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Delayed Perforation of the Esophagus by a Closed Thoracostomy Tube
selected reports Delayed Perforation of the Esophagus by a Closed Thoracostomy Tube* 0;:; M. Shapira, M.D.; GabrielS. Aldea, M.D., F.C.C.P; john Kupferschmid, M.D. ; and Richard]. Shemin , M.D ., F.C.C.P
We report on a previously undocumented complication of a trocar-free thoracostomy tube-delayed perforation of a normal esophagus. The complication presented clinically with fever and copious enteric drainage four days after thoracostomy tube insertion. Diagnosis was established by a contrast study of the esophagus. Retrospectively, the postinsertion chest radiograph showed the offending thoracostomy tube tip impinging on the posterior mediastinum, displacing an indwelling nasogastric tube. Early recognition and repositioning of the thoracostomy tube is the key in preventing this rare but serious complication. (Chest 1993; 104:1897-98) losed thoracostomy tube is frequently indicated in the management of blunt and penetrating chest trauma, and is often a life-saving pmcedme. However, it is associated with a variety of complications.' We herein report another potential complication of a trocar-free closed thoracostomy tube-delayed perforation of a normal esophagus in a patient with multiple trauma.
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Fl<:l•RF. I. Chest radiograph performed after placement of tht• third thoracostomy tuhe. The tip of this tube is impinging on the rmm .:3c1m • the na_~ogastric h1 hc .
CASE REPORT
A 25-year-old male patient was transferred to our facility IR h following a motor vehicle accident. He was an unrestrained driver of a car who lost control and struck a telephone pole at high speed. On presentation, the patient was in hypovolemic shock with multiple blunt injuries. These included severe head trauma (Glasgow coma score of 4), multiple rih fradures with a right flail chest and hemothorax, ahdominal trauma with a positive peritoneal lavage , and multiple pelvic fractures. A right-sided chest tuhe that had been placed at an outlying facility drained a total of 4,500 ml of hi~ hy the time he arrived. Lahoratory data were notable for severe <.~Jagulopathy. A chest radiograph showed multiple rightsided rib fradures, a right hemopneumothorax, and a normal mediastinum. Following aggressive resuscitation, a right exploratory thoracotomy was performed . A large clot was evacuated from the right hemithorax . The posterior diaphragm was noted to he avulsed from the chest wall with the bleeding arising from the retroperitoneum. No other abnormality was encountered in the thorax and the mediastinum was noted to he free of injury or hematoma. Two large chest tubes (32 Fr) were placed . Tht> patient then underwent an exploratory laparotomy at which time a ruptured spleen was resected , a tear in the retrohepatie vena cava was repaired , lacerations of the liver were drained , and the right hemidiaphragm was reattached to the chest wall. Postoperatively, the chest tubes <-•mtinued to drain approximately 400 ml of hi~ per hour. Twelve hours later, despite persistent *From the Department of Cardiothoracic Surgery, The University Hospital, Boston. Reprint reque.~s: Dr. Aldea , Department of Cardiothoracic Surgery, 88 F.ast Newton, Boston 02118-2.39.3
Flr:liRF. 2. Barium esophagogram demonstrating impingement of the chest tube on the midesophagus with displacement of the nasogastrie tube . There is a free perforation at the tip of the thora<..,stomy tube with the <-•mtrast material heing <-• lmpletely drained by the tuht•. CHEST I 104 I 6 I DECEMBER, 1993
1897
and a follow-up harinm study showed the healed perli>ration site with no leak or strietnre (Fig 3). 0tSCUSSION
Fu;nu-: :3. Follow-up harinm esophagogram demonstrating the healed perli>ration site (armrc) with no leak or stricture. magulopath): the chest tnhe output w:L~ markedly reduced with reacemnnlation of the hemothor:L\. A third right d1t~st tuhe was inserted via the sixth intermstal spact• at the :Ulterior axillan· line \\ithont the use of a trocar, effeetivdy evacuating the effusion (Fig I). Tlu· patient's condition was stahle until the fourth postoperative day when his temperature rose to 39.6°C, associated with u>pious enteric-like drainage from the last chest tuhe. Methylene hlne that was injt•ded into the nasogastric tuhe selectively stained the third ehest tuhe <"llluent. A harium t•sophagogram confirmed a midt'sophageal rwrforation at the tip of the chest tuhe that was placed postoperatively (Fig 2). Because of the patienf~ critical status and exll'nsive nature of his injuries (particularly the severe head trauma), a const·n·ativt• therapeutic approach was selected. The tnhe was pullt•d hack 2 em to prevent further injury to the esophagus, hut to allow t•lfeetin· drainagt•. In addition, hroad-spectrnm intravenous antibiotics and total parenteral hyperalirnentation were administered. Fi>nr weeks later, the drainage from that chest tuhe ceased, 1898
