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Perforation of the Esophagus from External Trauma or Blast Injuries
Perforation of the Esophagus from External Trauma or Blast Injuries* HoWELL RANDOLPH, M.D., F.c.c.P., DERMONT W. MELicK, M.D., F.c.c.P., AND AUSTIN R. GRANT, M.D., F.C.C.P.
Phoenix, Arizona
E
of the esophagus by pressure from an already overdistended stomach. The site is usually at the lower end of the esophagus on the left where there are longitudinal muscle fibers in the external coat, a layer of circular fibers and a few longitudinal muscle fibers in the mucosa muscularis. The weakest point is just above the cardia and since the esophagus deviates to the left as it approaches the diaphragm, vomitus or pressure from below impinge directly on the left esophageal wall. At this point, the left side is less protected by mediastinal tissues than the right. The violent ascent and descent of the diaphragm would appear to have something to do with the pressure relationship and in one case, a complete evulsion of the esophagus just above the diaphragm was discovered. In most cases, the rupture is in the form of a longitudinal tear. Diagnosis: Since immediate surgical intervention is known to produce the highest percentage of satisfactory results, the importance of making an early diagnosis is recognized. The most common presenting symptom is severe retrosternal and upper abdominal pain radiating to the left back, shortly after vomiting. There is rapidly increasing interscapular pain with simultaneous dyspnea and cyanosis and marked increase in the pulse rate. Often these symptoms are interpreted as indicating an acute coronary occlusion. Abdominal rigidity develops and emphysema appearing in the neck after several hours is present in 50 per cent of the reported cases. If emphysema does occur, or the rupture is suspected, x-ray films taken after contrast medium is swallowed will give the unequivocal diagnosis. This may be positive even before a significant amount of fluid
XTERNAL TRAUMA OR BLAST INJURIES
causing rupture of the esophagus have been reported only rarely. In this discussion we will review briefly the development of recurrent important factors relating to concepts of causes and treatment of esophageal perforation and report two cases which illustrate blast or external trauma injuries which may be met more frequently in the industrial and space age ahead of us. Rupture of the esophagus due to traumatic in jury was described in the Smith Papyrus in 1800 B.C. 1 The wound in the cervical esophagus was "drawn together with stitching." "Spontaneous" or "traumatic" rupture of the thoracic esophagus was a very serious condition and until about 20 years ago most cases were fatal .... Prior to 1947, those who survived did so after surgical drainage of the pleural cavity, with the attendant esophagocutaneous fistula and long invalidism. In 194 7, Olsen and Clagett' and Barrett' each reported a case of "spontaneous" rupture successfully repaired. In 1945, Cram et af collected 53 cases of the so-called "spontaneous" perforation of the esophagus. Vomiting was the initiating factor. Fortyfour per cent had histories of peptic ulcer. Alcoholism was noted in 12 cases. Fortyseven were over 40 years of age and 80 per cent were men. Eighty-four per cent were on the left side just above the diaphragm. Moynihan10 reviewed the history of 200 cases reported up to 1954. He suggested the term "pressure perforation" as more accurate than "spontaneous rupture," inasmuch as perforation of the esophageal wall results from oveJWhelming distention *Presented at the IX International Congress on Diseases of the Chest, Copenhagen, August 2025, 1966.
121
122
Diseases of
RANDOLPH, MEUCK AND GRANT
appears in the chest, but hydrothorax may develop rapidly, pneumothorax seldom. If pneumothorax is present, some other pathology may be present to account for it. Upper abdominal emergencies such as ruptured viscus, gastric ulcer, diaphragmatic rupture, acute pancreatitis or other condition must be considered. "Spontaneous" rupture has been found in children but rarely. Treatment: Whether seen early or several days after rupture, the treatment calls for immediate surgical exploration and repair if possible and in any event, drainage. The acute early symptoms with shock, circulatory failure, with rapid pulse, cyanosis and intractable pain often lead to death if untreated. If shock is present, the best course is to start appropriate measures, to apply gastric suction and to prepare for immediate surgery. The shock is in part due to the chemical effect upon the mediastinal tisrue andjor absorption into the circulation of undigested food material causing a foreign protein reaction. Primary repair will be possible if the rupture is less than 20 hmm old and may be possible even after a week or more. In case of more extensive injury, cleansing irrigations, with adequate thoracic tube drainage may be the best approach. A gastrostomy is established and control of infection is facilitated by antibiotics. If the rupture can be repaired, esophageal rest ~ accomplished by Levine tube feeding for several days, especially in older individuals. Five cases of perforation of the esophagus were encountered and in each instance, recovery followed primary repair. Small fistulae required surgical drainage of the chest for several weeks in two of these, but complete functional restoration of the esophagus and diaphragm resulted in each. Three cases had complete primary healing of the esophagus. Air blast or external trauma was the etiology in two of our cases which will be reported with detail, because of the unusual nature of the circumstances causing the rupture.
