Clinical Challenges in Trauma Surgery: Traumatic Esophageal Injury

Nov 7, 2024

Dive into the complexities of traumatic esophageal injuries with expert insights on effective management strategies. Discover crucial decision-making processes, including distinguishing between blunt and penetrating trauma. Learn about key clinical indicators and the need for surgical intervention in cases of penetrating neck wounds. Explore essential surgical techniques for repairing esophageal trauma and the significance of a quick primary survey. Don't miss the pearls of wisdom that can shape your approach in critical situations!

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ADVICE

Penetrating Neck Trauma Management

Go to the OR immediately for hard signs of vascular or aerodigestive injury or hemodynamic instability.
If there are no hard signs, get a CTA of the neck.

ADVICE

Zone-Based Management

For penetrating neck wounds without hard signs, determine the zone of injury.
Zone 2 injuries go to the OR if symptomatic, otherwise, get a CTA.

ADVICE

Penetrating Chest Trauma

With penetrating chest injuries, consider if the trajectory is transmediastinal.
If so and the patient is stable, get a CTA of the chest; unstable patients go to the OR.

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The dreaded esophageal injury. Do you still have nightmares about mock oral board scenarios torturing you with the ins and outs of how to manage traumatic esophageal injury? Think you remember all the nuances? Whether you do or you don’t, this episode should serve as a good refresher for all levels while offering some pearls for management of this tricky scenario.

Hosts:
- Michael Cobler-Lichter, MD, PGY4/R2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (X/twitter)

- Dylan Tanzer, MD, 2nd-year Trauma/Surgical Critical Care Fellow
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center

- Eugenia Kwon, MD, Trauma/Surgical Critical Care Attending:
Loma Linda University
Recent graduate of University of Miami/Jackson Memorial Hospital/Ryder Trauma Center Trauma/CC Fellowship

- Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery, 5 years in practice
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@jpmeizoso (twitter)

Learning Objectives:
- Describe the diagnostic workup of a suspected traumatic esophageal injury
- Identify when someone with suspected esophageal injury needs immediate surgical management
- Describe appropriate surgical techniques for repair of both cervical and thoracic esophageal injuries

Quick Hits:
1. Don’t forget the primary survey. Unstable patients should be in the OR, as should patients with hard signs of vascular or aerodigestive injury
2. If there is concern for esophageal injury but no immediate indication for the OR, this should be further investigated with CTA of the affected area. Clinical exam has poor sensitivity.
3. The esophagus should be primarily repaired if the defect is able to come together without tension after debridement. Don’t forget a well-vascularized buttress
4. If you cannot perform a primary repair, your procedure of choice should be lateral esophagostomy with feeding jejunostomy and gastrostomy for decompression. Repair over T-tube can be considered for injuries with small amounts of tissue loss

References
1. Biffl WL, Moore EE, Feliciano DV, Albrecht RA, Croce M, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Diagnosis and Management of Esophageal Injuries. J Trauma Acute Care Surg 2015;79(6):1089-95.
https://pubmed.ncbi.nlm.nih.gov/26680145/

2. Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013;75(6):936-40.
https://pubmed.ncbi.nlm.nih.gov/24256663/

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