Esophageal Trauma

Mohammad Vaziri MD Thoracic Surgeon Iran University of Medical Sciences Member of European Society of Thoracic Surgeons New York Academy of Sciences

Esophageal Trauma

I-Injuries to the Cervical Esophagus IIII-Injuries to the Thoracic Esophagus 1-Intraluminal Penetrating Trauma Instrumental Foreign body injuries Barotrauma Boerhaaves syndrome Unusual injuries 2-Extraluminal Penetrating Trauma Gunshot/Stab wound Thermal Operative trauma Blunt trauma

Esophageal Trauma

IIIIII-Abdominal Esophageal Perforation IVIV-Drug Induced Esophageal Injuries V-Chemical Trauma

INJURIES OF THE CERVICAL ESOPHAGUS Most injuries are iatrogenic: Endoscopic procedures Endotracheal tube placement Bougienage Emergent tracheostomy Airway stent placement Impacted swallowed foreign body External trauma due to gunshot or stab wounds Chemical burns

Symptoms and Signs of Cervical Esophageal Injury Unusual difficulty or the occurrence of bleeding during the endoscopy Pain and stiffness in the neck Dysphagia Respiratory distress Fever Dysphonia Cervical tenderness. Crepitation

Symptoms and signs of cervical esophageal injury

Radiographic examination of the neck may reveal Air in the fascial planes Widening of the retroesophageal space Obliteration of the normal cervical vertebral curvature Massive pneumomediastinum Retroesophageal abscess with an air-fluid level In most patients with instrumental perforation of the cervical esophagus, neither radiographic examination with the use of a contrast medium nor esophagoscopy is indicated because they frequently fail to identify the site of perforation

Management of Perforating Esophageal Injuries

Anterior cervical mediastinotomy Repair of the laceration Drainage of the area Repair of the perforation is best performed with interrupted, non-absorbable,fine sutures.

Extraluminal Injuries of the Cervical Esophagus Cervical esophagus is injured in only about 0.5% of penetrating neck injuries. Gunshot wounds are the most common cause of injury Frequently are associated with an injury to the trachea, the large vessels of the neck, the spinal cord, or a combination of these.

Extraluminal Injuries of the Cervical Esophagus

Subcutaneous emphysema from an isolated injury of the esophagus occurs only in about one third of cases When crepitus is palpable, a combined injury of the trachea and esophagus must be considered. Occasionally, radiographs of the chest reveal a pneumomediastinum, but this finding almost always indicates concomitant airway injury.

Extraluminal Injuries of the Cervical Esophagus (Repair)

Drains should be left in place until oral feedings have been reinstituted (5 to 7 days) and there is no evidence of an esophagocutaneous fistula. Aspiration of the oropharyngeal secretions, as well as appropriate antibiotics, should be used in all these injuries. If the trachea and esophagus were injured simultaneously >>> rotation of a flap of viable muscle between the repair of the esophagus and that of the trachea.

INJURIES TO THE THORACIC ESOPHAGUS

Intraluminal Penetrating Trauma Intraluminal penetrating injuries are separated into four categories: (a) Instrumental (b) Foreign body injuries (c) Non instrumental (barotrauma) (d) Rare causes

Intraluminal Penetrating Injuries of the Thoracic Esophagus Instrumental injuries Esophagoscopic procedures Bougienage Pneumatic dilation Biopsy of esophageal mass Endotracheal tube placement Malposition of a Sengstaken-Blakemore tube Transesophageal echocardiography Erosion of an esophageal carcinoma Sclerotherapy for esophageal varices Transesophageal sclerosal therapy for bleeding Mallory-Weiss tear Foreign body injuries Barotrauma Pneumatic from compressed air source Boerhaave's syndrome ("spontaneous rupture") Blunt trauma Rupture of a Barrett's ulcer .. Necrotizing esophagitis in immunocomproimised patients Associated with a Zollinger-Ellison syndrome

Intraluminal Penetrating Injuries of the Thoracic Esophagus

Instrumental Injuries May occur during diagnostic or therapeutic procedures The incidence to be about 0.4% in routine diagnostic examination. The actual number of perforations might be increasing because of more frequent use of the flexible esophagoscope. The more common sites of perforation are at two of the normal anatomic sites of narrowing : the distal end as it reaches the diaphragm to join the stomach, and the area of narrowing at the level of the aortic arch and left main stem bronchus.

