Perforation of the intrathoracic esophagus from blunt trauma in a child: Case report and review of the literature

Perforation of the Intrathoracic in a Child: Case Report By Kennith

H. Sartorelli,

Esophagus From Blunt Trauma and Review of the Literature

Whitney Burlington,

J. McBride,

and

Rupture of the intrathoracic esophagus from blunt trauma is an exceedingly rare injury in children and often presents on a delayed basis. The authors encountered a case of this unusual injury and review six additional cases found in the literature.

J Pediatr Surg tiers Company.

I

esophagrams swallowing.

NTRATHORACIC PERFORATION of the esophagus from blunt trauma is an unusual event accounting for less than 0.2% of all blunt chest injuries.’ The majority of intrathoracic esophageal perforations from blunt trauma occur in adults as the result of high-speed motor vehicle accidents; consequently, the incidence of this type of injury in children is exceedingly low. A leading pediatric surgery text has even stated that in children “. . . intrathoracic esophageal rupture from blunt trauma does not appear to occur.“2 We recently encountered a child with an intrathoracic esophageal perforation from blunt trauma and herein review the literature concerning this extremely rare injury. CASE

REPORT

A previously healthy 1l-year-old boy was injured when a soccer goal tipped over landing on his anterior chest. He had immediate onset of chest pain and respiratory distress. Evaluation findings at a local hospital showed the presence of anterior chest and upper abdominal tenderness, subcutaneous emphysema, and mild hypoxemia. Plain chest radiographs and a chest computed tomography scan showed a small left apical pneumothorax, bilateral pulmonary contusions, and pneumomediastinum. The child was observed in an intensive care unit for 48 hours where treatment consisted of vigorous pulmonary toilet, supplemental oxygen, intravenous hydration, and restriction of oral intake. His respiratory status improved, and his pneumomediastinum and left pneumothorax resolved. On the third day postinjury he was started on a clear liquid diet and promptly became febrile. A chest x-ray showed a new right-sided pleural effusion, which was aspirated and showed a markedly elevated amylase. The diagnosis of a possible esophageal injury was entertained, and the child was transferred to the pediatric surgery service at University of Vermont. A gastrograffin esophagram demonstrated extravasation of contrast from the esophagus into the right pleural space. Approximately 72 hours had elapsed from the time of injury to the esophagram. During right thoracotomy, a 6-cm longitudinal tear extending from the mid-to-distal esophagus with a moderate amount of pleural space contamination was found. The esophagus was debrided and repaired using a single layer of interrupted 3-O polydioxine sutures reinforced with a pleural buttress. Chest drainage was accomplished using two large bore thoracostomy tubes; gastrostomy and jejunostomy tubes were also placed. An esophagram on postoperative day 10 showed no leak, and the patient was discharged on the 15th postoperative day tolerating a regular diet. Follow-up Journal

of Pediatric

Surgery,

Vol 34, No 3 (March),

1999:

pp 495-497

Dennis

W. Vane

Vermont

INDEX trauma.

WORDS:

34:495-497.

lntrathoracic

show no evidence

Copyright

esophageal

of a stricture,

o 1999

by W.B. Saun-

perforation,

blunt

and the child has normal

DISCUSSION

Esophageal perforations are the most rapidly fatal injuries of the alimentary tract.3 The majority of traumatic esophageal perforations occur as the result of iatrogenic injury during esophageal instrumentation.J External trauma accounts for 20% to 25% of esophageal disruptions, with less than 10% of all esophageal injuries occurring secondary to blunt trauma. The majority of blunt esophageal injuries involve the cervical esophagus, with intrathoracic esophageal injuries being rare.5,6 Wilson et al7 saw no intrathoracic esophageal perforations in a series 340 patients hospitalized with blunt chest trauma. An autopsy review of thoracic injuries in 585 fatal traffic accidents showed one intrathoracic esophageal perforation.’ Beal et aI6 reviewed all esophageal perforations (cervical, thoracic, and abdominal) from blunt trauma noting 96 published cases between 1900 and 1988; they estimated the overall incidence of blunt esophageal injuries at 0.001%. In 1997 Corder0 et al8 reviewed distal esophageal rupture after blunt trauma and found eight cases in the world literature. In our review of the English-language literature over the past 40 years there are six published cases of perforation of the thoracic esophagus from blunt trauma in children age 16 years and younger; the current report is the seventh case (excluding two toddlers who sustained esophageal perforations from pneumatic forces while biting tire inner tubes, Table 1).*-13 The proposed mechanisms by which esophageal rupture from blunt forces occurs include the following: a

