Khan, Naeem -uz-Zafar

Khan, Saima H

Mian, Asad

English

Penetrating firearm injuries of the chest have become commonplace in children living in violent urban areas. Esophageal perforation may present as a late manifestation of peadiatric thoracic trauma due to gunshot injury. Opinion varies as to the surgical or nonsurgical management of such a patient. The authors report a case of a 12-year-old girl who presented with a similar dilemma and her successful conservative management, that they opted for; is discussed

Khan, Saima H.

Khan, Naeem-uz-Zafar

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanJanuary 1997Late onset oesophageal perforation due to gunshotinjury of chest: successful non-operativemanagement in a young childAsad MianAga Khan University, asad.mian@aku.eduSaima H. KhanNaeem -uz-Zafar KhanFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Emergency Medicine CommonsRecommended CitationMian, A., Khan, S. H., Khan, N. (1997). Late onset oesophageal perforation due to gunshot injury of chest: successful non-operativemanagement in a young child. Journal of Surgery Pakistan, 2(1), 17-20.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/126LATE ONSET ESOPHAGEAL PERFORATION DUE TOGUNSHOT INJURY OF CHEST: SUCCESSFUL NONOP-ERATIVE MANAGEMENT IN A YOUNG CHILD.A Case ReportASAD I. MIAN*, SAIMA H. KHAN*, M. NAEEM-UZ-ZAFAR KHAN**ABSTRACT:Penetrating firearm iniuries oj the chest have become commonplace in childern living in vio-lent urban areas. Esophageal petforoiioti may present as a late manifestation oj peadiatricthoracic trauma due to gunshot injuru. Opinion varies as to the surgical or nonsurgical man-agement oj such a patient. The authors report a case oj a 12-year-old girl who presented witha similar dilemma and her successJul conservative management, that they opted [or; is dis-cussed.KEYWORDS: Esophageal perforation, firearm injuries, penetrating thoracic trauma.INTRODUCTIONPenetrating thoracic trauma by high-velocity projectileaccounts for 10% to 15%'2 of childhood firearminjuries, and is on the rise." It is the commonest causeof thoracic injury in childern 12-years of age or older,"The lesions are diverse and may involve any intratho-racic structure." Perforation of the esophagus, due tofirearm, is the most severe complication of esophagealinjury and a life-threatening condition that requiresprompt diagnosis and treatment." Unfortunately, dam-age to the esophagus due to intrathoracic trauma isoften overlooked during the initial examination, or isnot immediately apparent because of delay in presen-tation." Management of cases of delayed onsetesophageal perforation remains controversial.i'"Herein we describe the case of a child who developedlate onset esophageal perforation due to firearminjury of the chest. Her successful nonoperative man-agement is reported and discussed as described in lit-erature.CASE REPORT:A twelve-year-old girl presented 24 hours after sus-All correspondence to:M. Naeem-uz-Zatar Khan,Department of Paediatric Surgery. The Childern'sHospital, P.I.M.S.,lslarnabad,Pakistan.taining a bullet injury of the chest. The injury had ledto profuse bleeding from her right shoulder. The girldeveloped progressive difficulty in breathing andcyanosis. Bleeding was curtailed by pressure bandageuntil her arrival to the ER, where she was found to bein severe pain and obvious respiratory distress. Shehad heart rate of 120/min., respiratory rate of 30/min.,and blood -pressure of 90/60 mm of Hg. She had a1cm. x 1cm. wound of entry along the posterior axillaryfold on the left axilla, and the wound of exit was 5cm x3cm along the right suprascapular region. Left side ofthe chest had decreased expansion and absent breathsounds. A chest radiograph showed an air-fluid levelon the left and a needle thoracentesis was diagnosticfor a hemopneumothorax. Immediate chest intubationwas done and hemorrhagic fluid drained.In the intensive care unit broad-spectrum intravenousantibiotics (a third generation cephalosporin, anaminoglycoside and metronidazole) were prescribed,and oral intake was allowed. The, chest tube wasremoved after four days but subsequently the childdeveloped a continuous high grade fever. Bloodcounts showed a persistent leucocytosis with neu-trophilia. On the fifth day of admission, thick pus andsaliva started oozing from the wound of exit, followedtwo days later by frank discharge of foul smelling foodmaterial from the same site. This was the first clinicalindication of a delayed presentation of esophageal17 Journal of Surgery Pakistan (International) Vol. 2 (1); January 1997Late onset Esophageal Perforation due to Gunshot Injury of chest: successful Nonoperative Management in a young child.perforation, secondary to the transmediastinal trajec-tory of a projectile. A gastrografin (radiographic con-trast) study under fluoroscopic control on the eighthpost-traumatic day, confirmed the presence of a perfo-ration of the thoracic esophagus at the level of thethird thoracic vertebra. There was leakage of contrastthat communicated with the skin through the wound ofexit. Surprisingly, on the left side of the chest, leakageof contrast extends down to the level of the left domeof the diaphragm (Fig.1).Figure 1.Gastrografin contrast study performed eight days subse-quent to thoracic gunshot injury confirmed esophageal perforation;leakage of contrast can be seen on both sides of the thorax (arrows).The patient was put on nasogastric feeding in prop-upposition, with a high caloric intake. Continuous suctionat the wound of exit and toilet of the wound of entrywas initiated, alongwith continuous pharyngeal suctionand chest physiotherapy; intravenous antibiotic werecontinued. On the fourteenth post-trauma day, onceagain the left side of the chest showed diminishedventilation. A chest radiograph and a subsequent tho-racentesis revealed a left-side empyema thorax, whichwas drained by a wide thoracostomy tube with anunderwater seal. With the chest tube in place and con-tinued drainage of the purulent fluid, and subsequentchest radiographs showed progressive improvement.Conservative management of our patient helped puther on the path of steady recovery. Her Pyrexia settledand her thorax cleared. Chest tube was removed andsubsequent chest radiograph showed clear lung fields.Repeat gastrografin contrast studies over subsequentweeks showed progressive reduction of the fistuloustracts (Fig. 2A & 8).Figure 2AFigure 28.Repeat gastrografin studies over the subsequent weeks showingprogressive decrease in the sizes of the fistulous tracts. These wereperformed on the fifteenth (A) and the thirtieth (B) post-trauma days,respectively.DISCUSSION:Whenever a penetrating wound to the chest hascrossed the midline, one actively needs to excludeinjury to the mediastinal structures, such as the heart,aortic arch, bronchial tree, and the esophagus, eventhough injury to such structures may not be immedi-Journal of Surgery Pakistan (International) Vol. 2 (1); January 1997 18Asad I. Mian, Saima H. Khan, M. Naeem-uz-Zafar Khanately clinically apparent. 8.9 Esophageal perforationsoccur most commonly as an iatrogenic complication(75% to 77%),3.10.11with chest trauma accounting foronly 2% to 10%'·3.'0.'2.'3of all esophageal injuries. Theesophagus is infrequently the site of isolated traumabecause of its protected position and small diameter.The seriousness of perforation is heightened by thefact that the esophagus is surrounded by loose con-nective tissue that does not effectively prevent dis-semination of infection and inflammation; withouttreatment the outcome usually is fatal.' However, mostreports have been based on adult series with few chil-dren included. Thus the conclusions regarding etiolo-gy, treatment and outcome may differ and may not be7directly applicable to the paediatric patient. Fewguidelines are available which facilitate treatment of14patients with non iatrogenic injuries of the