Esophageal trauma

Mechanical injuries of the esophagus are among the most severe injuries, often ending in death even despite timely and fully implemented treatment measures. Anatomical injuries of the esophagus (wounds, ruptures, perforations by foreign bodies) are the competence of thoracic surgeons, however, traditionally, uncomplicated foreign bodies, chemical burns of the esophagus, some types of its strictures that do not require surgical treatment, continue to be treated by otolaryngologists throughout the world, although other surgical diseases of the esophagus are in the hands of general and thoracic surgeons, and therapeutic diseases are in the competence of gastroenterologists.

For otolaryngologists, knowledge and skills concerning the esophageal injuries that are encountered in their daily practice are of undoubted practical importance. However, the issue of direct and differential diagnostics of those esophageal injuries that are under the supervision of thoracic surgeons is of the same practical importance, since such patients often first come to an ENT specialist, and the patient's life may depend on how competently this specialist makes a presumptive diagnosis and purposefully determines the treatment tactics. Therefore, in our opinion, all practicing ENT doctors should be familiar with the list of possible traumatic injuries of the esophagus and at least in general terms know the symptoms that appear in 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 to the esophagus; during the same period, 56,595 patients sought help from the N.V. Sklifosovsky Institute of Emergency Care with complaints of foreign bodies getting stuck in the esophagus; in 5,959, the presence of foreign bodies was confirmed) and is presented with some abbreviations and textual additions and changes.

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Cause of Esophageal Injury

According to this criterion, all mechanical injuries to the esophagus are divided into injuries caused by foreign bodies, instruments, spontaneous, hydraulic and pneumatic ruptures, injuries caused by compressed air, gunshot and stab wounds, blunt trauma; neck, chest and abdomen.

The given classification answers many questions that arise in the problem of clinical description of mechanical injuries of the esophagus. According to the origin of the injury, all injuries of the esophagus are divided into external and internal. External injuries include injuries of the esophagus that can occur in its cervical, thoracic and abdominal sections. As follows from the given classification, these injuries are divided into isolated and combined.

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Esophageal injuries

Isolated wounds of the esophagus (stab, cut) are rare; they are often combined with damage to adjacent tissues and organs. Gunshot wounds of the esophagus are especially severe.

Cervical esophagus injuries

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

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Symptoms of Esophageal Injury

The symptoms of esophageal injury are as follows: pain when swallowing, saliva, blood and food coming out of the wound when eating. Subcutaneous emphysema may also often develop when the wound channel communicates with the larynx or cervical trachea. Any injury to the esophagus poses a serious risk of infectious and purulent complications, which are usually caused by anaerobic infection. Esophagitis often develops within 24 hours after the injury, periesophagitis on the 2nd day, and mediastinitis on the 3rd. The latter often develops as a result of purulent leakage. These complications are accompanied by swelling in the neck area and smoothing of its relief, serous-bloody, then purulent discharge from the wound, sharp pain in the throat and neck when turning the head, which intensifies when throwing the head back. This causes a forced position of flexion in the cervical spine. The body temperature reaches 39°C, the resulting septic condition is manifested by severe chills, pale skin, and cardiac dysfunction. The patient's general condition progressively worsens.

When the thoracic esophagus is injured, there may be injuries to the heart, lungs, large vessels of the mediastinum, trachea and bronchi, 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, bending and especially when extending the thoracic spine. In a soporous state, bloody vomiting may occur. When the esophagus is injured, combined with damage to the trachea or bronchi, severe mediastinal emphysema syndrome develops with compression of the lungs, heart and aorta. Mediastinitis, pleurisy, pericarditis quickly develop, usually ending in death.

Wounds of the abdominal esophagus may be combined with wounds of the stomach, parenchymatous organs of the abdominal cavity, large vessels. With such wounds, in addition to the general pain syndrome, signs of peritonitis, internal bleeding, intestinal obstruction develop.

Morphological changes in esophageal perforations

The dynamics of these changes goes through several stages.

