Oesophageal injuries: Position paper, WSES, 2013

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Title:
Oesophageal injuries: Position paper, WSES, 2013
Series Title:
World Journal of Emergency Surgery
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Creator:
Rao R Ivatury
Frederick A Moore
Walter Biffl
Ari Leppeniemi
Luca Ansaloni
Fausto Catena
Andrew Peitzman
Ernest E Moore
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World Journal of Emergency Surgery
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Abstract:
The oesophagus is a difficult challenge for the surgeon because of its lack of serosal covering, the tenuous, segmental blood supply and the common delay in the diagnosis of injury. Early diagnosis is the key to successful management. Recent introduction of newer, minimally invasive techniques have provided management alternatives for both the normal and the diseased organ that is injured with both early and delayed diagnosis.

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University of Florida
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University of Florida
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REVIEWOpenAccessOesophagealinjuries:Positionpaper,WSES,2013RaoRIvatury1*,FrederickAMoore2,WalterBiffl3,AriLeppeniemi4,LucaAnsaloni5,FaustoCatena6, AndrewPeitzman7andErnestEMoore8AbstractTheoesophagusisadifficultchallengeforthesurgeonbecauseofitslackofserosalcovering,thetenuous, segmentalbloodsupplyandthecommondelayinthediagnosisofinjury.Earlydiagnosisisthekeytosuccessful management.Recentintroductionofnewer,minimallyinvasivetechniqueshaveprovidedmanagementalternatives forboththenormalandthediseasedorganthatisinjuredwithbothearlyanddelayeddiagnosis.SurgicalanatomyTheoesophagusisalong,muscularorganthatbeginsat thepharyngooesophagealjunctionatthelevelofthe sixthcervicalvertebra.Itendsatthegastrooesophageal junction.Theareaofitsoriginatthecricopharyngeus muscleisanareaofpotentialinjurybytheendoscopist ortheneophyteanesthesiologist.Passingintothethorax, theoesophagusandthetracheatraversethesuperior mediastinumbehindthegreatvesselsandwithaslight curvepassesbehindtheleftmainstembronchus.From thispoint,theoesophaguscurvestotherightintheposteriormediastinum,curvesbacktotheleftbehindthe pericardiumandcrossesthethoracicaorta.Lyinganteriortothethoracicaorta,itreachestheabdomenthrough theoesophagealhiatusofthediaphragm.Thereisnoserosalcoveringforthestructure.Theouterlayersare composedentirelyoflongitudinalandcircularmusclefiberswithsquamousepitheliumasthemucosallining. Thebloodsupplyissegmentalandisderivedfrom branchesoftheinferiorthyroid,bronchial,intercostal arteriesandtheaorta.Venousdrainageisthroughsubmucosalchannelsintoaperioesophagealplexuswhich eventuallyentersintotheinferiorthyroidandvertebral veinsintheneck,theazygosandhemiazygosveinsin thethoraxandtheleftgastricveinintheabdomen.IntroductionOesophagealperforationisapotentiallylife-threatening clinicalsituationwithahighmorbidityandamortality. Theclinicalsymptomsandsignsarenon-specific.The relativepaucityofexperienceatanygivencentermakes thediagnosisdifficultandoftendelayed.Therearenorandomizedstudies,noclassIevidencefordiagnosticand managementprecepts.However,multipleseriesreported intheliteratureallowsomestrongrecommendations.ReviewofliteratureOesophagealperforationisslightlymorecommonin males[1-7]intheirsixties. Iatrogenicperforationisthemostcommoncauseof injury.Theincidenceissmall,lessthan0.5%,whenall theproceduresontheoesophagusareconsidered.Sclerotherapyofoesophagealvarices,nasogastrictubesandimproperlyplacedSengstaken-Blakemoretubeshavebeen knowntoproduceoesophagealperforation.Oesophageal “ stents ” ,temperatureprobes,repeatedattemptsatendotrachealintubation,impactedforeignbodies,bothsharp andblunt,mayallcauseoesophagealinjury.Blastinjury