|Year : 2015 | Volume
| Issue : 2 | Page : 121-125
Mediastinal traversing fatal oesophageal injury from an unusual trajectory: A case report and review of literature
Jameel Ismail Ahmad1, Ismail Mohammed Inuwa1, Mahmud Atiku2, Adamu Atiku3
1 Department of Surgery, Division of Cardiothoracic Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Anaesthesia, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||10-Nov-2015|
Jameel Ismail Ahmad
Department of Surgery, Division of Cardiothoracic Surgery, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Oesophageal perforation is a potentially lethal clinical condition. Penetrating thoracic oesophageal injury is associated with increased morbidity and mortality, especially if the interval between the injury and commencement of treatment is delayed beyond 24 h. We present a 20-year-old man with a 2 weeks history of mediastinal traversing thoracic oesophageal injury and secondary right empyema following assault. The injury was a stab using a long knife with an entry point at the upper left arm which took an unusual trajectory to traverse the left hemithorax and the mediastinum to penetrate the oesophagus in the right hemithorax. He was resuscitated and thoracotomy was done where the perforation was repaired and the lung decorticated, but he sustained cardiac arrest and could not be resuscitated. Delayed time interval between the time of oesophageal injury and the commencement of treatment is a key determinant of patients' outcome. Prompt diagnosis and institution of treatment significantly reduce the morbidity and mortality associated with oesophageal perforation.
Keywords: Late treatment of oesophageal perforation, mediastinal traversing injury, mortality
|How to cite this article:|
Ahmad JI, Inuwa IM, Atiku M, Atiku A. Mediastinal traversing fatal oesophageal injury from an unusual trajectory: A case report and review of literature. Niger J Basic Clin Sci 2015;12:121-5
|How to cite this URL:|
Ahmad JI, Inuwa IM, Atiku M, Atiku A. Mediastinal traversing fatal oesophageal injury from an unusual trajectory: A case report and review of literature. Niger J Basic Clin Sci [serial online] 2015 [cited 2021 Jun 23];12:121-5. Available from: https://www.njbcs.net/text.asp?2015/12/2/121/169288
| Introduction|| |
Oesophageal perforation is an uncommon clinical condition albeit with potential grave consequences. Iatrogenic perforation is the most common cause, but external trauma also plays a role. Penetrating thoracic oesophageal injury is caused mostly by gunshot injury although stab injury can also involve the oesophagus depending on the trajectory of the injuring object.
The clinical features are often non-specific with chest pain as the most common symptom. Chest X-ray gives a hint about the diagnosis, but contrast radiography (barium/gastrografin swallow) is the diagnostic investigation. Oesophageal repair is the treatment with the best outcome while other options exist including non-operative treatment.
There are many factors that determine the outcome of oesophageal perforation prominent among which is the time interval between injury and commencement of treatment. It is considered early if the time is within 24 h and delayed if it goes beyond 24 h. The mortality is doubled or worse if the interval is delayed. Thus, prompt diagnosis and commencement of treatment in earnest is crucial in mproving the overall patients' outcome.
| Case Report|| |
We present a 20-year-old man who was referred to our hospital from a Medical Centre in North-Eastern Nigeria (about 700 km away) with a 2 weeks history of stab injury to the left upper arm by a chased thief who mistook him as one of his pursuers. The stab knife penetrated into the chest with associated profuse bleeding. He was taken to the referring hospital where bilateral chest tubes were inserted due to radiological evidence of bilateral haemopneumothorax. The right chest tube started draining food eaten by the patient a day after and he was suspected to have oesophageal perforation and placed on nil per os. The left chest tube stopped draining for which it was removed and he was then referred to our centre.
When we reviewed him on a presentation, he was severely dehydrated, pale, afebrile and in septic shock. There was a wound on the anterior aspect of the left upper arm [Figure 1] which was the stab entry for the mediastinal traversing injury (MTI) into the left and then the right chest. The right chest tube was draining pus and there was marked decrease in air entry on the right chest zones. He was commenced on resuscitation with intravenous fluids and broad spectrum antibiotics for 3 days. A complete blood count revealed a haemoglobin level of 12.5 g/dl and leucocytosis of 22.96 × 109 (72.07% granulocytes). The serum urea, electrolytes and creatinine were essentially normal except that he was mildly acidotic. A dilute barium swallow was done within 8 h of presentation which confirmed the upper thoracic oesophageal perforation into the right pleural space with trapped right lung [Figure 2].
|Figure 1: The entry point and direction for the mediastinal traversing injury (arrow)|
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|Figure 2: Dilute barium swallow showing the leak due to oesophageal perforation|
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A diagnosis of penetrating thoracic oesophageal perforation due to stab injury with secondary right empyema thoracis was made. Following resuscitation, his haemodynamic status improved and he was making adequate urine although he was still in respiratory distress. He was thus planned for thoracotomy with the intention of primary repair of the oesophageal perforation if possible and an alternative plan of oesophageal exclusion and diversion.