tM Chat
CASE
REPORTS
CAsE 1 R.A, a two-year-old boy, was admitted to the hospital having sustained a blast of air at the oropharynx which caused esophagea I injury. The child was playing beside an inflated truck tire from which a blister of inner tube extruded from a defect in the casing. He bit the blister which exploded and he was rendered unconscious. On admission to the hospital, blood was coming from the nose and mouth, there was a laceration of the pharynx and marked swelling with crepitation of the tissues of the neck and face, indicating extensive subcutaneous emphysema of the neck, over the chest, in the arms to the crest of the ileum. There was very little dyspnea. The heart rate was 140 with no murmun. The abdomen was nonnal, except for crepitation. The extensive emphysema so soon after the injury was interpreted as due to the direct effect of the blast. Sedation, ftuids and oxygen were administered. Seven houn after admission, the respirations became embarrassed and a tracheotomy was performed. The following morning, iodized oil (Lipiodol) study of the esophagus disclosed a defect with contrast medium passing out of the esophagus to the left behind the cardiac shadow at the level of the eighth vertebra. There was no pneumothorax and the lung fields were clear. Left thoracotomy was perfonned 21 hours after the accident. Retraction of the left lung revealed a pocket of yellow-white material in the retropleural space. With a Levine tube identifying the esophagus, the perforation extended from just above the diaphragm to near the arch of the aorta. The mucosa was sutured with triple 0 continuous chromic. The muscularis was approximated with a second layer of interrupted triple 0 chromic sutures. The mediastinal pleura was loosely approximated. Pleural drainage was provided by way of catheters through two stab wounds. The postoperative course was stonny for the fint seven days, characterized by a high irregular fever. The pleural space was irrigated frequently and antibiotics were instilled daily. Small Levine tube feedings were started on the third day. Esophagogram demonstrated no leak in the esophagus. The Levine tube was removed on the fifth day and oral feedings were initiated. The chest tubes were removed on the tenth day and the tracheal canula was removed on the 16th day, alleviating the cough. He was discharged on the 26th postoperative day.
Blast injury: No reports of determination of air pressure tolerance of the esophagus have been found, but MacKenzieu determined that five to ten pounds of hydrostatic pressure are sufficient to disrupt
Volume 51, No. 2 February, 1967
123
PERFORATION OF THE ESOPHAGUS
the cadaver esophagus. He reported perforation of the lower third in most instances. The literature records two previous cases of ruptured esophagus caused by compressed air blast. The first, by Petren, 11 was discovered at post-mortem. The patient fell while holding a compressed air tube in his mouth. The second, by Kerr:• was theresult of an accident identical to the one detailed herein. Quoted case repon:•• A white boy, aged three, was admitted to the University Hospital, Ann Arbor, Michigan, with a history of having bitten the projecting bleb of a rubber inner tub three hours before. The pressure was believed to have been between 25 and 30 pounds per square inch. The patient ran crying into the house, coughing blood. There was emphysema of the tissues of the upper chest and neck with increasing dyspnea. Two small stab wounds were made in the neck by the home physician to let out air. The temperature was 103° F, pulse 112, respirations 32. The blood pressure was 84/60. Subcutaneous emphysema progressed until the left eye was completely shut. The mouth, nose and pahrynx were normal. The trachea and mediastinum were displaced to the right. Chest x-ray film revealed total collapse of the left lung. An intercostal tube was introduced and dyspnea was relieved. Stomach contenu were identified in the chest drainage bottle. Iodized oil ( Lipiodol) swallow demonstrated a perforation 6 em. above the cardia. Open repair of the esophagus was not done because of the patient's poor condition. Two intercostal tubes were utilized. One was removed five days later. The patient's nutrition and fluids were maintained by intravenous feeding, plus stomach feeding for 16 days. A gastrotomy was then perfonned. The empyema drainage ceased in 40 days.