Clinical Presentation of Thoracic Esophageal Perforation

Contamination of the visceral mediastinum >>> Perforation of the mediastinal pleural layer >>> Contamination of the affected pleural space. The left pleural space is usually involved when the injury is in the most distal portion of the esophagus The right, when the perforation is more proximal in the esophagus.

Clinical Presentation of Thoracic Esophageal Perforation

Pain, fever, dysphagia, respiratory distress. The pain may be thoracic, precordial, or even epigastric. Radiation of the pain may occur to the intrascapular region. Tachycardia frequently is disproportionate to the degree of temperature elevation. The degree of respiratory distress varies with the severity of the pleural contamination, the amount of hydropneumothorax, and, at times, the presence of airway compression. Excessive thirst may be present.

Clinical Presentation of Thoracic Esophageal Perforation

The infection may spread and involve other mediastinal structures : the pericardium or even the CNS A localized mediastinal abscess >>> esophagealsubarachnoid fistula >>> spinal and cranial meningitis.

Diagnostic Procedures in thoracic esophageal perforation

Radiographic examination of the chest may reveal Widened mediastinal shadow Mediastinal air Air or fluid, or both, in either pleural space Pneumopericardium Air in the spinal cord The radiologic examination may be normal in 12% to 33% of the cases Barium esophagography Chest CT scan

Management of Thoracic Esophageal Perforations The management of these injuries is based on four principles: (a) elimination of the source of soilage (b) provision of adequate drainage (c) antibiotics (d) adequate nutrition. The time of institution of therapy is of less importance than formerly believed At present immediate surgical intervention is recommended

Management of Thoracic Esophageal Perforations

Nonoperative strategy - Cameron criteria The perforation is contained within the mediastinum - the contrast material drains readily back into the esophageal lumen - no clinical signs of sepsis Sawyer criteria (a) a recent perforation (within 24 hours), (b) no food intake after the episode of perforation, (c) the perforation not proximal to a stenosis, (d) without clinical signs of sepsis (e) a contained perforation within the mediastinum, and (f) contrast studies showing good drainage from a small perforation

Operative Management of Esophageal Perforations Primary closure Primary closure with buttressing of suture lines Muscle flap closure Intercostal muscle Latissimus dosi muscle Rhomboid muscle Diaphragmatic muscle Exclusion and diversion T-tube drainage Esophagectomy Primary reconstruction Delayed reconstruction Intraluminal stent Minimally invasive repairs Video-assisted thoracic surgery Laparoscopic abdominal approach Drainage only

Operative Management of Esophageal Perforations Primary closure, usually with buttressing of the suture line is recommended Regardless of the amount of time that has elapsed since the occurrence of the esophageal perforation.

Operative Management of Esophageal Perforations The use of fibrin glue to obtain or to support a primary repair of a perforated esophagus. It has been used to seal the suture line, to obtain better adherence of a transposed muscle flap The use of an absorbable mesh-polyglactin mesh (over the primary repair)

Operative Management of Esophageal Perforations When the perforation has occurred after a pneumatic dilation for achalasia : 1- mobilize the lower esophagus and to perform a modified Heller esophagomyotomy opppsite the site of the perforation. If the integrity of the diaphragmatic hiatus has been compromised, an anti-reflux procedure should be done. 2- the esophageal wound is debried and the entire length of the mucosal tear is exposed and securely closed. An intercostal muscle flap is then sutured to the edges of the ruptured esoghageal muscle to ensure a tight closure. The approximation of the muscle flap to the ruptured edges of the esophageal muscle maintains the myotomy created b the balloon dilation.

