Figure-1

Introduction The Esophageal-Tracheal Combitube (ETC) is widely used for the management of the airway during cardiopulmonary resuscitation in the pre-hospital setting and is associated with a notable incidence of serious complications, including, though rarely, esophageal perforation. Esophageal perforation is a life-threatening condition associated with high morbidity and mortality rates. Traditionally, esophageal perforation was considered a surgical emergency. However, with the advent of broad spectrum antibiotics and less invasive operative interventions, nonoperative treatment of esophageal perforation has become more common.

Case Report A case of esophageal perforation due to ETC placement in a 38-year-old male is described here. The patient was involved in a high-speed motor vehicle collision and was intubated with a Combitube in the field prior to being airlifted to our level-1 trauma center. The Combitube was found to have perforated the esophagus on computed tomography (CT) scan. A CT esophagogram confirmed this finding with a contained perforation. The patient was managed with nonoperative treatment.

Discussion Esophageal perforation following ETC placement is a rare, but potentially fatal complication. If recognized early, a patient with a limited and/or contained perforation with minimal symptoms may be managed with nonoperative treatment.

Nonoperative Management of an Esophageal Perforation Following Combitube Placement

Michael Eigenberg, MD, Rodrigo Arrangoiz, MD, Anthony Nigliazzo, MD, Chet Morrison, MD, Benjamin Mosher, MD, John Kepros, MD

Department of Surgery, Michigan State University, East Lansing, Michigan.

Contact: Michael Eigenberg, MD. E-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Citation: Eigenberg M, Arrangoiz R, Nigliazzo A, Morrison C, Mosher B, Kepros J. Nonoperative management of an esophageal perforation following Combitube placement. J Surg Radiol. 2010 Jul 1;1(1).

Download PDF
Nonoperative Management of an Esophageal Perforation Following Combitube Placeme	2633 Kb

Received: May 20, 2010; Accepted: June 6, 2010; Published: June 6, 2010

Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Contents

- Introduction
- Case Report
- Discussion
- References

Introduction

The recent rise in endoscopic procedures of the upper gastrointestinal tract and the development of different techniques for obtaining airway control in the trauma setting have resulted in an increased incidence of iatrogenic esophageal perforations.^1,2 Recent cardiac arrest resuscitation guidelines have instituted in their recommendations the use of the Esophageal-Tracheal Combitube (ETC) as an advanced airway management alternative for individuals who infrequently perform endotracheal (ET) intubation. The ETC is widely used for the management of the airway during cardiopulmonary resuscitation by emergency medical technicians (EMTs) in the pre-hospital setting and is associated with a notable incidence of serious complications (20.7%), which include, but are not limited to aspiration pneumonitis, mediastinitis, pneumothorax and pneumomediastinum, tracheal injury, and esophageal laceration and perforation.²

Esophageal perforation is a serious condition associated with high morbidity and mortality rates. A comprehensive review of literature published between 2000 and 2005 found that the mortality rate for esophageal perforation is 19.7% (3% to 67%).³ Given the significant morbidity and mortality associated with esophageal perforation, it was traditionally considered a surgical emergency; however, with the advent of broad spectrum antibiotics and less invasive operative interventions (e.g., percutaneous drainage, endoscopic stenting), nonoperative treatment of esophageal perforation has become more common. The approach to nonoperative treatment entails cessation of oral alimentation, implementation of total parenteral nutrition, and administration of broad spectrum antibiotics in the setting of a contained perforation without any hemodynamic instability secondary to sepsis.⁴

Although esophageal perforation is a known complication associated with insertion of an ETC, only a small number of cases have been reported. Vezina and colleagues performed a retrospective study between 1993 and 2003 of patients that were resuscitated with a Combitube as the primary airway device during cardiac or respiratory arrest.² Two of 280 patients were found to have suffered esophageal perforation. Another study by Klein et al. in 1997 presented a case of esophageal rupture associated with the use of a Combitube in a controlled operating room setting.⁵ Bagheri et al. in 2008 described a case of a 22-year-old male suffering blunt head trauma that was initially intubated with a Combitube and was subsequently found to have an esophageal perforation.⁶

We present a case of esophageal perforation secondary to the insertion of a Combitube in the pre-hospital setting that was managed nonoperatively.

Case Report

A 38-year-old previously healthy Caucasian male was airlifted to our level 1 trauma center after involvement in a high-speed motor vehicle collision. Upon initial evaluation by the EMT, the patient was found to have a Glasgow Coma Scale (GSC) score of eight at the scene. Due to his depressed mental status and concern for the patient’s inability to maintain his own airway, the decision was made to intubate the patient in order to secure his airway for airlift transfer. At this time an ETC was placed by an EMT without any obvious complication.