From the University of Vermont College of Medicine, Burlington, VT Address reprint requests to Kennith H. Surtorelli, MD, E-309 Given Building, University of Vermont, College of Medicine, Burlington, VT 05405. Copyright 0 1999 by WB. Saunders Company OOZZ-3468/99/3403-0032$03.00/O 495

496

SARTORELLI,

Table

1. Pediatric

Thoracic

Nolan Wychulis

SW

and Ashburns et aI’0

lniurv

14, M 16, F

Injuries

Associated lniuries

Age h/r). Studv

Esophageal

From

Blunt

Chest

MVA

air, TEF Chest crepitance,

Rib fx, PM SO air tracheal

pain,

Diagnosis/ D&v

cough,

AND

VANE

Trauma

SvmDtoms

MVA

MCBRIDE,

SO

Treatment

Esophagram

(+)/Y

(5 d)

PR

TEF

Esophagram

(+1/y

(74 d)

PR

SO air,

Esophagram

(+)/Y

(5 d)

PR

Esophagram Esophagoscopy Esophagram/N

(-jr/

(3 d)

PR

lac Chapman

and

12, M

Go-cart

CHI, PTX tracheal fx

16. M

MVA

Skull fx, pulmonary contusion Spleen, renal hepatic lacs

Braun” Lucas Corder0

Martin

et alI* et al*

de Nicolas

et an3 Current studv

16, F

MVA

14, M

Crush

injury

from

Tracheal

11, M

basketball Crush injury

hoop from

PTX, lung

soccer Abbreviations: repair; MVA,

motor

goal

Y, yes; N, no; PTX, pneumothorax: vehicle accident; lac, lacerations;

lac, rib

lac contusions,

PM CHI, closed head injury; TEF, tracheoesophageal

rapid rise in intraluminal pressure against a closed glottis resulting in disruption of the wall of the esophagus, disruption of the esophageal blood supply by decelerationtraction injury producing ischemia leading to rupture, and “blast effect” disruption of the esophagus produced by a concomitant tracheal injury in cases of combined tracheal and esophageal trauma.6J3 Despite the rarity of intrathoracic esophageal perforation from blunt trauma in children, several common features including mechanism of injury, associated additional injuries, and a delay in diagnosis of the esophageal injury were present in most of these cases. Motor vehicle accidents with the chest impacting on the steering wheel accounted for five of seven esophageal injuries, whereas two other perforations were caused by crush injuries from large falling objects. Multiple injuries in addition to the esophageal perforation were noted in six of seven children. Associated thoracic injuries were most common and included injuries such as tracheobronical lacerations, pneumothoraces, and pulmonary contusions (Table 1). The diagnosis of an esophageal injury can be very difficult to ascertain, and a high index of suspicion is required. Chest pain, fever, and subcutaneous emphysema are the most common signs and symptoms of esophageal perforation; unfortunately these findings often are produced by more prevalent injuries such as pulmonary contusions, pneumothoraces, and chest wall injuries, which may lead to a delay in diagnosis of the esophageal injury. This point is underscored by the fact that recognition of the esophageal injury was delayed in five of seven children reviewed (range, 3 to 74 days), three of whom had tracheoesophageal fistulas at presentation. When an esophageal injury is suspected, investigation is warranted using a contrast esophagram and

Neck crepitus, TEF Fever,

sepsis

Abdominal retrosternal scan Respiratory Abdominal PM fx, fracture; fistula.

pain,

(+) PR

air on CT distress pain,

Branch/N SO air,

SQ, subcutaneous;

Esophagectomy

Esophagram

1+)/Y (3 d)

PM, pneuomediastinum;

