Stented Esophageal Transfixion Injury

Ann Thorac Surg 2008;86:1367–9

References 1. Coffin CM, Hornick JL, Fletcher CD. Inflammatory myofibroblastic tumor: comparison of clinicopathologic, histologic, and immunohistochemical features including ALK expression in atypical and aggressive cases. Am J Surg Pathol 2007;31: 509 –20. 2. Coffin CM, Watterson J, Priest JR, Dehner LP. Extrapulmonary inflammatory myofibroblastic tumor (inflammatory pseudotumor). Am J Surg Pathol 1995;19:859 –72. 3. Kovach SJ, Fischer AC, Katzman PJ, et al. Inflammatory myofibroblastic tumors. J Surg Onc 2006;94:385–91. 4. Kurihara K, Mizuseki K, Ichikawa M, et al. Esophageal inflammatory pseudotumor mimicking malignancy. Intern Med 2001;40:18 –22. 5. Marchi S, Costa F, Mumolo MG, et al. Post-traumatic inflammatory pseudotumor of the esophagus. Gastrointest Endosc 2001;54:397–9. 6. Saklani AP, Pramesh CS, Heroor AA, et al. Inflammatory pseudotumor of the esophagus. Dis Esophagus 2001;14:274 –7. 7. Zwischenberger JB, Savage C, Bhutani MS. Esophagus. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston textbook of surgery, 17th ed. Philadelphia, PA: Saunders; 2004:1116 –7. 8. Gan SI, Rajan E, Adler DG, et al. Role of EUS. Gastrointest Endosc 2007;66:425–34.

Stented Esophageal Transfixion Injury Samer Bazerbashi, FRCS, Jaime Villaquiran, FRCS, Mark Bennett, MD, FRCA, Michael Jonathan Unsworth-White, FRCS, and Joe Rahamim, FRCS South West Cardiothoracic Centre, Derriford Hospital, Plymouth, United Kingdom

Esophageal perforation is a rare, but life-threatening condition with a mortality rate ranging between 10% and 40%. It can happen at the level of the cervical, intrathoracic, or intra-abdominal segment. It usually occurs as a result of iatrogenic injury after endoscopic procedures or as a spontaneous rupture. It is seen less frequently in trauma after gunshot or stab wounds. Stenting of the esophagus after iatrogenic perforation is well documented in the literature, but yet it is to be published for management of penetrating injury. We report a case of esophageal perforation with a wooden fence post treated successfully with a covered esophageal stent. (Ann Thorac Surg 2008;86:1367–9) © 2008 by The Society of Thoracic Surgeons Accepted for publication March 19, 2008. Address correspondence to Dr Bazerbashi, Derriford Hospital, Plymouth, PL6 8DH, United Kingdom; e-mail: [email protected].

© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc

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urgical repair of esophageal perforation remains the gold standard treatment of choice for traumatic injury with primary repair, pleural drainage, and antibiotics. Recently, esophageal stents have emerged as a safe and effective alternative to surgery in the management of esophageal perforation, secondary to malignant tumour and nonmalignant perforation [1]. We report a case of a 16-year-old man who fell (2 m) onto a wooden fence post resulting in chest impalement through the right axilla. He presented to the emergency department at a general hospital with the post in situ, complaining of chest pain and shortness of breath, and he had subcutaneous emphysema. In view of the pain, the need for transfer to imaging and the anticipated surgery, he was intubated and ventilated. A computed tomographic scan of the patient’s chest showed the post had penetrated the right upper lobe and had passed behind the trachea, transecting the esophagus before passing through the left upper lobe and abutting the chest wall at the top of the left pleural cavity (Figs 1 and 2). There were bilateral pneumothoraxes and a right hemothorax, but no damage to major vessels was identified. The patient was transferred to our center for further management. When he arrived, he was stabilized in the intensive care unit before being taken to the operating room. A flexible bronchoscopy demonstrated external compression of the trachea. An upper gastrointestinal endoscopic examination revealed obliteration of the esophageal lumen at 20 cm by the wooden post, which was clearly visible in the lumen. A right thoracotomy confirmed the computed tomographic findings. The post narrowly missed the superior pulmonary artery with severe bruising around it; it passed behind the trachea causing a 4-cm laceration of the mid-esophagus, involving two thirds of its circumference. Two thirds of the patient’s right upper lobe was resected to control the bleeding. Once the post had been removed, the options for managing the esophageal laceration were considered. The laceration was too large for a primary repair, because a portion of the esophageal wall had been torn away and the wound edges were necrotic. Another option might have been to resect the esophagus and de-function it, and aim for later gastric or colonic transposition. In view of the patient’s age and the need for optimal functional results, a third option emerged, which was to use a stent. Although there are no reports to back our decision, we opted for stenting because of our experience in managing nontraumatic esophageal perforations. If this technique failed, diversion or transposition was still an available option. The Niti S (Taewoong Medical, Gyeonggi, Korea) covered stent (18 mm ⫻ 150 mm) was deployed endoscopically, while the chest was opened with an image intensifier and guidance from a second operating surgeon who directly confirmed the optimal position across the perforation. Due to the large extent of the perforation, and the perfect seal by the covered stent, we did not use a pleural, pericardial, or intercostal muscle buttressing 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.03.028

