Stephanie Sea, MD, John Henry Pang, MD, Kasia Wolanin, MD, Heidi Miller, MD, Jorge Uribe, Jay Strain, MD, Mark Kaplan, MD, Pak Leung. Albert Einstein Medical Center
The management of traumatic esophageal injury is highly controversial in the literature, especially management after a delayed presentation. We report a case of a 25-year-old male who presented to the ER as a Level 1 trauma with multiple gun shot wounds to the left and right chest, as well as several extremity wounds. Initial upright CXR revealed a right hemothorax and a right chest tube was placed with 900cc bloody output. Vital signs were stable and the patient underwent a CT of his chest to identify the potential pathway of the bullet. Afterwards the patient was taken to the operating room for a right thoracotomy, right upper lobe wedge resection and an exploration of the posterior mediastinum and esophagus. No additional injuries were noted at that time and the patient was transferred to the SICU for resuscitation. On hospital day #4, the patient underwent a fluoroscopic swallow study that was negative for an esophageal leak and the patient’s diet was advanced. On hospital day #7, the patient was noted to have copious purulent drainage from his chest tubes. The patient appeared clinically septic and underwent a left thoracotomy with decortication and placement of chest tubes. A subsequent swallow study demonstrated a new proximal esophageal leak. The patient was placed on antibiotics, kept NPO and TPN was initiated. The patient clinically improved and we felt there was adequate source control with good drainage from both sides of the chest. Two weeks after the initial injury he was started on tube feeds to optimize his nutritional status. On hospital day #18, the patient underwent an EGD that demonstrated an esophageal perforation and a stent was placed. Intermittently he underwent swallow studies to assess the integrity of his esophagus on an outpatient basis. On post-injury day #78, the patient had his stent removed. His swallow study was negative, the diet was initiated and the chest tube was later removed. Our case demonstrates the management of a delayed esophageal blast injury successfully completed with conservative management and stent placement.