These two similar cases suggest that air pressure of 25 to 30 pounds will cause rupture of the esophagus when applied at the oropharynx, rather than the tracheo-bronchial structures. In case 1 the pressure was rapid enough and high enough to perforate the pleura, but not in the other. Fentonu described a fatal stomach perforation in an adult when a nasal catheter, inserted by the anesthetist into the upper esophagus, slowly blew up the stomach. Gain1• reported a similar case. Oxygen administration to the newborn has caused stomach rupture in several other reported cases.'f-1•
Cole and Burcher11 report stomach rupture by oxygen. into the thoracic esophagus and a case of blast injury to the oropharynx rupturing the esophagus. Both were successfully repaired and they postulated that "when there is a sudden rapid rise in pressure in the mouth, the presmre is transmitted to the laryngo-pharynx causing a reflex closure of the glottis. As the crico-pharyngeous gives way it gives a rise to a sudden distention of the esophagus. The cardia fails to relax as it does in the slower acting of swallowing and the dilated esophagus ruptures." Similarly, when there is a sudden rise of pressure at the lower end of the foregut as with vomiting and with abdominal crushing in juries, the cardia may give way and since the upper end of the esophagus is closed, it distends and ruptures at the point where the supporting structures are the weakest, the lower left side. CAsE2 A 24-year-old man sustained an injury to the left side of the chest and upper abdomen in an auto accident. Seven days later, after transfer from another hospital, the injury was disclosed to include fractures of ribs, four, five, six, seven, eight and nine and ten in two places, also 11 and 12. Also injured was the dome of the diaphragm, with spleen, colon and stomach displaced into the chest. At operation the spleen and the tail of the pancreas were removed, a small perforation in the transverse colon was repaired and a six inch perforation of the lower end of the esophagus was repaired with a double layer of triple 0 catgut over a Levine tube. Primary healing was obtained, but a week later a pyloroplasty was done for signs of obstruction and six months later an esophagogastric tion was necessary because of increasing stenosis of the esophagus at the point of repair. A good end result was obtained. SUMMARY
Since this type of in jury is likely to become more common, it is necessary to keep its occurrence in mind in all cases of lower chest and upper abdominal trauma. We have pointed out the similarities and differences in rupture of the esophagus from pressure perforation of vomiting, blast and external trauma. Earlier diagnosis depends chiefly on an awareness of the possibility of esophageal involvement, and it should
RANDOLPH, MELICK AND GRANT
be a part of every examination when injuries in the area are sustained. The diagnosis is easily established and treatment by surgical repair is usually successful. REsuMEN Es preciso tomar en cuenta Ia posibilidad de desgarro esofagico en todos los casos de traumatismo intenso del abdomen superior o regi6n inferior del t6rax. Hemos seiialado las similitudes y diferencias de esta entidad con Ia perforaci6n a presi6n debida a v6mito, explosi6n o traumatismo extemo. El diagn6stico precoz depende mucho del indice de sospecha, por lo que es preciso tener siempre en cuenta esa posibilidad en presencia de lesiones traumaticas del area esofagica. El diagn6stico no es dificil de establecer y el tratamiento quinlrgico suele ser efectivo. ZUSAMMENFASSUNG Nachdem dieser Typ der Unfallfolge vergleichsweise haufiger auftritt, ist es erforderlich, sein Vorkommen bei allen Fallen eines Traumas der unteren Throax und oberen abdominalen Bereiche in Erinnerung und oberen abdominalen Bereiche. Wir haben die Ahnlichkeiten und Differenzen in der Ruptur des Oesophagus von einer Druckperforation nach Erbrechen und iusserem Trauma herausgestellt. Eine Friihdiagnose hingh hauptsichlich davon ab, daP man an die Moglichkeit eines Betroffenseins der Speiserohre denkt und das muP ein Teil einer jeden Untersuchung werden, wenn Schidigungen in dem erwihnten Bereich anzunehmen sind Die Diagnose ist Ieicht zu bestitigen, und eine Behandlung auf chirurgischem Wege ist gewohnlich von Erfolg begleitet. REFERENCES BREASTED, J.: Th• Edwin Smith Pappru, Univ. of Chicago Press, 1930. 2 DARaEs, V. 1. AND MITCHELL, R. E. jR.: "Rupture of the esophagus," Surg•ry. 39: 865, 1956.