andspontaneousruptureoftheoesophagusaresecondary toasuddenriseinintraluminalpressureandoccurusually atthelowerendoftheoesophagus.Oesophagealtrauma hasbeenreportedasacomplicationfollowinganti-reflux procedures,pneumonectomy,truncalvagotomy(anincidenceof0.5%)andrarely,duringanteriorcervicalspinal fusionBluntoesophagealinjuryisexceedinglyrareand oftenismissed.Thepredominantsiteofruptureisinthe cervicalandupperthoraciclocation(82.3%),andassociated tracheooesophagealfistulaswerenotedin28patientsin oneseries.Penetratingobjects,usuallyGSW,injurethe oesophagusmorecommonlythandoesbluntmechanism. Itisnotaveryfrequentinjury.Inalargemulti-centerstudy fromtheAAST,Asensio[3]collected405patientsfrom34 traumacentersover10.5years.Ingestioninjurytothe oesophagusmayoccurwithcausticliquids[8],especiallyin *Correspondence: raoivatury@gmail.com1Surgery,VirginiaCommonwealthUniversityHealthSystem,Richmond,VA, USA Fulllistofauthorinformationisavailableattheendofthearticle WORLD JOURNAL OF EMERGENCY SURGERY 2014Ivaturyetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited.TheCreativeCommonsPublicDomainDedication waiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwise stated.Ivatury etal.WorldJournalofEmergencySurgery 2014, 9 :9 http://www.wjes.org/content/9/1/9

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childrenbycleaners,batteryliquidsandsolutionsusedin industrialoperations.Acidscausecoagulativetissuenecrosiswithalowerriskofpenetrationwhilealkalistendtobe morepalatableandcauseliquefactivenecrosisthatrapidly becomestransmural.Theamount,viscosityandconcentrationoftheagentandthedurationofcontactbetweenthe causticagentandtheoesophagealmucosadeterminethe depthandextentoftheinjury.DiagnosisTheclinicalsymptomatologyisnon-specificearlyafter perforation.Radiologiccluesaresubtleandmayeasilybe missed.Consequently,delayeddiagnosisofoesophageal perforationisextremelyfrequent.Thisisespeciallytruein non-endoscopiciatrogenictraumaandafterspontaneous perforation.IntheAASTstudy[3],delayeddiagnosisafter penetratingtraumaoccurredinabout50%ofpatients reachingtheoperatingroom. Pain,usuallylocatedinthechestwithcervicalperforationsandperhapsreferredtotheabdomenwiththoracic perforations,isafrequentcomplaintbypatientswith oesophagealperforation,occurringin70%to90%ofpatients.Painprecededbyrepeatedepisodesofvomitingisa particularlyimportanthistorythatneedstobeelicited. Dyspneaisthesecondcommonsymptom,especiallywith thoracicperforationsandinfrequentlyisseenwithcervical orabdominalperforations.Subcutaneousemphysemaand crepitusareseenfrequentlywithcervicalperforations. Dysphonia,hoarseness,cervicaldysphagiaandsubcutaneousemphysemaareencounteredinvariouscombinations inthisgroupofpatients.Thereissometimesacuteabdominalorepigastricpaininpatientswithperforation ofthegastrooesophagealjunction.Notably,perforationsrarelymanifestwithhematemesisorothersignsof gastrointestinalbleeding,includingmelena[1-7].PlainradiographsTheradiologicfindingsthataresuggestiveofthediagnosis arefreeairinthesofttissuesoftheneck,andretropharyngealorretrotrachealswelling.Chestradiographsmay revealfreemediastinalorcervicalair,mediastinalwidening,pneumothorax,or,indelayedcases,pulmonary infiltrates.ContraststudiesContrastoesophagographyisindicatedtoconfirmthe diagnosis,localizethesiteofperforationanddefinethe presenceorabsenceofassociatedoesophagealpathology.Incombinedoesophagealandtrachealinjuriesor wherethereissuspicionofanabnormaloesophagotracheobronchialcommunication,thinbariumisthe agentofchoice.Freeperforationsintothepleuraorthe mediastinum(thepresenceofpneumomediastinumor pneumothorax)arebestdemonstratedbygastrografin. Onceagrossextravasationisruledout,afluoroscopic studywiththinbariumisthenextsteptoruleouta smallperforationthatmayhavebeenoverlookedbythe