Eur J Cardiothorac Surg 1998;14:572-574
© 1998 Elsevier Science NL
War injuries to the thoracic esophagus
Nenad Ilic,
Ante Petricevic,
Zeljko Mimica,
Sonja Tanfara,
Nives Frleta Ilic
Thoracic Surgery Department, University Surgical Hospital, Clinical Hospital Split, Split, Croatia
Received 23 March 1998;
received in revised form 31 August 1998;
accepted 30 September 1998.
Corresponding author. Tel.:+385-21-556-277; fax: +385-21-365-738.
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Abstract
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Objective: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. Methods: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. Results: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. Conclusion: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.
Key Words: War injury • Esophagus • Surgical treatment
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Introduction
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Esophageal surgery in war circumstances and mass casualty situations remains one of the most technically demanding surgical disciplines today
[1]
[2]
[3]
[4]. War injuries to the thoracic esophagus are life-threatening, frequently unrecognized with high complications rate due to sustained injuries of other body organs
[5]
[6]
[7]. Timely and accurate diagnosis of esophageal trauma is critical, because the consequences of missed esophageal injury is devastating
[8]
[9]
[10]. Mortality commonly exceeds 20%, even for patients with promptly recognized esophageal injury
[11]
[12]
[13].
Examination for esophageal injury should always consider: missile trajectory (transcervical, transmediastinal, transdiaphragmatic); clinical signs (pain, dyspnea, dysphagia, peritonitis of upper abdomen, subcutaneous emphysema, pneumothorax, bloody nasogastric tube output); radiologic signs (pneumothorax, pneumomediastinum, pneumopericardium, retropharingeal air, pleural effusion)
[10]
[14]
[15]. Standard diagnostic studies for the evaluation of esophageal injury include water-soluble contrast esophagography, esophagoscopy (rigid or flexible) and surgical exploration
[10]
[16]
[17]
[18].
Surgical strategy in the treatment of war injuries to the thoracic esophagus, according to the war surgical doctrine, is as follows: temporary-double exclusion of the esophagus, chest-tube drainage, antimicrobial chemoprophylaxis, appropriate fluid therapy and intensive care
[19]
[20]
[21]
[22]. Definite surgical repair (simple suturing with covering by surrounding tissue for minor lesions; and gastric or intestinal interposition for severe lesions) should be performed after clinical stabilization of the patient
[1]
[15]
[23]
[24].
This study provides a comprehensive description of the surgical treatment of patients with injured thoracic esophagus at the Split University Hospital during the 1991–1995 wars in Croatia and Bosnia–Herzegovina.
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Patients and methods
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This is a retrospective evaluation of patients with war injuries to the thoracic esophagus treated at the Split University Hospital; a third echelon war hospital during the 1991–1995 wars in Croatia and Bosnia–Herzegovina. At that time, there were no facilities or inclination and time to investigate more carefully for battle casualties. Wounded persons were previously treated at field and second echelon war hospitals
[5]
[22]
[25]. In spite of that, the patients were admitted for treatment in generally very poor condition, mostly only with first aid measures undertaken.
We surgically treated 5 (0.2%) patients with injured thoracic esophagus among 2693 treated injured persons. Three of them had their esophagus totally shattered, while the remaining two had partially damaged esophagus (2% of 467 thoracic injuries).There were 4 men and 1 woman with a median age of 32. All except one were soldiers. Time elapsed between injury and established diagnoses were: less than 6 h (two patients), within 24 h (two patients), and 48 h (one patient).
The routine protocol for suspected esophageal injury was as follows: clinical investigation, appropriate fluid therapy, antibiotic and antitetanic prophylaxis, chest X-ray, water-soluble contrast esophagography, flexible endoscopy if necessary, and surgical treatment with intensive care. All patients received standard surgical treatment: temporary double-exclusion of the esophagus; chest-tube drainage; antimicrobial chemoprophylaxis (7 days penicillin, gentamicin and metronidazole therapy); and appropriate fluid and nutrition therapy.
Definite surgical repair was done after the patient's clinical, laboratory and radiological stabilization, usually after 2–3 weeks. Gastric interposition (modified Ivor–Lewis procedure with esophagogastric ananstomosis after resection of damaged portion of the esophagus) was performed in 3 patients and simple sutures (two rows) protected by pericardial flap was performed in one patient.