Diseases of the Chest
3 KINSELLA, T. J., MORSE, R. w. AND HERTZOG, A. J.: "Spontaneous rupture of the esophagus," J. Thor. Surg., 17:613, 1948. 4 STARKEY, G. W. jR.: "Spontaneow rupture of the esophagus," J. Thor. Surg., 30:3, 1965. 5 Picx, M. E. .urn LIDDLE, E. B., jR.: "Spontaneous rupture of the esophagus," Roeky Mountain M•d. ] .• 23:27, 1955. 6 ANDERSON, R. L. JR.: "Rupture of the esophagus," ]. Thor. Surg., 24:369, 1952. 7 OLsEN, A. M. AND CLAGETT, 0. T.: ''Spontaneous rupture of the esophagus," Postgrtul. M•d., 2:417, 1947. 8 BARRETT. N. R. : ''Report of case of spontaneow perforation of oesophagus s u c c eu f u II y treated by operation," Brit. ]. Surg., 35:216, 1947. 9 Ca.ur, R. M., BRADT, D. J. AND PosTON, F. T.: "Two cases of spontaneow rupture of the esophagus," Canad. M•d. ] .• 71:250, 1954. 10 MoYNIHAN, N. H.: ''Ruptured esophagus," Laned, 2: 728, 1954. 11 PR.JVJTERJ, C. A. AND GAY, B. B. jR.: Spontaneous rupture of the esophagus with report of five cues," Radiplogy. 57 : 48, 1951. 12 KERR, M.: ''Determination of the hydrostatic pressure necessary to rupture of the esophagus," Dis. Nos•. Throat and Ear, 1884. 13 PETREN, G.: "Ein fall van traumatiacher oesophagus rupture, nebst bermerkungen iiber die entstelung der oesophagus rupturen," B•itr. z. Klin. Chir., 61:265, 1908. 14 KERR, H. H., SLOAN, H. AND O'BRIEN, c. E.: "Rupture of the esophagus by compreaed air," Surg., 33:417, 1953. 15 FENTON, E. S. N.: ''Danger of nasal catheter wed as means of oxygenation postoperatively," Brit. ]. Anusth., 28:220, 1956. 16 GAIN, E. A.: "Pneumoperitoneum; a complication of nasal oxygen therapy: A case report," Canad. Anusth. Soe. ] .• 5:7, 1958. 17 PENDERGRAss, E. P. AND BooTH, R. E.: ''Reportative case of ruptured stomach in infant three days old,'" A mer. ]. Ro•ntg•nol., 56: 590, 1946. 18 MussER, H. H.: "Etiology of rupture of stomach in newborn,'" Ohio M•d. ] .• 52:838, 1956. 19 COLE, D. S. AND BuRCHER, S. K.: "Accidental pneumatic rupture of esophagus and stomach, Laneet. 1 : 1961. For reprints, please write: Dr. Randolph, 909 East Brill, Phoenix.