gastrografinstudy[1,2].EndoscopyEndoscopyhasalimitedapplicationasthe only investigation.Ininstancesofbluntorpenetratingtrauma wherethepatientisrushedtotheoperatingroomfor controlofotherinjuries,intraoperativeoesophagoscopy maybeemployedtoruleoutgrossoesophagealinjury. Subtleperforationsmaybemissed,especiallybyflexible endoscopy.Inpatientswithasuspicionofoesophageal injuryafterexternaltrauma,tripleendoscopy(laryngoscopy,oesophagoscopyandbronchoscopy)isindicated. Injurytooneofthesestructuresshouldraisethesuspicion ofinjurytotheadjacentorgans.Thesameprinciplesare recommendedfortransmediastinalmissilewoundsaswell ascervicalpenetratingwounds.Thesensitivityandspecificityofendoscopyinthediagnosisofoesophagealinjury areunknown,butdefinitelyarerelatedtooperatorexperience.Thecombinationofcontraststudiesandendoscopy areaccurateinmorethan90%ofpatients.Intra-operative endoscopywhilepalpatingtheesophagusnearthepenetratingtractandinsufflationofairlookingforair-leakare usefultechniques.Perforationscausedbytheendoscopist duringoesophagoscopyareusuallypromptlysuspected.MiscellaneousdiagnosticmethodsCT,inaddition,mayshowcollectionofairorfluidin themediastinum,pleuraleffusions,pneumopericardium andpneumoperitoneumasimportantdiagnosticfindings inthesepatients.Thetractofthebulletinproximityto theesophagusgivesanotherclue.Thesiteofperforation andthedegreeofcontainmentmayalsobenoted.Tube thoracostomyforahydrothoraxwiththedemonstration ofacontinuousairleaknotinsynchronywithrespirationmaysuggestanoesophagealinjury.Increased levelsofamylaseinchesttubefluidintheappropriate clinicalscenarioishighlysuggestiveofoesophageal perforation[1-7].Operativeexplorationisausefuldiagnosticmodality.Especiallyinpatientswithpressingindicationsforsurgicalexploration(hemorrhage,vascular injury),theoesophagusmustbeinspectedinproximity injuriesandoperativelyexploredintheregionofthe penetratingwound.Adjunctivemethodsatexploration includeinstillationofsalineordye(methyleneblue) intraluminallywithmanualcompressionoftheorganto excludealeak.Thesamepurposemaybeachievedby fillingtheoperativefieldwithsalineandvigorously injectingairintotheoesophagustodemonstrateanair leak.Asmentionedearlier,intra-operativeendoscopyis ausefuloption.Ivatury etal.WorldJournalofEmergencySurgery 2014, 9 :9Page2of7 http://www.wjes.org/content/9/1/9

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ManagementThechoiceofapproachdependsonthefollowingfactors:1. theanatomiclocationoftheperforation,2.thetimeinterval betweentheonsetofperforationandtheinitiationof treatment,3.whethertheinjuryiscontainedorfree,4.the severityofillnessofthepatient,5.themechanismofinjuryand6.Whethertheoesophagusisnormalorthereis anassociatedlesion[1,3,5,6].InjuriestothecervicaloesophagusThemanagementofcervicaloesophagealperforationdependsonthemechanismofinjury.Neckexplorationis performedthroughaleftneckincisionalongtheanterior borderofthesternocleidomastoidmusclewithmedial retractionofthecarotidvessels.Adequatemobilization behindthetracheaandpalpationofthenasogastrictube facilitateidentificationoftheoesophagus.Therecurrent laryngealnerveneedstobeprotectedinthedissectionandfrequentlymaybepalpatedorvisualized.The oesophagealperforationisidentifiedeitherbydirect visualizationorwiththehelpofintraluminalsalineor dye.Theperforationisrepairedinoneortwolayers. Neitherthenumberofsuturelayersnorthetypeofsuturematerial(absorbableornon-absorbable)seemto influencetheincidenceoffistulizationaftertherepair. Iftheoperativeexplorationisdelayed,suturingmaybe difficultbecauseofextensiveinflammationinthearea. Ineitherinstance(earlyor delayedoperation),wide drainageisthekeytosuccess.Closedsuctiondrains (Jackson-Pratt)usuallyarepreferred.Broad-spectrum antibiotics(usuallyasyntheticpenicillin)arecommenced andcontinuedperi-operatively.Thedrainsareleftfora periodof5 – 7days.Mostsurgeonsrecommendacontrast