esophagus.Esophageal perforations due to penetrating trauma ofthe chest may lead to a linear tear in the esophagusallowing leakage into the mediastinum, producingmediastinitis, and immediate or delayed rupture into1Sthe pleural space, producing empyema. These twocomplications were late manifestations in our patient.There are distinct clinical patterns of presentation,depending on the level of esophageal perforation.Atleast 75% of patients with perforation have dyspha-gia and excruciating pain on swallowlnq." In the olderchild, severe pleuritic pain or substernal pain are thehallmarks of perforation. Fever may often be quite highand a rapid, toxic progression to shock may occur inpatients of any age, but seems to be commoner inolder children with free pleural involvement. However,esophageal perforations may occasionally present inan obscure fashion, as in our patient, without the dra-matic explosion described above. In such instances,the diagnosis may be missed for many days orweeks.'° Late sequelae are rare because patients donot survive the initial trauma or because the injury isrecognized early and treated appropriately." In ourpatient a fistula between the esophagus and skin viathe wound of exit was a late sequela because ofunrecognized trauma to the esophagus.Early diagnosis of esophageal perforation is suspect-ed clinically and confirmed radioloqically." The resultsof plain radiographs of the chest and neck will suggestthe diagnosis in the majority of cases.' Characteristicfindings are subcutaneous emphysema, pneumome.di-astinum, pleural effusion and/or pneumothorax, whichwere absent in our patient. It is noteworthy that upperthoracic perforations, as in our case, present with left-sided effusion, while lower thoracic perforations have7right-sided signs. This is contrary to previous findings.Anatomically the left pleura is closely related to theesophagus in the superior medistinum, whereas theright pleura is in intimate contact with the distal two-thirds of the esophagus, except where it is crossed bythe azygos vein. This most likely accounts for the pat-tern of presentation. Plain radiographs should be fol-lowed by water-soluble (e.g. gastrografin; diatrizoatemeglamine) study to accurately delineate the patholo-gy. If contrast study findings are negative in a case ofsuspected perforation, a dilute barium study should bepertormed.":" Esophagoscopy offers no diagnosticadvantages and may in fact enlarge the perforation,• 1Scomplicating subsequent repair.The most appropriate therapy for esophageal perfora-tion depends on the site of perforation, the intervalbetween the perforation and its recognition, and the10 d.systemic response to injury. In the past authors IS-couraged conservative (i.e. nonoperative) manage-ment that was proposed by Mengoly and Klassen in1965.'0 The "drain and hope" regimen was thought tobe a disappointment and hence a more aggressiveapproach was advocated. They suggested that prima-ry suture with appropriate drainage should be atte~pt-ed in early diagnosis (within 24 hours of perforation);for late cases only drainage should be performed.However in recent years varying accounts of manage-ment and prognosis have been reported for late rec-ognized perforation. Some current studies reveal thatdespite a high incidence of associated complications,survival following esophageal perforations is high and• 12,14the impact of delayed diagnosis is decreasing. Onthe other hand, others still report high morbidity andmortality due to delayed diagnosis and continue to18advocate a surgical approach.Literature review revealed controversial managementoptions for cases in which the delay in diagnosisexceeds 24 hours.7.19In our patient, the perforationwas a delayed manifestation of firearm injury. Weopted for a conservative approach. Our managementis in contrast to protocols for adults, for whom the goldstandard ,remains early aggressive surgical therapy,aiming for primary closure of the