VENTILATION FOLLOWING OPERATIONS with no apparent reduction In lung volume. In paThe dlstrtbutlon of ventllatlon before and after tients with chronic lung disease upper abdominal common abdomlnal and thoracic operations was operations were performed without reducing the studied In 27 patients by a 2 balloon. open circuit uniformity of air-mixing. An operation of a lesser nitrogen washout technique. After pulmonary resecmagnitude such as a routine Inguinal hemla repair tion In patients with relatively normal lungs, there had no appreciable effect on thls aspect of pulmowas a measurable Improvement In distribution of nary function. ventilation concomitant with a reduction In lung volOKJNAKA, A. ].: "The distribution of ventilation follow· ume. In resections for bullous emphysema there was ing operations.'' S•rg. G1"''" ••tl Oluul., 12~: 6,, 1966. definite Improvement In Intrapulmonary alNDlxiDg
Phoenix, Arizona
E
of the esophagus by pressure from an already overdistended stomach. The site is usually at the lower end of the esophagus on the left where there are longitudinal muscle fibers in the external coat, a layer of circular fibers and a few longitudinal muscle fibers in the mucosa muscularis. The weakest point is just above the cardia and since the esophagus deviates to the left as it approaches the diaphragm, vomitus or pressure from below impinge directly on the left esophageal wall. At this point, the left side is less protected by mediastinal tissues than the right. The violent ascent and descent of the diaphragm would appear to have something to do with the pressure relationship and in one case, a complete evulsion of the esophagus just above the diaphragm was discovered. In most cases, the rupture is in the form of a longitudinal tear. Diagnosis: Since immediate surgical intervention is known to produce the highest percentage of satisfactory results, the importance of making an early diagnosis is recognized. The most common presenting symptom is severe retrosternal and upper abdominal pain radiating to the left back, shortly after vomiting. There is rapidly increasing interscapular pain with simultaneous dyspnea and cyanosis and marked increase in the pulse rate. Often these symptoms are interpreted as indicating an acute coronary occlusion. Abdominal rigidity develops and emphysema appearing in the neck after several hours is present in 50 per cent of the reported cases. If emphysema does occur, or the rupture is suspected, x-ray films taken after contrast medium is swallowed will give the unequivocal diagnosis. This may be positive even before a significant amount of fluid
XTERNAL TRAUMA OR BLAST INJURIES
causing rupture of the esophagus have been reported only rarely. In this discussion we will review briefly the development of recurrent important factors relating to concepts of causes and treatment of esophageal perforation and report two cases which illustrate blast or external trauma injuries which may be met more frequently in the industrial and space age ahead of us. Rupture of the esophagus due to traumatic in jury was described in the Smith Papyrus in 1800 B.C. 1 The wound in the cervical esophagus was "drawn together with stitching." "Spontaneous" or "traumatic" rupture of the thoracic esophagus was a very serious condition and until about 20 years ago most cases were fatal .... Prior to 1947, those who survived did so after surgical drainage of the pleural cavity, with the attendant esophagocutaneous fistula and long invalidism. In 194 7, Olsen and Clagett' and Barrett' each reported a case of "spontaneous" rupture successfully repaired. In 1945, Cram et af collected 53 cases of the so-called "spontaneous" perforation of the esophagus. Vomiting was the initiating factor. Fortyfour per cent had histories of peptic ulcer. Alcoholism was noted in 12 cases. Fortyseven were over 40 years of age and 80 per cent were men. Eighty-four per cent were on the left side just above the diaphragm. Moynihan10 reviewed the history of 200 cases reported up to 1954. He suggested the term "pressure perforation" as more accurate than "spontaneous rupture," inasmuch as perforation of the esophageal wall results from oveJWhelming distention *Presented at the IX International Congress on Diseases of the Chest, Copenhagen, August 2025, 1966.
121
122
Diseases of
RANDOLPH, MEUCK AND GRANT
appears in the chest, but hydrothorax may develop rapidly, pneumothorax seldom. If pneumothorax is present, some other pathology may be present to account for it. Upper abdominal emergencies such as ruptured viscus, gastric ulcer, diaphragmatic rupture, acute pancreatitis or other condition must be considered. "Spontaneous" rupture has been found in children but rarely. Treatment: Whether seen early or several days after rupture, the treatment calls for immediate surgical exploration and repair if possible and in any event, drainage. The acute early symptoms with shock, circulatory failure, with rapid pulse, cyanosis and intractable pain often lead to death if untreated. If shock is present, the best course is to start appropriate measures, to apply gastric suction and to prepare for immediate surgery. The shock is in part due to the chemical effect upon the mediastinal tisrue andjor absorption into the circulation of undigested food material causing a foreign protein reaction. Primary repair will be possible if the rupture is less than 20 hmm old and may be possible even after a week or more. In case of more extensive injury, cleansing irrigations, with adequate thoracic tube drainage may be the best approach. A gastrostomy is established and control of infection is facilitated by antibiotics. If the rupture can be repaired, esophageal rest ~ accomplished by Levine tube feeding for several days, especially in older individuals. Five cases of perforation of the esophagus were encountered and in each instance, recovery followed primary repair. Small fistulae required surgical drainage of the chest for several weeks in two of these, but complete functional restoration of the esophagus and diaphragm resulted in each. Three cases had complete primary healing of the esophagus. Air blast or external trauma was the etiology in two of our cases which will be reported with detail, because of the unusual nature of the circumstances causing the rupture.