The complications of tube thoracostomy can be divided into two categories: (1) technical, and (2) infectious. The technical complications can he further subdivided into the following: (a) inadequatt• function as a result of malposition or undersuction/oversuction , and (h) injury to chest wall structures, and intrathoracic or intra-abdominal viscera.,_, In the latter category, injury to the intercostal vessels is the most common, followed by laceration of the lung, diaphragm, stomach, liver, and spleen.' ·' We were unable to find any previous reports 011 perforation of a normal esophagus by a thoracostomy tube. Johnson and Wright' described disruption of esophageal anastomosis and myotomy site by a chest tube in two pediatric surgical patients following repair of esophageal atresia. The pathogenesis of the delayed perforation involves, most likely, direct contact between the rigid thoracostomy tube tip and the esophagus. We suggest that the continuous pressure, augmented by tht• stiff indwelling nasogastric tube, and motion of the thoracostomy tube with respiration and heart beat, eventually lead to the limnation of decubitus erosion and frank perforation. This mechanism may be similar to the development of tracheoesophageal fistula in patients with tracheostomy and indwelling nasogastric tube . Esophageal perforation should he considered whenever thoracostomy tube drainage assumes entt•ric character and is confirmed by an esophageal contrast study. Impingement on the mediastinum by the thoracostomy tube was noted in our patient on postinsertion chest radiograph. \Ve were previously unaware that such tube position can result in any (.'()mplication, and therefi>re we did not change the position of a well-functioning thoracostomy tube . This, undoubtedly, would have prevented the perforation in this patient. The therapeutic approach should be individualized, based primarily on the time interval between the diagnosis and treatment and comorbid risk factors.' Options include drainage, diversion, primary repair, and resection. Broad-spectrum antibiotics and adequate nutritional support are an integral part of any treatment regimen.' In conclusion, we suggest that a posteriorly placed thoracostomy tube impinging on the mediastinum can result in esophageal perforation. Increased awareness and recognition of the radiographic appearance of such thoracostomy tube malposition should result in prompt tube reposition to prevent this serious complication. REFERENCES
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5
Millikan JS, Moore EF. Steiner E. t•t al. Complications of tuhe thoramstorny fi>r acute trauma . Am J Surg l91l0; l40:731l-4l Miller KS, Salm SA. Chest tubes; indications teehni!Jue, management and mmplications. Chest 191l7; 91 :25/l-64 Helling TS, Gyles NR Ill, Eisenstein CL, Soracm CA. Complications following blunt and penetrating injuries in 216 vietims of chest trauma re!Juiring tnhe thorat,>Stomy. J Trauma 1989; 29: 1367-70 Johnson JF, \Vright DR. Chest tube perfimttion of esophagus fi•llowing repair of esophageal atresia. J Pediatr Surg 1990; 25: 1227-30 Jones \VJ II , Cinsherg RJ. Esophageal perforation; a continuing challenge. Ann Thorac Surg 1992; 53;5.'34-43 Delayed Perforation of the Esophagus (Shapira eta/)
We report on a previously undocumented complication of a trocar-free thoracostomy tube-delayed perforation of a normal esophagus. The complication presented clinically with fever and copious enteric drainage four days after thoracostomy tube insertion. Diagnosis was established by a contrast study of the esophagus. Retrospectively, the postinsertion chest radiograph showed the offending thoracostomy tube tip impinging on the posterior mediastinum, displacing an indwelling nasogastric tube. Early recognition and repositioning of the thoracostomy tube is the key in preventing this rare but serious complication. (Chest 1993; 104:1897-98) losed thoracostomy tube is frequently indicated in the management of blunt and penetrating chest trauma, and is often a life-saving pmcedme. However, it is associated with a variety of complications.' We herein report another potential complication of a trocar-free closed thoracostomy tube-delayed perforation of a normal esophagus in a patient with multiple trauma.
C
Fl<:l•RF. I. Chest radiograph performed after placement of tht• third thoracostomy tuhe. The tip of this tube is impinging on the rmm .:3c1m • the na_~ogastric h1 hc .