Upon arrival to our level 1 trauma center, the patient was found to be afebrile, hemodynamically stable, and ventilating well via the ETC. Primary and secondary surveys along with patient resuscitation were performed in accordance with standard Advanced Trauma Life Support (ATLS) protocol by our trauma team. As part of the secondary survey, a computed tomography (CT) scan of the head, neck, chest, abdomen, and pelvis was obtained. CT scan of the neck revealed subcutaneous emphysema in the region of the cervical spine with possible placement of the ETC outside the esophageal lumen. An esophageal injury was suspected; thus, a repeat CT scan of the neck with oral contrast (50 ml of gastrograffin [diatrizoate meglumine and diatrizoate sodium solution] were administered through a nasogastric [NG] tube placed at 15 cm from the incisors) (Figures 1 and 2). We identified a small amount of contrast outside the esophageal lumen originating from the right side of the esophagus around the second thoracic (T2) vertebral level with a small air bubble. This appeared to be a small, contained perforation (Figure 3). The patient was hemodynamically stable without signs of sepsis; thus, the decision was made to attempt a trial of nonoperative management. The patient was made nil per os (NPO), started on total parenteral nutrition, and placed on broad spectrum antibiotics. An esophagogram was repeated after seven days that demonstrated closure of the perforation, and the patient was started on an oral diet which he tolerated well.

Figure 1. CT scan showing the esophageal perforation with the Esophageal-Tracheal Combitube outside the lumen of the esophagus with subcutaneous emphysema in the soft tissues of the neck.

Figure 2. CT scan showing the esophageal perforation with the Esophageal-Tracheal Combitube outside the lumen of the esophagus with subcutaneous emphysema in the soft tissues of the neck.

Figure 3. CT scan of the neck with gastrografin contrast showing the contained esophageal injury.

Figure 4. Esophagogram performed after 7 days of non-operative management showing no extravasation of the contrast.

Discussion

A patent airway and adequate ventilation are critical for survival in the trauma setting. When assessments detect an obstructed airway, absence of a gag reflex, and / or inadequate levels of ventilation; insertion of an advanced airway is indicated. Due to difficulties in training pre-hospital personnel to perform ET intubation, devices have been developed to secure the airway more easily, such as the ETC.⁷ Vezina and colleagues’ primary finding was that the use of the Combitube by EMTs in the pre-hospital setting is associated with a notable incidence of serious complications (20.7%). Some of these complications are relatively severe, some being even potentially lethal, such as a full thickness esophageal tear.² Similar to any other device used in resuscitation, the operator and – equally important – the subsequent hospital trauma personnel need to be aware of potential complications associated with any given intervention. The presence of subcutaneous emphysema, which is commonly observed on the CT scan in the evaluation of trauma patients, is often explained by the presence of lacerations or other osseous and soft tissue injuries to the area. The possibility of esophageal injury should be considered with the use of an ETC. Any delay in the detection and initiation of proper therapy of esophageal rupture will result in a higher risk of morbidity and mortality. Therefore a high index of suspicion is necessary to diagnose and promptly manage esophageal injury with a known history of ETC intubation.

It has been suggested that the etiology for pharyngeal and esophageal injuries after ETC insertion have been caused by balloon over-inflation, as well as by the stiffness and the anterior curvature of the tube.⁷ According to their extent of injury, esophageal injuries are classified into (1) transmural, short and predominantly distally localized perforations; (2) mucosal, short lesions in the distal esophagus; and (3) intramural dissections.^8-10

Esophageal perforation is a life-threatening condition in which the choice treatment remains controversial. Prior to the introduction of antibiotics, nonoperative treatment of esophageal perforation almost always resulted in fatalities.¹¹ However, it should be noted that even operative management of esophageal perforation was highly unsuccessful for many years with the first reported case of successful surgical repair in 1944.¹²

In 1965 Mengoli and Klassen reported the first successful series of nonoperative treatment for esophageal perforation, in which only one patient was lost out of 18 treated for instrumental esophageal perforations of the cervical and thoracic esophagus (a mortality rate of 5.5%).¹³ Conversely, Michel and Grillo argued that esophageal perforation requires surgical intervention in every case without exception. In their series, nonoperative treatment was employed in 19 of 72 patients (eight thoracic and 11 cervical esophageal perforations). Mortality rates of cervical esophageal perforation and thoracic esophageal perforation were 18% and 12.5%, respectively. A zero percent mortality rate was observed in those cases managed with operative intervention.¹⁴ Eroglu and colleagues performed a retrospective clinical review of 44 patients treated for esophageal perforation over a 20 year period and concluded that the most optimal treatment for esophageal perforation is dependent on the cause and location of the injury, the presence of any underlying esophageal disease, the time required to establish the diagnosis, and the interval of time between the injury and the initiation of treatment.⁴