tM Chat
CASE
REPORTS
CAsE 1 R.A, a two-year-old boy, was admitted to the hospital having sustained a blast of air at the oropharynx which caused esophagea I injury. The child was playing beside an inflated truck tire from which a blister of inner tube extruded from a defect in the casing. He bit the blister which exploded and he was rendered unconscious. On admission to the hospital, blood was coming from the nose and mouth, there was a laceration of the pharynx and marked swelling with crepitation of the tissues of the neck and face, indicating extensive subcutaneous emphysema of the neck, over the chest, in the arms to the crest of the ileum. There was very little dyspnea. The heart rate was 140 with no murmun. The abdomen was nonnal, except for crepitation. The extensive emphysema so soon after the injury was interpreted as due to the direct effect of the blast. Sedation, ftuids and oxygen were administered. Seven houn after admission, the respirations became embarrassed and a tracheotomy was performed. The following morning, iodized oil (Lipiodol) study of the esophagus disclosed a defect with contrast medium passing out of the esophagus to the left behind the cardiac shadow at the level of the eighth vertebra. There was no pneumothorax and the lung fields were clear. Left thoracotomy was perfonned 21 hours after the accident. Retraction of the left lung revealed a pocket of yellow-white material in the retropleural space. With a Levine tube identifying the esophagus, the perforation extended from just above the diaphragm to near the arch of the aorta. The mucosa was sutured with triple 0 continuous chromic. The muscularis was approximated with a second layer of interrupted triple 0 chromic sutures. The mediastinal pleura was loosely approximated. Pleural drainage was provided by way of catheters through two stab wounds. The postoperative course was stonny for the fint seven days, characterized by a high irregular fever. The pleural space was irrigated frequently and antibiotics were instilled daily. Small Levine tube feedings were started on the third day. Esophagogram demonstrated no leak in the esophagus. The Levine tube was removed on the fifth day and oral feedings were initiated. The chest tubes were removed on the tenth day and the tracheal canula was removed on the 16th day, alleviating the cough. He was discharged on the 26th postoperative day.
Blast injury: No reports of determination of air pressure tolerance of the esophagus have been found, but MacKenzieu determined that five to ten pounds of hydrostatic pressure are sufficient to disrupt
Volume 51, No. 2 February, 1967
123
PERFORATION OF THE ESOPHAGUS
the cadaver esophagus. He reported perforation of the lower third in most instances. The literature records two previous cases of ruptured esophagus caused by compressed air blast. The first, by Petren, 11 was discovered at post-mortem. The patient fell while holding a compressed air tube in his mouth. The second, by Kerr:• was theresult of an accident identical to the one detailed herein. Quoted case repon:•• A white boy, aged three, was admitted to the University Hospital, Ann Arbor, Michigan, with a history of having bitten the projecting bleb of a rubber inner tub three hours before. The pressure was believed to have been between 25 and 30 pounds per square inch. The patient ran crying into the house, coughing blood. There was emphysema of the tissues of the upper chest and neck with increasing dyspnea. Two small stab wounds were made in the neck by the home physician to let out air. The temperature was 103° F, pulse 112, respirations 32. The blood pressure was 84/60. Subcutaneous emphysema progressed until the left eye was completely shut. The mouth, nose and pahrynx were normal. The trachea and mediastinum were displaced to the right. Chest x-ray film revealed total collapse of the left lung. An intercostal tube was introduced and dyspnea was relieved. Stomach contenu were identified in the chest drainage bottle. Iodized oil ( Lipiodol) swallow demonstrated a perforation 6 em. above the cardia. Open repair of the esophagus was not done because of the patient's poor condition. Two intercostal tubes were utilized. One was removed five days later. The patient's nutrition and fluids were maintained by intravenous feeding, plus stomach feeding for 16 days. A gastrotomy was then perfonned. The empyema drainage ceased in 40 days.