Operative Management of Esophageal Perforations When the esophageal injury has occurred in or above an obstructing lesion, direct repair of the esophageal injury is contraindicated unless the obstructing lesion can be corrected at the same time. If not >>> diversion of oropharyngeal and gastric secretions with adequate drainage of the mediastinal and pleural space.

Operative Management of Esophageal Perforations

Another technique in the management of a patient with perforation that is difficult to close (a friable esophageal perforation or one in which the diagnosis has been markedly delayed) is the use of a T tube to establish a controlled fistula First described by Abbott and associates in 1970, this technique may be considered as an acceptable alternative in a poor-risk patient.

Operative Management of Esophageal Perforations

In patients with carcinoma or other serious accompanying esophageal disease (megaesophagus, severe reflux with major strciture, severe lye burn) esophagectomy may be considered as the treatment of choice

Minimally Invasive Techniques in Esophageal Perforations

Intraoperative endoscopy is performed to assist in identifying the site of perforation. The suspected region can be submerged under irrigation during endoscopic insufflation to pinpoint the precise location of perforation. If the defect is small (< I cm) and surrounded by viable tissue, a primary closure can be performed with interrupted sutures. Perforations involving an esophageal diverticulum can be managed by minimally invasive diverticulectomy and drainage

Mortality and Morbidity In 11 reports in the literature beginning in 1995 through early 2003, 327 patients with esophageal perforations were reported, and an overall mortality rate of 11.9% was recorded. Early morbidity in most series is mainly due to a leak from the suture line Persistent empyema Late dysphagia

References 1-Shields TW. Esophageal trauma. In: Shields TW, Locicero J, Ponn RB, Rusch VW,editors. General Thoracic Surgery. 6thed. Lippincot; 2005. P: 2101-2120 2005. 21012-Sung SW, Park JJ, Kim YT, Kim JH. Surgery in thoracic esophageal perforation: primary repair is feasible. Dis Esophagus. 2002; 15( 2042002; 15(3): 204-9 3-Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg. 2003 Apr; 75(4): 1071-4 75( 10714-Rosiere A, Mulier S, Khoury A, Michel LA. Management of esophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement. Acta Chir Belg. 2003 Oct; 103(5): 497-501 103( 497-

References 5-Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004 Apr; 77(4): 147577( 147583 6-Jougon J, Mcbride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaaves syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac Surg. 2004 Apr; 25(4): 475-9 25( 4757-Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg. 1995 Jan; 109(1): 140-4 109( 1408-Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg. 1995 Aug; 60(2): 245-8. 60( 245-

INJURIES TO THE THORACIC ESOPHAGUS Intraluminal Penetrating Trauma

Foreign Body Injuries

Sharp foreign bodies lacerate the wall partially or completely. Most commonly, such laceration occurs in the cervical esophagus, but any point of normal narrowing or at a diseased area may be the site of perforation. Perforation of the wall may occur spontaneously or during the extraction of the foreign body.

Foreign Body Injuries

Radiographic examinations may reveal the foreign body, but frequently they are negative, The use of soft tissue techniques, permits visualization of about 75% of ingested bones, and further improvement may be noted with the use of xeroradiography.

Foreign Body Injuries

Endoscopy with removal of the foreign body is indicated Esophagotomy is necessary for removal of any foreign body that cannot be removed by endoscopic manipulation.

INJURIES TO THE THORACIC ESOPHAGUS Intraluminal Penetrating Trauma

Barotrauma (Noninstrumental lnjuries) Rapid increase of the intraluminal pressure within the esophagus may result in partial or complete rupture of the esophageal wall. Vomiting, defecation, convulsions, lifting, labor of childbirth, blunt abdominal trauma , deceleration injuries, exposure to compressed air, explosion of an inflated tire, carbonated beverages.

Boerhaave's Syndrome (Spontaneous Rupture)

Hermann Boerhaave described the first case of rupture of the esophagus in 1724.