A right posterolateral thoracotomy was done and the hemithorax was accessed via the 5th intercostal space. The collapsed right lung trapped by dense pleural peel was found and the site of oesophageal perforation was identified. The oesophagus was mobilised; the perforation edges were refreshened and a single layer transverse closure was done over a nasogastric tube. The right lung was also decorticated and it fully expanded. Unfortunately he suddenly developed cardiac arrest after completion of the procedure. Cardiopulmonary resuscitation was immediately commenced and after about 30 min he could not be resuscitated and he was confirmed dead. The possible causes of the cardiac arrest were septic shock and the added metabolic stress of the surgery, the severe chemical and bacterial mediastinitis and respiratory failure from chemical aspiration pneumonitis.
| Discussion|| |
Mediastinal traversing injury and its trajectories
MTI is a penetrating mediastinal injury commonly caused by firearm injury and infrequently by stab injuries. The presence of entry and exit wounds on either side of the chest, penetrating central chest wounds and radiological evidence of a bullet or an impaled object in the contralateral hemithorax suggest MTI.
The trajectories of MTI vary and include anteroposterior (parasternal or transpulmonary), descending (from the root of the neck), lower and upper transverse trajectories [Figure 3]. Our patient sustained the rare penetrating upper transverse MTI and the structures at risk of injury include the aortic arch, superior vena cava, brachiocephalic vein, pulmonary arteries, trachea and the oesophagus. The incidence of oesophageal injuries in MTI is uncommon.
|Figure 3: Trajectories in mediastinal traversing injury. Blue arrow = descending, red arrow = anteroposterior parasternal, yellow arrow = anteroposterior transpulmonary, green arrow = lower transverse, black arrow = upper transverse trajectory as in our patient|
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The outcome of patients with MTI depends on the injured structures and the management requires an algorithm to enable early recognition and prompt treatment of vascular and visceral injuries as depicted by Gunn et al.
Oesophageal perforation is a potentially life-threatening clinical condition with a high morbidity and mortality and non-specific clinical symptoms and signs. Some anatomical features of the oesophagus such as its lack of serosal covering, tenuous segmental blood supply, difficult accessibility and proximity to vital structures predispose to the increased morbidity and mortality associated with its perforation. This is coupled with the rarity of its occurrence which limits versed individual surgeon experience as well as lack of randomised studies and class I evidence for diagnosis and management protocols.,
Oesophageal perforation is uncommon with a reported incidence of <0.5%. Age standardised incidence of 3.1/1,000,000/year was also reported. Iatrogenic perforations (following oesophagoscopy) constitutes more than 50% of the aetiology which is followed by spontaneous perforation-Boerhaave's syndrome (15%), foreign body ingestion (12%), external trauma (9%), intraoperative trauma (2%) and malignancy (1%). These percentages may differ by reports.,,,, The perforations can occur on the cervical, thoracic or abdominal part of the oesophagus. Involvement of the thoracic oesophagus is most common in many reports (as in our patient) but the frequency of oesophageal segments' involvement also vary.,,,,
Penetrating oesophageal injury
This is very rare in most series. Asensio et al. reported 405 patients with penetrating oesophageal injury in a 10.5 years retrospective study involving 34 Trauma Centres in the United States of America. An analysis of the US National Trauma Data Bank for 2007–2008 involving 107 centres also discovered 227 patients. This and other reports indicate a mean patient number of 2/centre/year. Penetrating oesophageal injuries occur in about 0.7% of all patients with a gunshot injury to the chest. A gunshot is a more common cause (78.8%) than stab injury (18.5%) which our patient sustained.,
The principles of management of oesophageal perforation are a rapid diagnosis, haemodynamic support and monitoring, antibiotic therapy, the establishment of luminal integrity and control of extraluminal contamination. The clinical presentation is usually non-specific and some may be missed which can lead to delayed presentation and consequent fatality. Chest pain, dyspnoea, dysphagia, fever, tachycardia and subcutaneous emphysema are the common clinical features.,,,
The diagnosis of oesophageal perforation can be confirmed by plain chest X-ray, contrast X-rays and computed tomography (CT) scanning. Endoscopy has a limited role, but intraoperative endoscopy is relevant. Plain chest X-ray features include mediastinal emphysema within an hour and subsequently mediastinal widening, pleural effusion or pneumothorax as well as subcutaneous emphysema.