defect.7.19·21We con-clude that with appropriate conservative management,a good outcome can be expected with a traumaticesophageal perforation presenting late.REFERENCES:1. Nance, M.L. Sing R.F., Reilly P.M., et al: Thoracicgunshot wounds in children under 17 years of age.J Pediatr Surg. 1996, 31 (7):931-35.19 Journal of Surgery Pakistan (International) Vol. 2 (1); January 1997--Late onset Esophageal Perforation due to Gunshot Injury of chest: successful Nonoperative Management in a young child.2. Nance M.L, Templeton J.M., 0 Neill J.A.:Socioeconomic impact of gunshot wounds in anurban pediatric population. J Pediatr Surg.1994,29:39-43.3. Postlethwait R.w.: Surgery of the esophagus.New York, Appleton-Century-Crofts, 1979.4. Zavoski R.W., Lapidus G.D., et al: A population-based study of severe firearm injury among chil-dren and youth. Pediatrics. 1995, 96(2 Pt 1):278-82.5. Meller J.L., Little A.G., Shermata D.W. :Thoracictrauma in children. Pediatrics. 1984, 74:813.6. Reinberg 0., Genton N., Lacheretz M.:Particularities of thoracic trauma in children. In:Webb W.R., Besson A. (eds.): Thoracic surgery:Surgical management of chest injuries (chapter34). St. Louis, Mosby-Year Book, 1991,7:340.7. Panieri E., Millar A.J.W., et al: Iatrogenicesophageal perforations in children: Patterns ofinjury, presentation, management, and outcome. JPediatr Surg. 1996, 31(7):890-95.8. Haller J.A. Thoracic injuries. In: Welch K.J.,Randolph J.G., Ravitch MM, et al: Pediatricsurgery. Chicago, Year Book Medical Publishers,Inc. (chap 17); 1986, 143-53.9. Falcon O. Knott C., Elkins R.C. Gunshot woundstraversing the mediastinum: Guidelines for evalu-ation and management. J Okla State Med Assoc.87(4): 1994, 174-7.10. Popovici, Z.: Esophageal injuries. In: Webb, W.R.;Besson, A. (eds.): Thoracic surgery: Surgicalmanagement of chest injuries (chap 45). St. Louis,Mosby-Year Book. 1991, 7:443-66.11. Sawyer R., Philips C., Vakil N. Short and long-term outcome of esophageal perforations.Gastrointest endosc. 1995, 41(2):130-4.12. Reefder l.B., DeFilippi V.J., Ferguson MK.:Current results of therapy for esophageal perfora-tions. Am J Surg. 1996, 169(6):615-7.13. Besson A., Savary M.: Trauma of the esophagus.In: BessonA., Saegesser R.(eds.): SA colour atlasof chest trauma and associated injuries(chap. 11)London, Wolfe Medical Publications, Ud.(2):1983, 251-316.14. Weimam D.S., Walker W.A., Brosnan K.M.:Noniatrogenic esophageal trauma. Ann ThoracSurg. 1995, 59(4):845-9.15. Weber T.R.: Esophageal rupture and perforation.In: Welch K.J., Randolph J.G., Ravitch M.M.; et al:Pediatric Surgery.(chap 73) Chicago, Year BookMedical Publishers, Inc.: 1986, 725-27.16. Deslauriers J., Desaulniers D., Pomerleau S.:Late sequelae of thoracic injury. In:Webb W.R.,Besson A. (eds.): Thoracic surgery:Surgical man-agement of chest injuries.(chap. 48) St. Louis,Mosby-Year Book, Inc.; vol 7: 1991, 513-35.17. JamesA.E., Montaly R.J., Chafee V., et al: Bariumor gastrografin: which contrast media for diagno-sis of esophageal tears? Gastroenterology, 1975,68:1103.18. Andrade A.R. T-tube intubation in the manage-ment of late traumatic esophageal perforations:Case report. J Trauma. 1994, 37(1):131-2.19. White R.K., Morris D.M. Diagnosis and manage-ment of esophageal perforations. Am Surg. 1992,8:112-19.20. Santos G.H., Frater R.W.M. Transesophageal irri-gation for the treatment of mediastinitis producedby esophageal rupture. J Thorac Cardiovasc Surg.1986, 91:57-62.21. FlynnA.E.,VerrierE.D.,Way i.v«. et al: Esophagealperforations.Arch Surg. 1989, 124-1211-14..Journal of Surgery Pakistan (International) Vol. 2 (1); January 1997 20

Late onset oesophageal perforation due to gunshot injury of chest: Successful non-operative management in a young child

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Late onset oesophageal perforation due to gunshot injury of chest: successful non-operative management in a young child

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