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ageal IMT should be complete surgical resection. The selection of a surgical procedure should be based on preoperative evaluation of tumor size and involvement of the muscularis propria.

CASE REPORT BAZERBASHI ET AL STENTS IN ESOPHAGEAL TRAUMA

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CASE REPORT BAZERBASHI ET AL STENTS IN ESOPHAGEAL TRAUMA

Fig 1. Transverse computed tomographic scan section showing the penetration through the mediastinum.

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flap. In our opinion, these flaps have poor blood supply and may compromise the healing of the rent in the esophagus. Finally, a left-sided thoracoscopy revealed a minimal hemothorax and little air leak, considering the penetration through the left upper lobe. Postoperatively, the patient received total parental nutrition for 5 days until a swallow showed no evidence of esophageal leak. After the commencement of oral intake, he spiked a high temperature of 38°C with leukocytosis, and an esophageal leak was suspected. The contrast study was repeated and demonstrated only minimal leak. A computed tomographic scan of the chest did not show any mediastinal collection. He received naso-jejunal nutrition for a further 7 days. Furthermore, a water-soluble swallow confirmed no evidence of leak. Oral fluid intake was recommenced and was gradually built up to a normal diet without further problems and no signs of sepsis. He was discharged home on day 26 of his admission.

Ann Thorac Surg 2008;86:1367–9

much as 50% of cervical perforations that are not detected; therefore, this should not satisfy us if we clinically suspect it. Mortality because of these injuries is high, especially if there is a delay in the diagnosis and treatment. A high index of suspicion is essential to make an early diagnosis. There are few published reports dealing with noniatrogenic perforation of the esophagus. These emphasize the negative impact of delay on the final outcome [2, 4]. Asensio and colleagues [4] concluded that treatment must be commenced within 13 hours from the time of injury. In our case, the time between injury and surgery was 14 hours, mainly due to the transfer to our center and the need for imaging. The principles of managing esophageal perforation are elimination of the source of soiling and contamination, adequate pleural drainage, antibiotics, and adequate nutrition. The best treatment option for penetrating esophageal perforation is still controversial, but surgery with primary repair and drainage of the pleural cavity with or without a flap buttressing the repair is still accepted as the gold standard [4, 5]. Delayed perforation can be more difficult to treat and the options are primary repair, resection and diversion, T-tube drainage, or conservative management by pleural drainage alone. Esophageal stenting has increasingly become the management of choice for esophageal perforation from a wide range of causes. Stents seal the hole and prevent further contamination of the mediastinum and pleural cavity. This often results in an excellent outcome with minimal morbidity and mortality and may obviate the need for further surgery. This principle has also been applied for delayed perforations, but with less favorable outcomes [3]. In this case, the stent was highly successful, and at follow-up 3 months later, he was very well and leading a normal life. Ongoing management decisions included when to remove the stent and how difficult this would be to perform.

Comment Penetrating esophageal perforation is rare in chest trauma. Even in the largest trauma centers, only a few cases are encountered each year. This is due to the relatively small surface area of the esophagus, the proximity of vital vascular structures, and the protected location of the esophagus deep within the mediastinum [2]. Penetrating injury to the esophagus occurs mainly to the cervical part, with morbidity and mortality usually related to the associated injuries. At this location, it is easier to treat than either intrathoracic or intraabdominal perforations [3]. A water-soluble contrast study is a useful diagnostic tool in stable patients and has a high sensitivity rate of 93%. If combined with intraoperative flexible esophagoscopy, the sensitivity is almost 100% [2]. A negative study does not rule out esophageal injury, because there are as

Fig 2. Longitudinal computed tomographic scan section showing the penetration through the mediastinum.