CASE REPORT
A 25-year-old male patient was transferred to our facility IR h following a motor vehicle accident. He was an unrestrained driver of a car who lost control and struck a telephone pole at high speed. On presentation, the patient was in hypovolemic shock with multiple blunt injuries. These included severe head trauma (Glasgow coma score of 4), multiple rih fradures with a right flail chest and hemothorax, ahdominal trauma with a positive peritoneal lavage , and multiple pelvic fractures. A right-sided chest tuhe that had been placed at an outlying facility drained a total of 4,500 ml of hi~ hy the time he arrived. Lahoratory data were notable for severe <.~Jagulopathy. A chest radiograph showed multiple rightsided rib fradures, a right hemopneumothorax, and a normal mediastinum. Following aggressive resuscitation, a right exploratory thoracotomy was performed . A large clot was evacuated from the right hemithorax . The posterior diaphragm was noted to he avulsed from the chest wall with the bleeding arising from the retroperitoneum. No other abnormality was encountered in the thorax and the mediastinum was noted to he free of injury or hematoma. Two large chest tubes (32 Fr) were placed . Tht> patient then underwent an exploratory laparotomy at which time a ruptured spleen was resected , a tear in the retrohepatie vena cava was repaired , lacerations of the liver were drained , and the right hemidiaphragm was reattached to the chest wall. Postoperatively, the chest tubes <-•mtinued to drain approximately 400 ml of hi~ per hour. Twelve hours later, despite persistent *From the Department of Cardiothoracic Surgery, The University Hospital, Boston. Reprint reque.~s: Dr. Aldea , Department of Cardiothoracic Surgery, 88 F.ast Newton, Boston 02118-2.39.3
Flr:liRF. 2. Barium esophagogram demonstrating impingement of the chest tube on the midesophagus with displacement of the nasogastrie tube . There is a free perforation at the tip of the thora<..,stomy tube with the <-•mtrast material heing <-• lmpletely drained by the tuht•. CHEST I 104 I 6 I DECEMBER, 1993
1897
and a follow-up harinm study showed the healed perli>ration site with no leak or strietnre (Fig 3). 0tSCUSSION
Fu;nu-: :3. Follow-up harinm esophagogram demonstrating the healed perli>ration site (armrc) with no leak or stricture. magulopath): the chest tnhe output w:L~ markedly reduced with reacemnnlation of the hemothor:L\. A third right d1t~st tuhe was inserted via the sixth intermstal spact• at the :Ulterior axillan· line \\ithont the use of a trocar, effeetivdy evacuating the effusion (Fig I). Tlu· patient's condition was stahle until the fourth postoperative day when his temperature rose to 39.6°C, associated with u>pious enteric-like drainage from the last chest tuhe. Methylene hlne that was injt•ded into the nasogastric tuhe selectively stained the third ehest tuhe <"llluent. A harium t•sophagogram confirmed a midt'sophageal rwrforation at the tip of the chest tuhe that was placed postoperatively (Fig 2). Because of the patienf~ critical status and exll'nsive nature of his injuries (particularly the severe head trauma), a const·n·ativt• therapeutic approach was selected. The tnhe was pullt•d hack 2 em to prevent further injury to the esophagus, hut to allow t•lfeetin· drainagt•. In addition, hroad-spectrnm intravenous antibiotics and total parenteral hyperalirnentation were administered. Fi>nr weeks later, the drainage from that chest tuhe ceased, 1898
The complications of tube thoracostomy can be divided into two categories: (1) technical, and (2) infectious. The technical complications can he further subdivided into the following: (a) inadequatt• function as a result of malposition or undersuction/oversuction , and (h) injury to chest wall structures, and intrathoracic or intra-abdominal viscera.,_, In the latter category, injury to the intercostal vessels is the most common, followed by laceration of the lung, diaphragm, stomach, liver, and spleen.' ·' We were unable to find any previous reports 011 perforation of a normal esophagus by a thoracostomy tube. Johnson and Wright' described disruption of esophageal anastomosis and myotomy site by a chest tube in two pediatric surgical patients following repair of esophageal atresia. The pathogenesis of the delayed perforation involves, most likely, direct contact between the rigid thoracostomy tube tip and the esophagus. We suggest that the continuous pressure, augmented by tht• stiff indwelling nasogastric tube, and motion of the thoracostomy tube with respiration and heart beat, eventually lead to the limnation of decubitus erosion and frank perforation. This mechanism may be similar to the development of tracheoesophageal fistula in patients with tracheostomy and indwelling nasogastric tube . Esophageal perforation should he considered whenever thoracostomy tube drainage assumes entt•ric character and is confirmed by an esophageal contrast study. Impingement on the mediastinum by the thoracostomy tube was noted in our patient on postinsertion chest radiograph. \Ve were previously unaware that such tube position can result in any (.'()mplication, and therefi>re we did not change the position of a well-functioning thoracostomy tube . This, undoubtedly, would have prevented the perforation in this patient. The therapeutic approach should be individualized, based primarily on the time interval between the diagnosis and treatment and comorbid risk factors.' Options include drainage, diversion, primary repair, and resection. Broad-spectrum antibiotics and adequate nutritional support are an integral part of any treatment regimen.' In conclusion, we suggest that a posteriorly placed thoracostomy tube impinging on the mediastinum can result in esophageal perforation. Increased awareness and recognition of the radiographic appearance of such thoracostomy tube malposition should result in prompt tube reposition to prevent this serious complication. REFERENCES
2 3
4
5
Millikan JS, Moore EF. Steiner E. t•t al. Complications of tuhe thoramstorny fi>r acute trauma . Am J Surg l91l0; l40:731l-4l Miller KS, Salm SA. Chest tubes; indications teehni!Jue, management and mmplications. Chest 191l7; 91 :25/l-64 Helling TS, Gyles NR Ill, Eisenstein CL, Soracm CA. Complications following blunt and penetrating injuries in 216 vietims of chest trauma re!Juiring tnhe thorat,>Stomy. J Trauma 1989; 29: 1367-70 Johnson JF, \Vright DR. Chest tube perfimttion of esophagus fi•llowing repair of esophageal atresia. J Pediatr Surg 1990; 25: 1227-30 Jones \VJ II , Cinsherg RJ. Esophageal perforation; a continuing challenge. Ann Thorac Surg 1992; 53;5.'34-43 Delayed Perforation of the Esophagus (Shapira eta/)