studybeforetheremovalofthedrain,becauseofthe frequentoccurrenceoffistulawithoutclinicalsymptomatology.Nutritionalsu pportmaybedeliveredduringthisperiodbyanasogastrictube. Cervicaloesophagealfistulasarereportedin10%to28% ofcasesafteroesophagealrepair.Thefactorsthatcontributetothiscomplicationincludeinadequatedebridement, oesophagealdevascularization,tensiononthesutureline andassociatedinfection.Adequatedrainage,exclusionof distalobstructionandmaintenanceofnutritionalsupport arethecornerstonesoffistulamanagementandthemajorityofthemhealwithtime[1,5]. Combinedtracheo-oesophagealinjuries:Combined tracheo-oesophagealtraumaposesspecialproblems: theyaredistinctlyuncommonandthusmayleadtomanagementerrors,theyproduceuniquetechnicalproblems andmayleadtocomplexcomplicationsintheremote postoperativeperiod.Nearlyalwaysduetogun-shotinjury,energytransfer;e.g.,closerangeSGWvs.jacketed32 caliberbulletsdeterminestheoutcome.Felicianoandcolleagues[3],basedonan11-yearexperienceof23patients, recommendthefollowingprinciples:1.theadditionof tracheostomytoasimplerepairofthetracheamayactuallyleadtoahigherinfectiousmorbidityintermsofpneumonia,mediastinalabscessesandwoundinfections.2.For extensiveoesophagealinjuriesinthecervicalarea,acervicaloesophagostomy,sideorend,shouldbeconsidered attheinitialoperation.3.Sternocleidomastoidor,preferably,strapmuscleinterpositionshouldbeemployedbetweentrachealandoesophagealrepairsaswellastocover carotidarteryrepairs.Itmustberememberedthatthe sternocleidomastoidhasasegmentalbloodsupplyin thirdsandtheupper(fromoccipitalartery)andthemiddle(fromthesuperiorthyroidartery)aremorereliablefor flapcreation.And4.Drainageofcombinedcervicalinjuriesshouldbedirectedanteriorlyandthroughthecontralateralneckifacarotidarteryinjuryispresent.InjuriestothethoracicoesophagusIatrogenicandtraumarelatedperforationsNon-operativemanagement: Aconservative,non-surgical approachoccasionallyisrecommendedforthoracic oesophagealperforationsinselectedpatients.Theperforationhastobecontainedforeligibilityfornon-operative management.SantosandFrater[8]describedasystemof “ transoesophagealirrigationofthemediastinum ” asa methodofconservativemanagementinpatientswitha delayeddiagnosisofspontaneousrupture.Theauthorsreportedexcellentresults(7of8survived)withaLevintube placedintheoesophagusproximaltothetear,achesttubeplacedinproximitytotheoesophagus,constantirrigationthroughtheLevintubeandcontinuoussuctionto thechesttube:amethodthatensuredconstant,mediastinalirrigation.Othersusedmediastinalirrigationbya transnasalcatheter.Percutaneousdrainageofpleuraleffusions,collectionsorabscesses[9],temporaryendoscopic oesophagealstents[10-12]tosealoesophagealleakage andtorecovergastrointestinalcontinuityarebeingrecommendedinselectedpatients.Useofendoscopicclips forperforationclosure,endoscopicvacuumspongetherapyarebeingintroducedrecentlytoaidsuccessfuldrainageandhealingofoesophagealperforationoranastomotic insufficiency[2]. Forinstance,Fischer[13]reportedin2006nonoperativetreatmentof15benignoesophagealperforations afterendoscopicprocedureswithself-expandablecoveredmetalstents.Sevenpatients(group1)underwent stentinsertionwithanaveragetimedelayof45minutes. In8patients(group2),themediandelaywas123hours. Allpatientsingroup1hadanuneventfulrecoveryand lefthospital5days(range,3to9)afterstentinsertion. Onepatientingroup2(1of8)diedofpneumoniaafter 6days.Intheother7cases,perforationshealedsuccessfullyafterstentplacement,buttheclinicalcoursewas generallycomplicatedwithsepsisandmultipleorganIvatury etal.WorldJournalofEmergencySurgery 2014, 9 :9Page3of7 http://www.wjes.org/content/9/1/9