The etiology of Boerhaave's syndrome is thought to be a rapid increase of the intraluminal pressure of the esophagus that may occur with the act of vomiting High pressure forced through a patent lower esophageal sphincter against a closed upper esophageal sphincter (the cricopharyngeus muscle)

Boerhaave's Syndrome (Spontaneous Rupture) Most often, the rupture is located in the distal portion of the intrathoracic esophagus (the terminal 6 to 8 cm). The injury extends through all layers of the posterolateral wall on the left. This is the result of the distribution of the smooth muscle at this location. The longitudinal fibers taper out as they pass onto the stomach wall, resulting in a weakened area Lack of support from adjacent structures, the esophagus being covered on its left lateral wall only by the parietal pleura.

Boerhaave's Syndrome (Spontaneous Rupture)

On occasion, a partial disruption occurs. Rarely, extensive dissection of the air within the intramural layers of the esophagus occurs A partial laceration of the wall may extend into the proximal stomach and cause major upper gastrointestinal bleeding, the Mallory-Weiss syndrome In this situation, the problem is control of the bleeding. If bleeding does not stop with supportive management surgical intervention is required: gastrotomy, and suture ligation of the bleeding point.

Clinical Features of Boerhaave's Syndrome Varying amounts of bleeding Severe chest pain and dyspnea after an episode of vomiting. Shoulder pain Some patients complain only of abdominal pain Marked thirst is occasionally observed. The physical findings: Subcutaneous emphysema is present in most patients Epigastric tenderness Upper abdominal distention Decreased Bowel sounds

Diagnosis of Boerhaave's Syndrome. Radiographic examination: mediastinal emphysema, pleural effusion, hydropneumothorax,and rarely pneumoperitoneum. Patchy, irregular density may be visible behind the left cardiac silhouette: V sign CT with contrast media opacification of the esophagus is especially helpful

Treatment of Boerhaave 's Syndrome Direct surgical repair, when there has been either an early diagnosis or a late one, with buttressing of the closure is the procedure of choice, and leads to the least morbidity and mortality. In some recent cases Thoracoscopic/or/ laparoscopic approach Most complications (development of an empyema, persistent fistulas, and late abscess formation) are related to leakage from the site of repair .

Unusual Injuries of the Esophagus Rupture of a Barrett's Ulcer Most of the patients were men. the symptoms in the order of decreasing frequency were: (a) hematemesis (39%), (b) fever (35%), (c) abdominal pain (30%), (d) thoracic pain (30%), (e) melena (26%), and (f) nausea and vomiting (26%) The preferred surgical procedure is an early esophagectomy with either an immediate or a delayed reconstruction With non-surgical management only 22% of patients survived. With surgical intervention 77% survived. The overall mortality rate was 45%

Unusual Injuries of the Esophagus

Esophageal Perforation Associated with Gas Gangrene of the esophagus, mediastinum, and adjacent structures following the endoscopic ethanol injection of a bleeding Mallory-Weiss tear. Emergency esophagectomy and local debridement were carried out. Multiple broad-spectrum antibiotics Seven hyperbaric oxygen therapy sessions finally controlled the infection. Multiple surgical procedures were required, and gastrointestinal continuity was reestablished by a colon interposition with eventual full recovery.

Rupture and Necrotizing Esophagitis in lmmunocompromised Patients Overall, a 72.7% survival rate was noted in the surgically managed patients (Esophagectomy) survival rate of only10% in patients manage conservatively. Tuberculous (TB) infection of the esophagus is rare and is usually the result of extension from the lung or involved mediastinal nodes. In the immunocompromised patient, however, the infection may be primary in nature Ulceration, fistulization, or even perforation may occur. An adequate course of anti-tuberculosis medication and subsequent surgical closure are indicated

Esophageal Perforation Associated with Zollinger-Ellison Syndrome Ng and colleagues (2001) recorded a nonbarometric spontaneous perforation of the distal portion of the thoracic esophagus. Other than the presence of a Zollinger-Ellison syndrome, no other etiology could be discerned.