The serous inflammation stage is characterized by rapidly increasing traumatic edema of the loose periesophageal tissue, emphysema of the tissues of the neck and mediastinum. A complication of mediastinal emphysema may be a rupture of the mediastinal pleura.

The stage of fibropurulent inflammation occurs 6-8 hours after the injury: the edges of the esophageal wound are covered with a fibrin coating and infiltrated with leukocytes. In the pleural cavity corresponding to the side of the injury, a reactive hemorrhagic effusion is formed. Often, 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 contributes to a more rapid course of mediastinitis. As for emphysema, with a favorable course of the 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 cited authors, by the so-called purulent-resorptive fever and wound exhaustion. At this stage, 7-8 days after perforation, the spread of purulent leaks occurs, resulting in secondary pleural empyema, purulent pericarditis, and abscess formation of lung tissue. Such patients die from erosive bleeding from large vessels of the mediastinum, which occurs as a result of the strong fibrinolytic effect of purulent exudate. Late complications of the pathological condition in question include purulent-fibrinous pericarditis, which occurs with perforations of the lower third of the esophagus, as well as in cases where the false passage canal passes in close proximity to the pericardium.

The reparation (healing) stage usually occurs after the abscess has been opened, emptied and drained, especially if the purulent focus is limited or encapsulated.

Closed injuries of the esophagus

Closed injuries of the esophagus are very rare and occur with severe bruises and compressions of the chest and abdominal cavity as a result of road traffic accidents, falls from height, at work with failure to observe safety precautions 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 of the accident 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 abscess cavity in the periesophageal tissue, but on the size of the esophageal wall, since recovery can occur only after the cessation of the contents of the esophagus into the mediastinum.

The esophageal defect is closed by secondary intention. Unsutured defects larger than 1.5 cm are replaced by scar tissue, which subsequently results in esophageal deformations and the formation of diverticula with their inherent dysfunction.

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Classification of mechanical injuries of the esophagus

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Localization of injury

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

Injuries to the cervical esophagus are the most common and occur as a result of wedging of foreign bodies or an unsuccessful attempt to remove them. During bougienage, esophageal injuries are localized in the thoracic esophagus, during cardiodilation - in the supradiaphragmatic and abdominal sections. The most dangerous manipulation is "blind" bougienage of the esophagus, which often causes multiple perforations due to the loss of elasticity of its wall. By involvement of the walls in the pathological process: anterior, posterior, right, left, their combinations, circular damage. The anterior wall is damaged relatively rarely. Foreign bodies most often injure the lateral walls. Instrumental ruptures of the cervical esophagus are most often located on the posterior wall, thoracic esophagus - on the right wall. Hydraulic ruptures are observed on the right wall of the middle third of the thoracic esophagus, spontaneous ones - in the lower third of this section and more often on the left. Circular injuries, characterized by ruptures of the esophagus, occur with blunt trauma to the chest and abdomen.

Depth of injury

• Non-penetrating injuries (abrasions, scalp ruptures of the mucous membrane and submucous layer, submucous hematomas) are the most common type of esophageal injury and are associated with foreign bodies or rough manipulation with instruments. Penetrating injuries (perforations, through wounds) can be caused by the same mechanism as non-penetrating ones, or by gunshot wounds. Depending on the mechanism, injuries can be isolated or combined with damage to adjacent organs and anatomical structures. Mechanism of injury
• Stab, cut, lacerated, gunshot wounds, bedsores with perforation, combined.
• Damage by foreign bodies most often appears as a puncture wound and much less often as a cut wound, which occurs as a result of a double-edged blade being wedged into the esophagus. Instrumental damage appears as lacerated wounds, and intraoperative damage appears as linear wounds with smooth edges.

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Esophageal wall condition

• A cicatricial wall affected by varicose veins, deep chemical burns, or cancer.

The selection of this classification feature is of great practical importance, since the course of the injury and surgical tactics largely depend on: the previous state of the esophageal walls. In particular, purulent complications in the case of rupture of a cicatricial esophagus develop later than in the case of rupture of an unchanged wall. In addition, the esophagus with pronounced cicatricial changes is a functionally defective organ that has lost its elasticity and compliance - such important qualities for the safe implementation of instrumental manipulations. In the case of varicose veins, there is a risk of profuse bleeding, and in the case of damage to the esophageal wall by a cancerous tumor, there is a significant probability of its perforation during esophagoscopy with a rigid esophagoscope.