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failure.Theaveragehospitalstaywas44days(range,15 to70). Linden[9]described43proceduresontheoesophagus witha30-dayorin-hospitalmortalityof7.0%andan overallmorbidityof47%.Mostacutethoracicoesophageal perforationsweretreatedwithprimaryrepairwithalow mortalityrateof5%.Mostdelayedperforationswere treatedwithT-tuberepairandhadamortalityrateof 8.7%.Thecomplicationratewasmuchlowerintheinthe grouprepairedwithin24hours. Freeman[10]reportedon17patientstreatedwith silicone-coatedstentsplaced endoscopicallyutilizing generalanesthesiaandfluoroscopywithadequatedrainage ofinfectedareas.Leakocclusionwasconfirmedbyoesophagogramin16patients(94%).Fourteenpatients(82%) wereabletoinitiateoralnutritionwithin72hoursofstent placement.Onepatient(6%)experiencedacontinuedleak afterstentplacementandunderwentoperativerepair. Stentmigrationrequiringrepositioning(2)orreplacement (2)occurredin3patients(18%).Allstentswereremoved atameanof52+/ 20daysafterplacement.Hospital lengthofstayforpatientstreatedwithoesophagealstent placementwas8+/ 9days(median,5).Inanothervariationofnon-operativetreatment,Linden[9]usedT-tube repairindelayedperforationswithamortalityrateof 8.7%.Inanotherrecentseries(12),14consecutivepatients withspontaneousoesophagealperforationweretreated withcoatedself-expandablestentandadebridementprocedure(threepatientsbythoracotomy,fourbythoracoscopy,threebytubedrainage,andtwopatientswithno drainage).Eightpatientshadonestent,whilesixpatients neededoneormoreadditionalstentstoachievesource control.Twopatients(14%)diedduringthein-hospital stay,bothofthemhavingreceivedmorethanonestent. Eightpatientshadonestent,whilesixpatientsneeded oneormoreadditionalstentstoachievesourcecontrol. Fourteenpercentofpatientswhounderwentstenting within24hourstostentplacementwereinsepticshock comparedwith86%ofpatientswithadelayofmorethan 24hours. Inarecentreview,Kuppusamy[11]described81consecutivepatientswithacuteoesophagealperforation.48 patients(59%)weremanagedoperatively,33(41%)nonoperatively,and10patientswithhybridapproachesinvolvingacombinationofsurgicalandinterventional techniques;57patients(70%)weretreated<24hours and24(30%)receivedtreatment>24hoursafterperforation.LOSwaslowerintheearly-treatmentgroup; however,therewasnodifferenceincomplicationsor mortality.Nonoperativetherapyincreasedfrom0%to 75%overtime.Nonsurgicaltherapywasmorecommon inreferredcases(48%vs30%)andinthe>24hours treatmentgroup(46%vs38%).Overtheperiodofstudy, thereweredecreasesincomplications(50%to33%)and LOS(18.5to8.5days).Mortalityfortheentireseriesinvolved3patients(4%):2operativeand1nonoperative. Theauthorconcludedthatreferraltoatertiarycare center,treatmentwithin24hours,anexperiencedsurgicalmanagementteamusingadiversifiedapproachcan expecttoshortenLOSandlimitcomplicationsand mortality. Surgicalinterventionisindicatedifthepatientshould worsenonconservativetreatmentorshoulddevelopa mediastinalabscessorempyema.Thepresenceorthe developmentofpneumothorax,pneumoperitoneum,systemicsignsofsepsisorshockarecontraindicationsfora nonoperativeapproach.Non-operativetreatmentshould alsobeusedwhentheperforationisrelatedtoaninoperablemalignantstricture.Patientoutcomedepends mainlyonthepropertreatmentofmediastinalandpleural contamination.Indicationsforpercutaneousdrainageor moreextensivedrainagebysurgicalinterventionshould beconsideredcarefullyifthereisgrosscontamination [1,11]. Operativemanagement:Operativerepairisthetreatmentofchoiceforfreeperforations.Thisistrueforinjuriesdiagnosedbothearly(<24hours)andlate(>24hours.) Theoperativeapproachconsistsofthoracotomyonthe sideoftheleak(leftthoracotomyforloweroesophagealinjuryandrightthoracotomyforupperoesophagealinjury), exposureoftheoesophagusandthoroughdebridementof allnecrotictissue.Theperforationisidentifiedandclosed. Inpenetratingtrauma,multipleperforationarenotuncommonandshouldbelookedfordiligently.Thechoice ofsuturematerialforclosureoftheperforationisvariable betweensurgeons,asisthenecessityforatwo-layered