Extraluminal Penetrating Esophageal Injuries

Gunshot and Stab Wounds of the Chest and Upper Abdomen Injuries of the esophagus represent less than I% of the intrathoracic injuries caused by penetrating trauma The central anatomic location of the esophagus; the protection afforded by the vertebral bodies, heart, and aorta; and the relatively small, compact size of the esophagus all diminish its susceptibility to injury. The diagnosis of penetrating injuries of the thoracic esophagus is difficult. Most often, these injuries occur as part of a complex injury involving at the least the thoracic wall and lung

Symptoms and findings in penetrating injuries of the esophagus Dysphagia strongly suggests the possibility of esophageal injury, but it often is not present. Pneumomediastinum is frequently present when the esophagus is injured, but it is caused more commonly by tracheal or bronchial injury.

The treatment of penetrating injuries is based on early recognition, primary repair, and adequate drainage The associated injuries to other vital structures in the thorax lead to early exploration in many of these patients. Most of the esophageal injuries are through-and-through perforations, in which there should always be an even number of rents in the esophagus. Occasionally, a lateral tear occurs, resulting in one large laceration. when early diagnosis and exploration occur, the esophageal defect should be repaired primarily. At times, only a minimum of debridement is necessary

Extraluminal Penetrating Esophageal Injuries

when significant esophageal tissue has been destroyed and primary closure is impossible without a stricture of the lumen, a muscle flap should be used to close the defect The latissimus dorsi is the muscle of choice. When this is not available,a flap from the rhomboid muscle brought into the chest by excising a portion of the fourth rib. With distal wounds, a diaphragmatic flap has been used

Thermal injury to the esophagus with subsequent perforation First reported by Mohr and colleagues (2001) during intraoperative radiofrequency ablation of atrial fibrillation (IRAAF). The perforation occurred late in the postoperative period (postoperative day 10) and created a fistula between the esophagus and left atrium with the occurrence of air embolisms to the CNS Surgical intervention was successful. The salient features are the development of neurologic symptoms late in the postoperative period (10 to 12 days) after IRAAF. Successful treatment is prompt diagnosis followed by closure of the atrial defect and esophagectomy.

Operative Trauma Laceration of the cervical esophagus during thyroidectomy or laryngectomy The thoracic esophagus may be injured during mediastinoscopy, vagotomy, hiatal hernia repair, antireflux procedure, removal of an adherent mediastinal tumor or cyst in the visceral compartment and pneumonectomy, most often for inflammatory disease.

Blunt trauma to the esophagus Deceleration injuries to the chest, such as hitting the steering wheel during high-speed collisions. The esophageal wall may be ruptured simultaneously with the adjacent membranous tracheal wall, or its blood supply may be compromised so that necrosis and subsequent perforation into the trachea occur. This injury may occur when the esophagus and trachea are compressed between the sternum and thoracic vertebral bodies. Infrequently, an acute rupture results from a rapid increase in intraluminal pressure. Esophageal rupture occurring with fractures of the cervical spine. Rarely, a necrotizing injury of the esophageal wall occurs if the esophagus is torn away from its blood supply by severe blunt injury.

In the compressive injury of the esophagus and trachea, The presence of the fistula is evidenced, usually sometime after the third day, by spasms of coughing on eating or drinking or aspiration of oropharyngeal secretions into the lungs The diagnosis should be confirmed by endoscopic and radiographic studies. When the condition of the patient is stabilized, direct repair of the fistula is indicated through a right thoracotomy. Division of the azygos vein is done to permit wide exposure.The fistulous openings of each organ are closed. A flap of adjacent tissue, usually pleura or, when this is unavailable, a vascularized pedicled flap of intercostal muscle, should be interposed between the two closures. A tracheostomy,has been suggested to protect the tracheal suture line.