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Associated damage

• Perforation of the esophageal wall with a complex course without damage to adjacent organs.

These injuries concern only the esophagus and occur when it is perforated by foreign bodies, balloon probes, an esophagoscope, a bougie, a biopsy probe, an endotracheal tube, a gastric tube, and are always accompanied by the appearance of a so-called false passage of varying length with destruction of the periesophageal tissue of the neck or mediastinum. Perforation of the esophageal wall with damage to the mediastinal pleura.

Such damages can be localized on the right, left or be bilateral. They can be combined with damages of the tracheobronchial tree, large vessels.

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Diagnosis of esophageal trauma

Esophageal injury diagnostics is an extremely important stage in the measures to cure this injury. The factor of early diagnostics with the establishment of the cause, size and depth of the esophageal lesion is extremely important, since the nature of medical care depends on this. The following sequence of diagnostic measures is generally accepted: overview fluoroscopy of the neck and posterior mediastinum, radiological examination methods with contrast, diagnostic esophagoscopy, puncture of the pleural cavity. The results of these studies, as well as the anamnesis, assessment of the circumstances that led to the esophageal injury syndrome and the nature of the clinical course allow for differential diagnostics both between different types of esophageal injuries and between the latter and other forms of esophageal diseases.

During general X-ray examination, air bubbles are visible in the periesophageal tissue; this phenomenon is called deep emphysema. Pneumothorax and hydrothorax indicate damage to the pleura.

When performing radiographic examination methods with contrast, some thoracic surgeons and radiologists prefer oil-based iodine-containing contrast agents. However, with a narrow perforation tract, the oil solution does not always penetrate it due to its viscosity, which does not allow diagnosing the damage. In addition, when these drugs come into contact with the mediastinal tissue, they are firmly fixed to it, and it is much more difficult to wash them off than a suspension of barium sulfate. The most acceptable are di- and triiodine-containing water-soluble compounds, which have become widespread in the diagnosis of esophageal ruptures. They do not irritate the mediastinal tissue and, having low viscosity, penetrate well even into small wound defects. As noted by B.D. Komarov et al. (1981), these contrast agents are quickly absorbed, which makes them indispensable in cases of esophageal obstruction and suspected esophageal-respiratory fistulas, they have a bactericidal effect and can be used repeatedly in dynamic monitoring of the healing process of the damaged area in the postoperative period.

When using radiological examination methods with contrast, it is possible to detect damage to the mucous membrane, the release of the contrast agent beyond the esophagus contour, determine the position, direction and size of the false passage, its relation to the lumen of the esophagus, mediastinal pleura, diaphragm, retroperitoneal space. All this is of decisive importance when choosing treatment tactics.

Diagnostic esophagoscopy for esophageal injuries is not as widespread as X-ray examination. The reasons for this are as follows: esophagoscopy cannot always be performed due to the severity of the patient's condition; after this manipulation, the condition always worsens. These obstacles are eliminated using intratracheal anesthesia with muscle relaxation, which makes it possible to carefully and calmly examine the esophagus along its entire length and accurately determine the location, size and depth of the injury. Diagnostic esophagoscopy has not only diagnostic but also therapeutic value, since it can be used to remove blood and other masses accumulated in the mediastinum from the false passage, as well as to insert a feeding tube into the stomach.

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

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Differential diagnostics of mechanical injuries of the esophagus

In differential diagnostics, it should be borne in mind that in case of open trauma to the neck and chest, the diagnosis of esophageal damage is established during primary surgical treatment: in case of intraoperative trauma, esophageal damage is usually detected during surgery (manipulation - probing, esophagoscopy with a rigid esophagoscope); esophageal damage in case of closed trauma to the chest or abdomen can only be diagnosed radiologically, since signs of traumatic shock prevail in the clinical picture.

