuries by a foreign body, instrumental lesions up to 5-8 mm with a false course of the same length, then patients during this period can be led on complete parenteral nutrition. In such cases, patients should receive 2000-2500 ml of various solutions, including 800 ml of a 10% glucose solution with insulin (16 units), 400 ml of a 10% solution of Aminosol or Aminone, 400 ml of a balanced solution of electrolytes and vitamins. Deficiency of amino acids is replenished by intravenous injection of Amnoplasmal E.

If the healing of the damage to the esophagus is assumed to be prolonged, for example, if there is a decubitus scar, the esophageal wall, an instrumental rupture larger than 1 cm with a false stroke of the same length, then the patients should immediately be switched to probe nutrition. To do this, only thin silicone probes are used, which can be in the esophagus up to 4 months without causing irritation to the mucous membrane and without causing any disturbance to the patient. The food is carried through a funnel or with a syringe to rinse the cavities with products of creamy consistency, including mashed meat and boiled vegetables, broths, sour-milk products. After feeding, the probe should be washed, passing 100-150 ml of boiled water at room temperature. With extensive destruction of the esophagus, requiring reconstructive surgical procedures, the patient is fed through the gastrostomy.

Treatment of injuries of the esophagus that are not subject to non-surgical treatment consists in an urgent surgical operation, which is performed by a specialist surgeon in the field of cervical surgery, a thoracic or abdominal surgeon depending on the level of injury. In severe injuries, the esophagus is exposed in the neck, mediastinotomy or laparotomy and diaphragmotomy. When the cervical esophagus is injured, the wound of its wall is sewn, leaving the rest of the tissues of the wound uncleaned, the wound cavity is drained at the same time. After the operation, the patient is placed on a bed with a lowered head end to prevent the contents of the wound, including inflammatory exudate (pus), from flowing into the mediastinum. Power is carried out by means of a probe inserted through the nose, in especially severe cases, a gastrostomy is applied. Within 3 days they forbid drinking and eating. Assign antibiotics.

With the development of mediastinitis, pleurisy or peritonitis mediastinotomy, pleurotomy and laparotomy are shown, which are produced by the corresponding specialists in the respective departments.