PR

PR, primary

esophagoscopy. Negative study results do not completely exclude esophageal injury because the false-negative rate of these examinations may be as high as 40% for contrast studies and 30% for endoscopy.5J4 The esophageal injuries of the seven children in this report were identified by several methods; five were discovered by esophagrams; and one each by esophagoscopy (following a negative esophagram), and bronchoscopy performed for a tracheal laceration. Numerous options are available for the management of esophageal injuries including nonoperative treatment, primary repair, esophagectomy, and exclusion and diversion.5,6.14 Direct repair of the perforation with tissue buttress reinforcement of the repair is the preferred approach in children.14 Primary repair helps avoid the need for reoperation to restore esophageal continuity and has been associated with a reduction in mortality rates from esophageal injuries. I5 The use of pleura or local muscle flaps to buttress the repair is felt to reduce leak rates, morbidity rates, and overall mortality rate.16J7 Controversy remains concerning the ideal management of thoracic esophageal perforations that present late. Delays in the diagnosis and treatment over 24 hours have been associated with markedly increased morbidity and mortality in adults.15-17 Traditional surgical dictum has been to resect or exclude the injured esophagus in cases of delayed presentation, but several recent reports have suggested that primary repair of the esophagus can be accomplished with excellent results in these patients.15-17 Although primary repair of the esophageal injury appears to be the optimal treatment, surgical management must be individualized according to the size of the defect, degree of inflammation and contamination, and the patient’s overall condition. Review of the seven pediatric cases of

INTRATHORA~I~

ESOPHAGEAL

497

PERFORATION

blunt trauma-induced intrathoracic esophageal injuries showed that primary repair was accomplished in six children, including those with delayed presentation and tracheoesophageal fistulas. One child underwent esophagectomy and proximal esophagostomybecauseof hemodynamic instability. Buttressing of the repair with pleura or muscle flap wasperformed in four children. There was no lnorbidity at~butable to either primary repair itself or primary repair in the setting of delayed diagnosisin six

children who underwent primary repair of their esophageal inj my. Perforation of the intrathoracic esophagus in children is an extremely rare injury but doesoccur. A high index of suspicionis necessaryto pursue workup of this unusual injury, and delayed presentationis not unusual. Primary repair of the injury usuaily can be accomplishedin both the acute and delayed settings,but this must be individualized to eachpatient.

REFERENCES 1. Kemmere WT, Eckert WG, Gaithright JB, et al: Patterns of thoracic injuries in fatal traffic accidents. JTrauma 1:195-198, 1961 2. Rowe MI, O’Neill JA, Grosfeld JL, et al: Thoracic trauma, in Rowe MI, O’Neill JA, Grosfeld JR, et al (eds): Essentials of Pediatric Surgery. St Louis, MO, Mosby, 1995, p 195 (chap 18) 3. Sealy WC: Rupture of the esophagus. Am J Surg 105:505-508, 1963 4. Attar S, Hankins JR, Suter CM: Esophageal perforation: A therapeutic challenge. Ann Thorac Surg 50:45-50, 1990 5. Glatterer MS, Toon RS. Ellestad C. et at: M~agement of blunt and pen~~ating external esophageal trauma. J Trauma 25:784-791, 1985 6. Beal SL, Pottmeyer EW, Spisso JM: Esophageal perforation following blunt trauma. J Trauma 28: 1425-1432, 1988 7. Wilson RF, Antoneko D, Gibson DB: Shock and acute respiratory failure after chest trauma. J Trauma 17:697-705, 1977 8. Corder0 JA, Kuehler DH, Fortune JB: Distal esophageal rupture after external blunt trauma: Report of two cases. J Trauma 42:321-322, 1997 9. Nolan JJ, Ashbum FS: Trachea-esophageal fistula as an isolated

effect of steering-wheel injury. Med Ann Dist Columbia 29:384-426, 1960 10. Wychulis AR, Ellis FH, Andersen HA: Acquired nonmalignant esophagotracheobronchial fistula. JAMA 196:117-122, 1966 11. Chapman ND, Braun RA: The management of tracheoesophageal fistula caused by blunt trauma. Arch Surg 100:681684,1970 12. Lucas AE, Snow N, Tobin GR, et al: Use of rhomboid major muscle flap for esophageal repair. AnnThorac Surg 33:619-623, 1982 13. Martin de Nicolas JL, Gamez AP, Cruz F: Long tracheobronchial and esophageal rupture after blunt chest trauma: Injury by airway bursting. Ann Thorac Snrg 62:269-272,1996 14. Engum SA, Grosfeld JL, West KW, et al: Improved survival in children with esophageal perforation. Arch Surg 131:604-611,1996 15. Bufkin BL, Miller JI, Mansour KA: Esophageal perforation: Emphasis on management. Ann Thorac Surg 6 1: 1447- 1452. 1996 16. Wright CD, Mathisen DJ, Wain LC, et al: Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 60:245-249, 199s 17. Wang N, Razzouk AJ, Safavi A, et al: Delayed primary repair of intrathoracic esophageal perforation: Is it safe? J Thorac Cardiovasc Surg 111:114-122, 1996