When the thoracic esophagus ruptures, the symptoms of esophageal injury that arise may 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, dissecting aortic aneurysm, pleuropneumonia, spontaneous pneumothorax, intercostal neuralgia).

Closed chest trauma with esophageal rupture has a certain similarity with diaphragmatic rupture in its clinical picture. As clinical practice shows, due to the fact that the physical examination data (tachycardia, hypotension, hydro- and pneumothorax), as well as the further course of the process (increasing intoxication, increased body temperature, soporous and comatose state) do not have specific signs of esophageal damage, differential diagnostics in case of its traumatic rupture cannot be carried out with a sufficiently high probability with most of the above diseases. However, as B.D. Komarov et al. (1981) point out, a clear anamnesis (vomiting with spontaneous and hydraulic ruptures, foreign bodies or endoscopic manipulations) makes it possible to suspect esophageal damage. This suspicion can be confirmed or refuted only by conducting an X-ray examination of the patient, but if this examination does not provide a clear answer to the condition of the esophageal wall, then an esophagoscopy is performed.

Rupture of the lower third of the thoracic esophagus and abdominal esophagus manifests itself with symptoms very similar to those of perforation of hollow organs of the abdominal cavity, in particular, perforated gastric ulcer.

According to B.D. Komarov et al. (1981), differential diagnostics for esophageal 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 organs (perforation of a hollow organ, acute pancreatitis and cholecystitis, thrombosis of the mesenteric vessels).

In differential diagnostics of esophageal injuries, one should keep in mind some similarity with Hamman syndrome, which occurs in women in labor during labor: subcutaneous emphysema, pneumothorax, dyspnea, cyanosis, blood circulation disorders, pain, extracardiac murmurs synchronous with heart contractions. Radiologically - air in the mediastinum.

Against the background of primary symptoms associated with esophageal rupture, significant difficulties arise in the differential diagnosis of acute mediastinitis due to esophageal trauma from chronic sclerosing mediastinitis, which is a consequence of long-term inflammatory processes in the chest cavity and mediastinum (nonspecific pneumonia, bronchiectasis, pneumoconiosis, etc.) and is characterized by diffuse infiltration of the mediastinum, against which foci of calcification can be determined radiographically. These foci can simulate leakage of contrast agent beyond the contours of the esophagus, if due attention is not paid to them during general fluoroscopy of the mediastinum.

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Treatment of esophageal injury

Treatment of esophageal trauma is divided into non-operative and surgical. When determining the treatment tactics and choosing its method, the cause of the injury, its mechanism, morphological features of the damaged tissues, localization, the state of the periesophageal tissue and the time elapsed since the injury to the esophagus are taken into account.

As a rule, non-surgical treatment of esophageal trauma is indicated for patients with non-penetrating injuries of the esophagus, perforations of the esophagus by a foreign body, and instrumental injuries of the esophagus.

In case of non-penetrating damage to the esophagus, the need for hospitalization and non-surgical treatment arises when multiple and deep abrasions of the mucous membrane and submucous layer, accompanied by edema of the paraesophageal tissue of the neck and mediastinal tissue, are detected during esophagoscopy and X-ray examination. According to B.D. Komarov et al. (1981), with superficial abrasions of the mucous membrane without pronounced edema of the paraesophageal tissue, patients can undergo outpatient treatment, which in the overwhelming majority of cases leads to recovery. They are recommended to eat gentle warm food, mucous decoctions, take beaten raw egg white, drink small portions of decoctions of St. John's wort, medicinal chamomile and other herbs with antiseptic properties that are not capable of irritating the mucous membrane. With this form of home treatment, the patient should be informed about the possible appearance of signs of complications of the existing injury (increased pain, difficulty swallowing, chills, increased body temperature). If they occur, you should immediately consult a doctor. As noted by the above authors, according to their observations, in 1.8-2% of patients with non-penetrating injuries of the esophagus out of 372, after 5-6 days, abscesses formed in the periesophageal tissue immediately adjacent to the zone of non-penetrating injury.

