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Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma

A single-center review of 86 cases

Madsen, Andre S. MD; Oosthuizen, George V. MBChB; Bruce, John L. MBChB; Bekker, Wanda MBChB; Laing, Grant L. MBChB; Clarke, Damian L. MBBcB

Journal of Trauma and Acute Care Surgery: September 2018 - Volume 85 - Issue 3 - p 541–548
doi: 10.1097/TA.0000000000001973

BACKGROUND This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM).

METHODS This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation.

RESULTS Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19–8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13–6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks.

CONCLUSION Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration.

LEVEL OF EVIDENCE Clinical Management Study, Level V evidence.

From the Pietermaritzburg Metropolitan Trauma Service, Department of Surgery (A.S.M., G.V.O. J.L.B., W.B., G.L.L., D.L.C.), University of KwaZulu-Natal, Nelson R Mandela School of Medicine, Pietermaritzburg, KwaZulu-Natal, South Africa; and †Department of Surgery (C.D.L.), University of the Witwatersrand, Johannesburg, South Africa.

Submitted: December 19, 2017, Revised: April 23, 2018, Accepted: April 26, 2018, Published online: May 22, 2018.

Address for reprints: Dr Andre Steiner Madsen, Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, 201 Townbush Road, Pietermaritzburg, 3201, South Africa; email:

© 2018 Lippincott Williams & Wilkins, Inc.