Prior to oral nutrition all the patients underwent water-soluble contrast studies of the esophago-gastric junction. Four wounded persons were discharged from the hospital as cured (able to eat normal food) and one patient died due to septic complications and associated injury to the spinal cord prior to the definite surgical repair.
This report is based on detailed medical documentation we kept in the hospital.
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Results
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The location, extension of esophageal lesions and injury mechanism in patients with war injuries to the thoracic esophagus is shown in Table 1. We considered a short section of partially damaged esophagus as minor esophageal injury, while totally shattered esophagus was considered as severe injury.
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Table 1. Location, extension and injury mechanism in treated patients with war injuries to the thoracic esophagus
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Indications for surgery are listed in Table 2. Several patients had more than one indication. Esophageal lesion was detected intraoperatively in one patient. In one case we discovered the injury after the patient underwent urgent thoracotomy due to sustained lung injury followed by significant air-leakage and intrathoracic bleeding.
After surgical treatment and intensive care, the definite surgical repair was usually done after 2–3 weeks (median 18 days). In spite of a high complication rate (Table 3), 80% of our patients were discharged from the hospital as cured. We did not have intraoperative technical and general problems. Minor empyema and wound infection were successfully treated by prolonged chest-tube drainage and antibiotic treatment according to the antibiogram. One patient died due to septic complications and associated injuries to the spinal cord in spite of antimicrobial prophylaxis regularly performed in all wounded persons.
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Table 3. Postoperative complications in patients with war injuries to the thoracic esophagus and therapeutic measures undertaken
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Discussion
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War injuries to the thoracic esophagus are life-threatening and frequently unrecognized until signs of infection supervene
[1]
[2]
[4]
[11]. Some injured persons never reach the surgeon because of sustained injuries of other vital intrathoracic structures
[7]
[9]
[25]
[26]. Prognosis is largely dependent upon the timely moment of the operative intervention (mortality in repair within 24 h after injury is 10%, in delayed exceeded 20%)
[11]
[13]
[23]
[27].
Distribution, stratification and complication rate of the patients we treated, corresponds to the literature data
[4]
[7]
[21]. Time elapsed between injury and surgical treatment did not exceed 48 hours, in spite of sometimes difficult transportation toward the hospital
[5]
[9]
[22].
We generally did not vast time with some highly sensitive diagnostic methods (CT-scan, angiography and bronchoscopy), because signs and symptoms of possible esophageal lesion usually were presented with a gunshot wound
[10]
[16]
[18]. Clinical, radiological and endoscoopic findings were our guiding indications for surgery. Some concerns include the conversion of a partial-thickness injury into a complete perforation during passage of the endoscope and the possibility of mediastinal contamination during contrast esophagography
[10]
[16]. Although these concerns are real, they are irrelevant if immediate surgical treatment is to be undertaken when an esophageal injury is discovered
[7]
[11]
[16]
[24].
In surgical management of our patients we followed NATO war surgical strategy (resuscitation, appropriate fluid therapy, immediate transportation, antibiotic and antitetanic prophylaxis, temporary double-exclusion of the esophagus and definite surgical repair)
[19]
[21]
[22]. We did not try to primarily suture the injured esophagus because the two-step surgical procedure was considered safer in such cases with contaminated war injuries
[7]
[9]
[22]. Two patients admitted to hospital within 6 h after injury had multiple sustained injuries of other body regions so we considered possible primary repair of the esophagus unsafe procedure at that time. Temporary double-exclusion of the injured esophagus with intensive care allowed better control of the patients' clinical condition and possible infective complications. In definite surgical repair after a 2–3-week time period, we performed esophageal resection with gastric interpostion in all patients with extended lesions to the esophagus. Two rows of simple suturing protected by a pericardial flap were placed to the esophagus when it was considered safe regarding potential leakage. Postoperative contrast studies confirmed that all repairs were intact. Mortality rate (20%) in our patients were similar or smaller when compared with other related literature data
[7]
[12]
[21]
[24]
[27].
One of the reasons we were compelled to report our experience is the paucity of data considering war injuries to the thoracic esophagus
[4]
[7]
[19]
[22]. We believe that prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in such injuries.
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Abstract
Introduction