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

The presence of a foreign body in the lumen of the damaged esophagus causes massive infection of the periesophageal tissues and the development of phlegmonous (often putrefactive) inflammation. Attempts at non-surgical treatment of such patients are erroneous, since delays in surgical intervention lead to the development of diffuse mediastinitis with unpredictable consequences.

In case of instrumental injuries of the esophagus, non-surgical treatment of esophageal trauma is possible only in the presence of effective outflow of purulent discharge from the damaged area 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 the surrounding organs and mediastinal pleura, and the false passage in the tissue of the neck or mediastinum does not exceed 2 cm. In case of instrumental ruptures of the cicatricially altered wall of the esophagus, in which the false passage does not exceed 3 cm, non-surgical treatment is also possible, since sclerotic changes in the periesophageal tissue, accompanying sclerosis of the esophagus, prevent the spread of the inflammatory process.

Usually, non-surgical treatment of esophageal trauma and corresponding indications is carried out either in a surgical thoracic or ENT department, especially if the latter was used to remove an uncomplicated (non-penetrating) foreign body that left behind damage requiring only non-surgical treatment.

In terms of methodology, non-surgical treatment of esophageal trauma, carried out according to appropriate indications in hospital conditions, consists of massive antibiotic therapy and limitation or exclusion of oral nutrition for a certain period.

In case of non-penetrating injuries of the esophagus that do not require complete exclusion of oral nutrition, along with antibiotics, a penicillin solution (1 million units in 200 ml of water) or a furacilin solution 1:5000 is prescribed per os, the purpose of which is to wash deep abrasions and scalp wounds from fibrin, pus and food debris.

In case of penetrating injuries of the esophagus, the dose of antibiotics is increased to the maximum possible, oral nutrition is excluded until the defect of the esophageal wall heals. The tactics of managing a patient with such an injury to the esophagus, according to the recommendations of B.D. Komarov et al., should be as follows. If healing is expected to occur within a week, which usually occurs with stab wounds with a foreign body, instrumental injuries up to 5-8 mm with a false passage of the same length, then patients can be managed during this period on full parenteral nutrition. In such cases, patients should receive 2000-2500 ml of various solutions, including 800 ml of 10% glucose solution with insulin (16 U), 400 ml of 10% solution of Aminozol or Aminon, 400 ml of a balanced solution of electrolytes and vitamins. The deficiency of amino acids is compensated for by intravenous administration of Amnoplasmal E.

If the healing of the esophagus injury is expected to be long, for example, in the presence of a bedsore of the cicatricially deformed wall of the esophagus, an instrumental rupture larger than 1 cm with a false passage of the same length, then the patients should be immediately transferred to tube feeding. For this, only thin silicone probes are used, which can be in the esophagus for up to 4 months without irritating the mucous membrane and without causing any discomfort to the patient. Feeding is carried out through a funnel or using a syringe for washing the cavities with products of a creamy consistency, including mashed meat and boiled vegetables, broths, fermented milk products. After feeding, the tube should be washed by passing 100-150 ml of boiled water at room temperature through it. In case of extensive destruction of the esophagus, requiring reconstructive surgical interventions, the patient is fed through a gastrostomy.

Treatment of esophageal injuries that cannot be treated non-surgically consists of emergency surgery, which is performed, depending on the level of injury, by a surgeon specializing in cervical surgery, a thoracic surgeon, or an abdominal surgeon. In severe cases, the esophagus is exposed at the neck, mediastinotomy or laparotomy and diaphragmotomy are performed. In case of injury to the cervical esophagus, the wound of its wall is sutured, leaving the remaining tissues of the wound unsutured, and the wound cavity is drained. After the operation, the patient is placed on a bed with the head end lowered to prevent the wound contents, including inflammatory exudate (pus), from flowing into the mediastinum. Nutrition is carried out through a tube inserted through the nose; in especially severe cases, a gastrostomy is applied. Drinking and eating are prohibited for 3 days. Antibiotics are prescribed.

In the event of mediastinitis, pleurisy or peritonitis, mediastinotomy, pleurotomy and laparotomy are indicated, which are performed by the appropriate specialists in the appropriate departments.