Migration of a Foreign Body into the Esophagus Migration and erosion of an Angelchik prosthesis into the esophageal lumen. This prosthesis, introduced by Angelchik and Cohen in 1979, had a period of brief popularity in the treatment of GERD but is no longer used because of its many complications. Lucite plombage spheres also have eroded into the esophagus.

Abdominal Esophageal Perforations Signs and symptoms of an acute abdominal catastrophe. One must remember that perforation of the distal thoracic esophagus may mimic such an event. Radiographic examination of the chest and abdomen, as well as of the esophagus, with contrast material should resolve the actual site of the perforation. At times, the injury may be confined to the retroperitoneal space, and a more indolent course may be observed.

DRUG-INDUCED ESOPHAGEAL INJURIES Factors such as preexisting esophageal pathologic conditions, ingestion of tablets or capsules unaccompanied by water, or recumbence at the time of or shortly after the ingestion of medication may predispose to retention of medication within the esophagus Result in mild esophagitis or actual ulceration and, in rare instance, perforation of the esophagus. The most commonly reported drugs associated with these injuries are tetracycline, emperonium, and potassium chloride.

DRUG-INDUCED ESOPHAGEAL INJURIES

Diagnosis is usually established by esophagoscopy or barium swallow in a patient with recent onset of retrosternal pain, odynophagia, or dysphagia. Because of the frequently superficial changes in many of these injuries, esophagoscopy is the preferred diagnostic approach. Treatment consists of withdrawal of the medication by the oral route, substitution of a liquid form if available. As with any injury of the esophagus, patients must be observed for stricture formation. If this occurs, esophageal dilations provide adequate treatment.

CHEMICAL TRAUMA of the Esophagus Result from the ingestion of caustic substances, either a strong acid or alkali. The latter is the more common offender Most of the injuries occur from accidental ingestion by young children, usually under 5 years of age. The site of caustic injury of the esophagus may be located almost equally in anyone of its anatomic subdivisions or may be widespread throughout. Normally, the greater period of contact is in the lower esophagus; hence, more extensive injury usually occurs in this area.

The burn injury to the esophagus has been divided into three phases. Inflammation, edema, and necrosis occur during the initial few days after injury. Sloughing of esophageal tissue with mucosal ulceration and moist granulation tissue occur in the second phase. The esophageal wall is weakest during this period, which may last 3 to 4 weeks. In the third phase >>> cicatrization and stricture formation

The signs and symptoms of the initial injury are related to the strength and amount of the substance swallowed. Increased salivation and dysphagia are common. Bums of the mouth and pharynx Respiratory distress occurs when the burn extends into the epiglottis or larynx. When the offending agent happens to be in a very dilute solution, symptoms may be minimal

CHEMICAL TRAUMA of the Esophagus

Treatment is designed to minimize the extent of scarring and subsequent stricture formation. Early esophagoscopy, within the first 2 days, is recommended. The esophagoscope is passed until the first area of burn is observed. No attempt is made to pass beyond this area Further examination of the esophagus usually is not necessary for 3 to 4 weeks. At this time, the indicated examination is a barium esophagography to detect any strictures

Use steroids in patients with severe grade II and grade III burns of the esophagus. steroid use is not indicated in grade I or mild grade II injuries. Regardless of the use of steroids, strictures of varying degrees occur in almost all patients with severe injuries. Subsequent bougienage is recommended in those patients with a definite stricture of the esophagus. This procedure is started during the early phase of cicatrix formation, which begins the third or fourth week after injury. Danger of instrumental perforation, is present, and a string or wire guide is essential The most important factor, is the ability of the patient to swallow. Recurrent or increasing dysphagia indicates the need for additional mechanical dilation.

CHEMICAL TRAUMA of the Esophagus

Surgical intervention is seldom necessary in the acute phase of caustic injuries unless there is extension of the injury through the entire wall of the esophagus. To determine such a situation >>> CT scan of the esophagus Acute tracheoesophageal fistulas resulting from caustic ingestion in small children >>> tracheostomy,cervical esophagostomy, and gastrostomy with isolation (blind-ending) of the thoracic esophagus are required.