These two similar cases suggest that air pressure of 25 to 30 pounds will cause rupture of the esophagus when applied at the oropharynx, rather than the tracheo-bronchial structures. In case 1 the pressure was rapid enough and high enough to perforate the pleura, but not in the other. Fentonu described a fatal stomach perforation in an adult when a nasal catheter, inserted by the anesthetist into the upper esophagus, slowly blew up the stomach. Gain1• reported a similar case. Oxygen administration to the newborn has caused stomach rupture in several other reported cases.'f-1•
Cole and Burcher11 report stomach rupture by oxygen. into the thoracic esophagus and a case of blast injury to the oropharynx rupturing the esophagus. Both were successfully repaired and they postulated that "when there is a sudden rapid rise in pressure in the mouth, the presmre is transmitted to the laryngo-pharynx causing a reflex closure of the glottis. As the crico-pharyngeous gives way it gives a rise to a sudden distention of the esophagus. The cardia fails to relax as it does in the slower acting of swallowing and the dilated esophagus ruptures." Similarly, when there is a sudden rise of pressure at the lower end of the foregut as with vomiting and with abdominal crushing in juries, the cardia may give way and since the upper end of the esophagus is closed, it distends and ruptures at the point where the supporting structures are the weakest, the lower left side. CAsE2 A 24-year-old man sustained an injury to the left side of the chest and upper abdomen in an auto accident. Seven days later, after transfer from another hospital, the injury was disclosed to include fractures of ribs, four, five, six, seven, eight and nine and ten in two places, also 11 and 12. Also injured was the dome of the diaphragm, with spleen, colon and stomach displaced into the chest. At operation the spleen and the tail of the pancreas were removed, a small perforation in the transverse colon was repaired and a six inch perforation of the lower end of the esophagus was repaired with a double layer of triple 0 catgut over a Levine tube. Primary healing was obtained, but a week later a pyloroplasty was done for signs of obstruction and six months later an esophagogastric tion was necessary because of increasing stenosis of the esophagus at the point of repair. A good end result was obtained. SUMMARY
Since this type of in jury is likely to become more common, it is necessary to keep its occurrence in mind in all cases of lower chest and upper abdominal trauma. We have pointed out the similarities and differences in rupture of the esophagus from pressure perforation of vomiting, blast and external trauma. Earlier diagnosis depends chiefly on an awareness of the possibility of esophageal involvement, and it should
RANDOLPH, MELICK AND GRANT
be a part of every examination when injuries in the area are sustained. The diagnosis is easily established and treatment by surgical repair is usually successful. REsuMEN Es preciso tomar en cuenta Ia posibilidad de desgarro esofagico en todos los casos de traumatismo intenso del abdomen superior o regi6n inferior del t6rax. Hemos seiialado las similitudes y diferencias de esta entidad con Ia perforaci6n a presi6n debida a v6mito, explosi6n o traumatismo extemo. El diagn6stico precoz depende mucho del indice de sospecha, por lo que es preciso tener siempre en cuenta esa posibilidad en presencia de lesiones traumaticas del area esofagica. El diagn6stico no es dificil de establecer y el tratamiento quinlrgico suele ser efectivo. ZUSAMMENFASSUNG Nachdem dieser Typ der Unfallfolge vergleichsweise haufiger auftritt, ist es erforderlich, sein Vorkommen bei allen Fallen eines Traumas der unteren Throax und oberen abdominalen Bereiche in Erinnerung und oberen abdominalen Bereiche. Wir haben die Ahnlichkeiten und Differenzen in der Ruptur des Oesophagus von einer Druckperforation nach Erbrechen und iusserem Trauma herausgestellt. Eine Friihdiagnose hingh hauptsichlich davon ab, daP man an die Moglichkeit eines Betroffenseins der Speiserohre denkt und das muP ein Teil einer jeden Untersuchung werden, wenn Schidigungen in dem erwihnten Bereich anzunehmen sind Die Diagnose ist Ieicht zu bestitigen, und eine Behandlung auf chirurgischem Wege ist gewohnlich von Erfolg begleitet. REFERENCES BREASTED, J.: Th• Edwin Smith Pappru, Univ. of Chicago Press, 1930. 2 DARaEs, V. 1. AND MITCHELL, R. E. jR.: "Rupture of the esophagus," Surg•ry. 39: 865, 1956.