closurewithaninnerabsorbableandouternonabsorbable sutures.Apleuralflaporvariousneighboringstructures (diaphragm,intercostalmuscle,vascularizedorafreegraft ofpericardium,extracostalchestwallmuscle,omentumor apedicledjejunalsegment)maybeusedasa “ buttress ” to therepair … Inthelowerthoracicarea,thegastricfundus hasbeenusedasanonlaytypeofpatchbyenlargingthe oesophagealhiatusandbringingthegastricfundustothe perforation.Drainageoftheareaextensively,usuallywith largecaliberchesttubesplacedinthevicinityofthe oesophagealrepair,isthemostimportantpartoftreatment.Primaryrepairofoesophagealperforationispossible,especiallyinpatientsadmittedtothehospitalwithin 24hoursoftheevent.However,multiplerecentstudies foundthatmortalityriskwasnotrelatedtowaittimeexceeding24Hours.Whenrepairisattemptediniatrogenic caseswithastricturedistaltotheperforation,amyotomy mightbeindicatedandthedefectcoveredwithafundoplication.RepairoveraT-tubeisanalternativetreatment thatallowsforacontrolledesophago-cutaneousfistulato beestablished.Thisallowshealingtotakeplacewithout contamination[9].TheT-tubecanberemovedinmostIvatury etal.WorldJournalofEmergencySurgery 2014, 9 :9Page4of7 http://www.wjes.org/content/9/1/9

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patientsafter4 – 6weeks,andthefistulawilleventually close. Withrecentadvancesinvideoendoscopy,identification andrepairofoesophagealperforationbyVideoAssisted ThoracicSurgery(VATS)hasbeenreported.Thefuture willdetermineifthismodalitywillenableanearlier,more efficientrecognitionofoesophagealinjury. Treatmentofdelayedrecognitionoftheperforation: Oesophagealexclusionandotheradjunctivetechniques: Theproblemsofdelayedtreatmentinvolveextensive mediastinitis,necrosisoftheoesophagealwallandthe difficultyofeffectivelyclosingtheperforation,evenwith variousbuttressingmethods.Evenwhenrepairistechnicallyfeasible,subsequentbreakdownoftherepairis theruleratherthantheexception.Itisinsuchpatients that “ exclusion ” procedureswerepreviouslyrecommended.Therationaleforthisapproachistoexclude therepairfromtherestoftheoesophagusandallowit tohealwhilenutritionalsupportismaintainedbyintravenousorenteralroute.Thedecisiontoperformexclusion orrepairdependsonthelocalfindingsatthoracotomyas wellasthetimedelaybetweenperforationandoperative treatment.Inseveralseries,exclusionproceduresgenerally werereservedforadelayintreatmentofmorethan 48hours. Theprinciplesofexclusionproceduresare:1.todivert theoesophagusfromabove,2.topreventgastricreflux frombelowand3.Todraintheareawidely,usuallyby tubethoracostomyand4.Feedingjejunostomy. 1.Diversionfromabove:byalongT-Tubewiththe sidearmbroughtoutthroughtheperforationandthe chestwalltodivertthesalivaandachieveacontrolled fistula.Othertechniquesdescribedincludedalateral cervicaloesophagostomybymakinganopeninginthe cervicaloesophagusandsuturingtheopeningtothe skin.Theoesophagusdistaltotheostomymaybeclosed orstapled.2.Diversionfrombelow:Someauthorsrecommendedloopingthedistaloesophaguswithaprolenesuturethatisbroughtoutoftheabdomenalongwitha gastrostomy.Aftertheoesophagealperforationhealed,the Prolenesuturewasremoved,withoutlaparotomy,restoringoesophagealcontinuity[14]. Theproblemofexclusion-diversionproceduresisthat themajorityofthesepatientsrequireasecondaryproceduretorestorecontinuityoftheGItractafterthefistulahadhealed.Theseproceduresinvolveacolonor gastricinterposition,dependingonthesurgeon ’ spreference.Inmanyinstances,theexclusionbecomespermanent.Oesophagealexclusionisnowreservedforthevery poorriskpatientwhocannottolerateanymajorsurgical procedures. Perforationwithpre-existingpathology: OesophagealResection: Emergencyresectionoftheperforatedoesophagus isundoubtedlythetreatmentofchoicewhenthereis associateddistalobstruction.Theresultsofoesophagectomyforsimpleordelayedperforationswithorwithout associatedoesophagealdiseasehavebeenpoorinmost