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CASE REPORT IZUTANI ET AL EARLY AORTIC BIOPROSTHETIC VALVE DETERIORATION

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Early Aortic Bioprosthetic Valve Deterioration in an Octogenarian Hironori Izutani, MD, PhD, Takanori Shibukawa, MD, Jun Kawamoto, MD, Shingo Mochiduki, MD, and Dairoku Nishikawa, MD Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Center, Hiroshima, Japan

We experienced extremely early aortic bioprosthetic valve deterioration with leaflet calcification and stiffening 21/2 years after aortic valve replacement in a female octogenarian. We could not identify the possible reason for this devastating complication; however, daily calcium supplement consumption may play a role of acceleration of calcium deposition in the leaflets of implanted bioprosthetic heart valves. (Ann Thorac Surg 2008;86:1369 –71) © 2008 by The Society of Thoracic Surgeons

Our experience with esophageal stents is limited to its use for malignant disease and iatrogenic perforations. We usually attempt to remove the stent at 3 months after insertion to pre-empt adherence to the esophageal wall and tumor overgrowth. Occasionally it can prove very difficult to remove them. Since there were no previously published reports to guide us, we believed that the same principles could be applied here. The patient was electively readmitted 3 months later for removal of the stent. Fortunately the stent came out without difficulty, and it was noted that the perforation site was completely epithelialized. He did well postoperatively and a barium swallow was entirely satisfactory (Fig 3). The patient was discharged home 2 days later. The covered esophageal stent clearly has a role to play in the management of non-iatrogenic traumatic esophageal perforation. We look forward to hearing of others’ experience in this field.

References 1. Fischer A, Thomusch O, Benz S, von Dobschetz E, Baier, P, Hopt UT. Non-operative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 2006;81:467–73. 2. Smakman N, Nicol AJ, Walther G, Brooks A, Navsaria PH, Zellweger R. Factors affecting outcome in penetrating esophagael trauma. Br J Surg 2004;91:1513–9. 3. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser R, Kucharczuk C. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475– 83. 4. Asensio JA, Chahwan S, Forno W, et al. Penetrating oesophageal injuries: multicenter study of the American association for surgery of trauma. J Trauma 2001;50:289 –96. 5. Vogel SB, Rout WR, Martin TD, Abbitt. Esophageal perforation in adults. Aggressive, conservative treatment lowers morbidity and mortality. Ann Surg 2005;241:1016 –23. © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc

ong-term durability and stability of the hemodynamic performance of commercially available second generation Carpentier-Edwards stented bovine pericardial aortic bioprostheses (Perimount valve; Edwards Lifesciences, Irvine, CA) is reported based on echocardiographic findings during a 17-year period of follow-up examinations [1]. With a low rate of valve-related events and an especially low rate of structural failure, the Perimount valve (Edwards Lifesciences) is a reliable choice for patients with calcified aortic stenosis by a report of 18 years follow-up study [2]. Prosthetic valve deterioration of the Perimount valve usually occurs late and is age-dependent. Therefore, aortic valve replacement with a bioprosthesis is a reliable surgical management for elderly patients with severe aortic stenosis. We describe bioprosthetic valve deterioration of a Perimount valve with severe congestive heart failure 21/2 years postoperatively that developed in an octogenarian patient. An 80-year-old woman who had no history of heart disease was hospitalized for congestive heart failure. She had a history of myelodysplastic disorder, which had been followed regularly with steroids for more than a decade. Her echocardiography showed severe aortic stenosis with a maximum pressure gradient of 100 mm Hg, moderate mitral regurgitation, and moderate tricuspid regurgitation with normal left ventricular function. It was recommended for the patient to undergo elective heart valve surgery. She underwent aortic valve replacement with a 21-mm Perimount valve, mitral annuloplasty with a 26-mm Cosgrove-Edwards annuloplasty ring (Edwards Lifesciences), and tricuspid annuloplasty with modified DeVega technique under standard open heart proceAccepted for publication March 27, 2008. Address correspondence to Dr Izutani, Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Center, 3-1 Aoyama-cho, Kure, Hiroshima, 737-0023, Japan; e-mail: [email protected]. osaka.jp.

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Fig 3. Post-stent removal barium swallow.

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