Diseases of the Chest
3 KINSELLA, T. J., MORSE, R. w. AND HERTZOG, A. J.: "Spontaneous rupture of the esophagus," J. Thor. Surg., 17:613, 1948. 4 STARKEY, G. W. jR.: "Spontaneow rupture of the esophagus," J. Thor. Surg., 30:3, 1965. 5 Picx, M. E. .urn LIDDLE, E. B., jR.: "Spontaneous rupture of the esophagus," Roeky Mountain M•d. ] .• 23:27, 1955. 6 ANDERSON, R. L. JR.: "Rupture of the esophagus," ]. Thor. Surg., 24:369, 1952. 7 OLsEN, A. M. AND CLAGETT, 0. T.: ''Spontaneous rupture of the esophagus," Postgrtul. M•d., 2:417, 1947. 8 BARRETT. N. R. : ''Report of case of spontaneow perforation of oesophagus s u c c eu f u II y treated by operation," Brit. ]. Surg., 35:216, 1947. 9 Ca.ur, R. M., BRADT, D. J. AND PosTON, F. T.: "Two cases of spontaneow rupture of the esophagus," Canad. M•d. ] .• 71:250, 1954. 10 MoYNIHAN, N. H.: ''Ruptured esophagus," Laned, 2: 728, 1954. 11 PR.JVJTERJ, C. A. AND GAY, B. B. jR.: Spontaneous rupture of the esophagus with report of five cues," Radiplogy. 57 : 48, 1951. 12 KERR, M.: ''Determination of the hydrostatic pressure necessary to rupture of the esophagus," Dis. Nos•. Throat and Ear, 1884. 13 PETREN, G.: "Ein fall van traumatiacher oesophagus rupture, nebst bermerkungen iiber die entstelung der oesophagus rupturen," B•itr. z. Klin. Chir., 61:265, 1908. 14 KERR, H. H., SLOAN, H. AND O'BRIEN, c. E.: "Rupture of the esophagus by compreaed air," Surg., 33:417, 1953. 15 FENTON, E. S. N.: ''Danger of nasal catheter wed as means of oxygenation postoperatively," Brit. ]. Anusth., 28:220, 1956. 16 GAIN, E. A.: "Pneumoperitoneum; a complication of nasal oxygen therapy: A case report," Canad. Anusth. Soe. ] .• 5:7, 1958. 17 PENDERGRAss, E. P. AND BooTH, R. E.: ''Reportative case of ruptured stomach in infant three days old,'" A mer. ]. Ro•ntg•nol., 56: 590, 1946. 18 MussER, H. H.: "Etiology of rupture of stomach in newborn,'" Ohio M•d. ] .• 52:838, 1956. 19 COLE, D. S. AND BuRCHER, S. K.: "Accidental pneumatic rupture of esophagus and stomach, Laneet. 1 : 1961. For reprints, please write: Dr. Randolph, 909 East Brill, Phoenix.
VENTILATION FOLLOWING OPERATIONS with no apparent reduction In lung volume. In paThe dlstrtbutlon of ventllatlon before and after tients with chronic lung disease upper abdominal common abdomlnal and thoracic operations was operations were performed without reducing the studied In 27 patients by a 2 balloon. open circuit uniformity of air-mixing. An operation of a lesser nitrogen washout technique. After pulmonary resecmagnitude such as a routine Inguinal hemla repair tion In patients with relatively normal lungs, there had no appreciable effect on thls aspect of pulmowas a measurable Improvement In distribution of nary function. ventilation concomitant with a reduction In lung volOKJNAKA, A. ].: "The distribution of ventilation follow· ume. In resections for bullous emphysema there was ing operations.'' S•rg. G1"''" ••tl Oluul., 12~: 6,, 1966. definite Improvement In Intrapulmonary alNDlxiDg