series.Amoreoptimisticevaluationofemergencyoesophagectomyforoesophagealdisruptionwasreportedby OrringerandStirling[15].Adiversegroupof24patients waspresentedincluding20withpreexistingoesophageal diseases(chronicstrictures,achalasia,refluxesophagitis, carcinoma,diffuseoesophagealspasmandmonilial esophagitis).Forty-fivepercentofthepatientshada delayof>3dayspriortooesophagectomy.Alimentary tractcontinuitywasrestoredin13ofthe24byoesophagogastricanastomosis.In11patients,theoesophaguswas resectedpreservingasmuchofthenormalesophagusas possible.Theproximaloesophaguswasthendelivered intotheneck,tunnelledinfrontoftheclavicleandthe endwasconstructedasanostomyonthechestwall.The authorsfeltthattheriskofoesophagealresectioninthese patientswaslessthanthatfromrepairorexclusion procedures. Recentseriesofoesophagealinjury:Eroglu[16]performedaretrospectiveclinicalreviewof44patients treatedforoesophagealperforationin2009.Perforation occurredinthecervicaloesophagusin14patients(32%), thoracicoesophagusin18patients(40%),andabdominal oesophagusin12patients(27%).Theperforationwas treatedbyprimaryclosurein23patients(52%),resection in7patients(16%),andnonsurgicaltherapyin14patients (32%).Inthesurgicallytreatedgroup,themortalityrate was3of30patients(10%).2of14patients(14.3%)diedin theconservativelymanagedgroup.Fourofthe14nonsurgicalpatientswereinsertedwithcoveredself-expandable stents.Describingasinglesurgeonexperience,Kiernan etal.[17]reportedon48patientswithasurvivalof96% withearlysurgicaltreatment.Evenwhenthediagnosis wasdelayed>24hours,hospitalsurvivalwas82.6%,increasingto92.3%whentreatedwithsurgery.Theauthors recommendedaggressive,definitivesurgeryforthoracic oesophagealperforationsandreservedconservative,medicaltherapyinpatientswith ‘ microperforations ’ withno continuingleak. Richardson[18]summarizedtheresultsofaggressive surgicalmanagementforoesophagealperforation.All weretreatedbyoperativerepairs,buttressedwithmuscle orpleura.Sternocleidomastoidmusclewasusedtobuttressorprimarilyclosethedefectsintheneck,andaflap ofdiaphragmwasoftenusedforthoracicperforation.Patientswithperforatedcancerorsevereunderlyingdisease hadanoesophagectomy.Withthesetechniques,50of64 patientsunderwentpreservationoftheoesophagusafter closureoftheperforationand14underwentresection. Theleakratewas17%,butallhealed.Onepatienttreated withprimaryclosuredied(1.5%mortality)andonly1patientrequiredsubsequentoesophagectomy.Ivatury etal.WorldJournalofEmergencySurgery 2014, 9 :9Page5of7 http://www.wjes.org/content/9/1/9

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Vallbhmer[19]describedaninstitutionalexperience of44patientsoveraperiodof12years.Iatrogenicinjury wasthemostfrequentcauseofoesophagealperforation. Eightpatients(18%)underwentconservativetreatment withcessationoforalintake,antibiotics,andparenteral nutrition.Twelve(27%)patientsreceivedanendoscopic stentimplantation.Surgicaltherapywasperformedin24 (55%)patientswithsuturingofthelesioninninepatients, oesophagectomywithdelayedreconstructionin14patients,andresectionofthedistaloesophagusandgastrectomyinonepatient.Thehospitalmortalityratewas6.8% (3of44patients):onepatientwithaniatrogenicperforationafterconservativetreatment,andtwopatientsafter surgery(onewithBoerhaavesyndrome,onewithiatrogenicrupture).Nodeathoccurredinthe25patientswhen thediagnosiswasmadeinlessthan24hours.Whenit wasdelayed,19%of16patientsdied(P=0.05). Keelingetal.