Patients with second-degree burns >>> intraesophageal stenting through a celiotomy and the stent is left in place for at least 21 days. Antibiotics and steroids also are given. In patients with third-degree burns without full-thickness involvement, a stent is likewise used In those with extensive full-thickness necrosis, urgent radical total esophagogastrectomy is carried out along with cervical esophagostomy and jejunostomy. Reconstruction is performed at a later date. When an esophagectomy is indicated it is best done by the transhiatal route.

CHEMICAL TRAUMA of the Esophagus

Surgical intervention may also be considered in longstanding lye strictures when it becomes difficult or impossible to maintain an adequate lumen despite repeated dilation. Create a substitute esophagus using either the stomach, a reversed gastric tube, or a colon interposition An increased risk for the development of carcinoma in residual, strictured esophagus has been suggested and the remaining esophagus should be excised.

Reinforced Primary Repair in Delayed Thoracic Esophageal Perforation Mohammad Vaziri MD* Thoracic Surgeon Hazrat Rasool Hospital Iran University of Medical Sciences Fax: Fax: 66509056 E-mail: dr_m_vaziri@yahoo.com Thoracic Surgery Ward- Hazrat Rasool Hospital WardNiayesh Ave- Shahrara- Tehran Ave- Shahrara-

Abstract A 55-year-old man with severe right-sided empyema 55-yearrightwas admitted to our hospital . Six days before this hospital. admission, he had undergone upper GI endoscopy in another center to remove a retained chicken bone in lower esophagus and despite documented thoracic esophageal perforation, perforation, treatment was surprisingly delayed. The perforation was closed with primary sutures and reinforced with intercostal muscle flap wrap and pleural patch. Esophagography performed 3 weeks after the operation showed a well-healed esophagus without stenosis or wellleakage. We conclude that regardless of the time interval between the injury and the operation, reinforced primary repair is recommended for non-malignant thoracic nonesophageal perforation and provide a one -stage operation onewith preservation of the native esophagus

Case Report A 55-year-old man with obvious right55-yearrightsided empyema and clinical signs of sepsis was admitted to our hospital. Six days before this admission he had undergone upper GI endoscopy in another center to remove a retained chicken bone in lower esophagus following which chest pain, fever and dyspnea appeared. A chest radiography had shown a significant right pleural effusion (Fig 1) and a chest tube had been inserted. Surprisingly no definitive treatment had been performed and worsening empyema ensued

Vital signs at presentation include: PR=110/min, PR=110/min, RR=28/min, T=39 RR=28/min, T=39 Cand BP=110/75mmHg. The BP=110/75mmHg. patient was a farmer and had no underlying disease and physical examination revealed no other significant finding. Laboratory tests were normal except for WBC=13000 and PMN=90%. WBC=13000 PMN=90%. Following resuscitation of the patient and insertion of CVP and Foley catheters and administration of broad-spectrum antibiotics, an broademergency barium esophagography was performed and esophageal perforation including its site and extent was confirmed (Fig 2).
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A right postero-lateral thoracotomy was posteroperformed and after evacuation of significant pus and complete clearing of the operative site by irrigation, irrigation, the esophageal perforation was closed and reinforced with pleural patch and intercostal muscle flap wrap. A jejunostomy tube was also wrap. inserted. Post-operatively, 5-litre daily irrigation Post(by a catheter within the chest tube) and antibiotics were given until the drainage was clear and the patient became afebrile.

Esophagography performed 12 days after the operation (Fig.3) showed a scant leakage.Thus, (Fig.3 leakage.Thus, feeding via jejunostomy tube and antibiotics were continued while the patient remained completely stable with no signs of sepsis. Esophagography performed 3 weeks after the operation showed a well-healed esophagus with wellno leakage.The patient increasingly tolerated a normal diet and discharged after 35 days of hospital stay with no complication. FollowFollow-up of the patient since 6 months after the operation has revealed no dysphagia or any other difficulty in swallowing.