Contrast radiograph in the form of barium or gastrografin swallow is sensitive in identifying the perforation. There is a debate on which contrast is the best between barium sulphate and gastrografin (meglumine sodium). Although barium has a higher density and better mucosal adherence and so increased leak detection rate, it leads to more intense mediastinal inflammation and fibrosis and stays longer to confuse future mediastinal and pleural radiological diagnosis. On the other hand, gastrografin has lower detection rate but is devoid of the inflammatory and diagnostic shortcoming. Its other shortcoming is severe necrotising pneumonitis if aspirated. On a balance note, a dilute or thin barium swallow is a preferred option., Our patient did the dilute barium swallow [Figure 2]. Contrast CT scan is also a sensitive tool. A pleural fluid that yields food particles (as in our patient), pH of <6.0 and raised serum amylase is also suggestive.
There are many options in the treatment of oesophageal perforation. The surgical options include primary oesophageal repair which has the best outcome as shown by a meta-analysis of 75 studies involving 2971 patients. It involves thoracotomy, mobilisation and debridement of the oesophagus and tension free closure of the perforation which may be buttressed by a pleural or muscle flap. The pleural space is then debrided and drained.
Other options include oesophagectomy, exclusion and diversion, use of T-tube, diversion alone and minimally invasive procedures such as temporary endoscopic stenting, use of endoclips and video assisted thoracic surgery. Non-operative treatment is reserved for contained leak in stable patients.,,
Outcome of delayed oesophageal injury
The factors that determine the outcome of oesophageal injury are the location of the injury, time interval between injury and commencement of treatment, containment of the injury, severity of patient's clinical status, mechanism of injury and the premorbid state of the oesophagus. Early oesophageal perforation is when the treatment is instituted within 24 h of the injury while delayed is when the treatment is commenced beyond 24 h. This determines the patient's outcome significantly.
The perforation leads to contamination of the visceral mediastinum with oesophageal and gastric contents which perforates the mediastinal pleura and cause pleural effusion. The contamination incites an intense inflammatory response with consequent cytokine activation, overwhelming chemical and bacterial mediastinitis, fluid sequestration, hypotension and cardiopulmonary collapse. Septic shock leads to multiple organ failure and death.,
Delayed presentations have consistently resulted in increased mortality in oesophageal perforation. Several reports revealed at least doubling of the mortality in delayed presentations when compared to early presentations. Brinster et al. reviewed 11 recent series and reported an increase mortality from 14% (0–28%) to 27% (0–46%) when the presentation is delayed beyond 24 h. This is similar to other reports., The least mortality of 8% was reported by Port et al.
Most of the delayed presentation in the above series presented within 48–72 h while our patient presented after 2 weeks in septic shock, severe chemical and bacterial mediastinitis, empyema and collapsed right lung and therefore, a very high operative risk and he was operated 3 weeks after the injury. The reported cases closest to our patient were by Sengul et al. which included three patients presenting on the 3rd day of the perforation and two patients on the 7th day. All the five patients died and the mortality increased from 0% to 50% from the early to the delayed presentation. Similarly, Javaherzadeh et al. reported a 16.7% mortality among whom was a patient who presented 15 days after perforation and she died a day after surgery due to cardiopulmonary arrest as in our patient.
| Conclusion|| |
Mediastinal traversing injuries can cause oesophageal injury depending on the trajectory. Oesophageal perforation is a potentially lethal condition which is still characterised by increased morbidity and mortality. Delayed presentation of more than 24 h has a significant impact on the overall outcome. Most series of delayed presentation demonstrated (at least) doubling of the mortality. There are many surgical treatment options to be chosen based on several factors. We advise physicians to have a high index of suspicion for oesophageal perforation to ensure early diagnosis and prompt institution of appropriate treatment within 24 h which is imperative to improve the patients' outcome.
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[Figure 1], [Figure 2], [Figure 3]