[20]in2010retrospectivelyreviewedall casesofoesophagealperforationfrom1997through 2008atEmoryUniversity.Among91patients,theperforationwasiatrogenicin50(52%),spontaneousin23 (24%),andidiopathicin22(23%).Theauthorsconcludedthattheoverallmortalityfromoesophagealperforationcanbelessthan10%.Primaryrepairshouldbe consideredasfirst-linetreatmentwhenappropriateeven inpatientswhopresentmorethan24hoursafterperforation.Non-operativemanagement,inappropriatepatients,canbeusedinselectedpatients.Similarresults wererecordedbytheHoustongroup[21]andtworecentmeta-analyses[22,23].ResultsandprognosticconsiderationsInthemulti-institutionalseriesreportedbyAsensio[4], alogisticregressionof346patientsreachingtheO.R. afterpenetratingtraumaestablishedthatadelayinpreoperativeevaluation,AASTorganinjuryscore>2and resectionanddiversionwereindependentfactorsforincreasedoesophagus-relatedcomplications.Theprognosis appearstobemuchimprovedwithmodernapproachesto diagnosisandcriticalcarebutisstillhighwithdelayed diagnosisandtreatment.Emphasisshouldbeplacedon earlydiagnosisofinjuryandcarefulselectionofoperative versusnon-operativetreatmentbyexperiencedclinicians. Theexcellentresultswithnonoperativemanagementof iatrogenicinjuriesmaskthepotentiallife-threatening complicationsofpathologiclesions,andtraumaisin between.RecommendationsWerecommendastrongsuspicionforoesophagealinjury intheappropriateclinicalsituationofpotentialinjuryto theorganandaggressivepursuitofdiagnosistobemade within12to24hours.CTscanningisausefuldiagnostic modalityincasesofsuspectedperforation. Werecommendpromptsurgicalexposureandclosure ofoesophagealperforationinlayerswithadequate drainageoftheareaandantibiotictherapy.Incervical oesophagealinjurieswithassociatedtrachealor vascularrepairs,theseshouldbeseparatedfromthe oesophagealrepairbysternocleidomastoidorstrap muscleinterposition. Werecommendthatthetreatmentoftheinjured oesophagusbegivenbycliniciansexperiencedinthe endoscopicorsurgicalmanagementoftheorgan,ideally inatertiarycenterwithmultispecialtyavailabilitybyexperiencedclinicians. Wesuggestnon-operativemanagementofsmall perforationsdiagnosedwithin24 – 48hoursinastable patientwithnomediastinitisorempyema. Innon-traumainjuries,thatareinitiallymissedand/or presentinadelayedfashion,theinitialmanagementof sepsisbyresuscitation,antibioticsandchestdrainageis thepriority.Avarietyoftechniquesincludingstents, t-tubesandclippingareavailableandshouldbeindividualizedtotheclinicalsituationandpatient.These patientsneednutritionalsupplementation,preferably enteral,whiletheoesophagusheals.Wesuggestcareful observationofthesepatientsforsignsofescalatingseptic complicationsandpromptsurgicalintervention,should theseoccur. Wesuggestoesophagealresectionbyexperiencedsurgeonsforperforationofthediseasedorganandplanned reconstructionofesophago-gastriccontinuity.Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Authors ’ contributions “ RRIdraftedthemanuscript.FAM,WB,AL,LA,FC,AP,EEMreviewedthedraft andmadecorrectionsandrevisions ” .Allauthorsreadandapprovedthefinal manuscript. Authordetails1Surgery,VirginiaCommonwealthUniversityHealthSystem,Richmond,VA, USA.2AcuteCareSurgery,UniversityofFlorida,Gainesville,FL,USA.3Surgery, DenverHealthMedicalCenter,UniversityofColoradoSchoolofMedicine, 777BannockSt.,MC0206,Denver,CO80204,USA.4Surgery,Meilahti Hospital,Haartmaninkatu4,P.O.Box:34000029Helsinki,Finland.5SurgeryI, PapaGiovanniXXIIIHospital,PiazzaOMS1,24127Bergamo,Italy.6DepartmentofEmergencySurgery,ParmaUniversityHospital,Parma,Italy.7DepartmentofCSurgery,UniversityofPittsburgh,Pittsburgh,USA.8UniversityofColoradoDenver,Denver,CO80206,USA. Received:27December2013Accepted:30December2013 Published:21January2014 References1.AttarS,HankinsJR,SutterCM: Esophagealperforation:atherapeutic challenge. AnnThoracSurg 1990, 50: 45. 2.SoreidelJA,AsgaustV: ScandJtraumaEsophagealperforation:diagnostic work-upandclinicaldecision-makinginthefirst24hours. ResuscEmerg Med 2011, 19: 66. 3.FelicianoDV,BitondoCG,MattoxKL, etal : Combinedtracheoesophageal injuries. AmJSurg 1985, 150: 710 – 715.Ivatury etal.WorldJournalofEmergencySurgery 2014, 9 :9Page6of7 http://www.wjes.org/content/9/1/9

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