Delayed oesophageal injury

[Timothy Craig Hardcastle]

Ranjith

After 16 hours with minimal debridement primary repair is still an
option. Mobilise the oesophagus well and if necessary explore BOTH sides
of the neck. Antibiotics (I would use Augmentin alone) for 3 days max.
and place a nasogastric or other feeding tube under vision during the
procedure - this allows feeding from day 1.

The repair itself should ALWAYS be a single layer and tissue coverage (a
muscle flap) is traditional, but we in RSA have seldom used it in the
cervical oesophagus, with low fistula rates. For the thoracic oesophagus
will always use a flap.

I leave a corrugated rubber drain for the first 5 days to drain the
tissue planes created in mobilizing the oesophagus but try to not abut
the repair itself.

Contrast swallow with Ultravist or Hexabrix on day 5 to 7 - if no leak -
feeding tube out and eat then discharge next day.

The reason I leave the swallow till day 5 - 7 is that most leaks occur
on or after day 5 and you miss them with an early swallow study!!!!!

Suffice to say that I practice in an environment where we see many stab
necks (about 500 per year in Cape Town where I was till two months ago)
and I've repaired about 15 - 20 oesophagus stabs in the last two years.
The trick is to keep it simple and avoid man-made fistulas.

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban
 
Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal
 
timothyhar at ialch.co.za 
 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ranjith Ellawala
Sent: 29 May 2008 19:13
To: Trauma &amp, Critical Care mailing list
Subject: Delayed oesophageal injury

Young male with a stab in from left side of neck, penetrating both
walls. presenting 16hrs after the injury. My colleague performed surgery
which involves mobilizing oesophagus onto the surface on left , keeping
the proximal part as a fistula , applying a pursestring suture to distal
opening. The wound was infected at the time of surgery. Additional
feeding jejunostomy was performed as well
  Please let me know how you deal with this situation ?
  Dr.Ranjith Ellawala
  Consultant Surgeon
  Trauma Unit,
  The National Hospital of Sri lanka
  Colombo
  Sri lanka

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