In regard to nonoperative treatment of esophageal perforations, criteria were first defined by Cameron et al. in 1979 and later modified by Altorjay et al. in 1997.^15,16 Nonoperative treatment is the treatment of choice in cases where the patient has suspected or limited perforation, minimal symptoms, an instrumental injury in the cervical region, a drained cavity in the esophagus, and no obstructive neoplasm.¹⁷ Patients who are managed nonoperatively are monitored for 7 to 10 days without oral alimentation, started on total parenteral nutrition, and placed on broad spectrum antibiotics. If a patient remains stable after this time, an esophagogram with gastrograffin contrast is performed to check whether or not the perforation is closed. If there is no evidence of contrast extravasation, the patient is started on oral alimentation.

Based on the aforementioned criteria, our patient was an ideal candidate for nonoperative treatment. His injury was a high thoracic esophageal perforation secondary to instrumentation (e.g., Combitube) that was identified quickly and appeared to be contained as evidenced by the esophagogram. By employing a nonoperative treatment regimen, our patient was able to avoid a major operation.¹⁸

After reviewing the literature, it can be concluded that esophageal perforation following Combitube placement is a rare, but potentially fatal complication. Early recognition and treatment is essential to prevent the life-threatening complications. Nonoperative treatment of esophageal perforation has been shown to be beneficial in certain patient populations. However, the choice treatment for esophageal perforation should be evaluated on a case-to-case basis.

References

Wesdorp IC, Barelsman JF, Huibregtse K, den Hartog Jager FC, Tygat GN. Treatment of instrumental oesophageal perforation. Gut 1984; 25: 398-404. | CrossRef | PubMed |

Vezina MC, Trepanier CA, Nicole PC, Lessard MR. Complications associated with the esophageal-tracheal Combitube® in the pre-hospital setting. Can J Anesth 2007; 54: 124-28. | CrossRef |

Lang MH, Bruns DH, Schmitz B, Wuerl P. Esophageal perforation: principles of diagnosis and surgical management. Surg Today 2006; 36: 332-40. | CrossRef | PubMed |

Eroglu A, Turkyilmaz A, Aydin Y, Yekeler E, Karaoglanoglu N. Current management of esophageal perforation: 20 years experience. Diseases of the Esophagus 2009; 22: 374-80. | CrossRef | PubMed |

Klein H, Williamson M, Sue-Ling HM, Vucevic M, Quinn AC. Esophageal rupture associated with the use of the Combitube. Anesth Analg 1997; 85: 937. | CrossRef |

Bagheri SC, Stockmaster N, Delgado G, Kademani D, Carter TG, Ramzy A, Dierks EJ. Esophageal rupture with the use of the Combitube: report of a case and review of the literature. J Oral Maxillofac Surg 2008; 66: 1041-44. | CrossRef | PubMed |

Kurola J, Harve H, Kettunen T. Airway management in cardiac arrest - Comparison of the laryngeal tube, tracheal intubation and bag-valve mask ventilation in emergency medical training. Resuscitation 2004; 61:149-53. | CrossRef | PubMed |

Vezina D, Trepanier CA, Lessard MR, Bussieres J. Esophageal and tracheal distortion by the esophageal-tracheal combitube: a cadaver study. Can J Anesth 1999; 46: 393-97. | CrossRef |

Marks IN, Keet AD. Intramural rupture of the oesophagus. BrMed J 1968; 3: 536-37. | CrossRef | PubMed |

Weiss S, Mallory GK. Lesions of the cardiac orifice of the stomach produced by vomiting. JAMA 1932; 98: 1353-55.

Bradley SL, Pairolero PC, Payne WS, Gracey DR. Spontaneous rupture of the esophagus. Arch Surg 1981; 116: 755-58. | PubMed |

Jones WG, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992; 53: 534-43. | PubMed |

Olson AM, Clagget OT. Spontaneous rupture of the esophagus: report of a case with immediate diagnosis and successful surgical repair. Postgrad Med 1947; 2: 17-21.

Mengoli LR, Klassen KP. Conservative management of esophageal perforation. Arch Surg 1965; 91: 232-40.

Michel L, Grillo HC. Operative and nonoperative management of esophageal perforations. Ann Surg 1981; 194: 57-63. | CrossRef | PubMed |

Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 1979; 27: 404-8. | PubMed |

Altorjay A, Kiss J, Voros A, Bohak A. Nonoperative management of esophageal perforations. Is it justified? Ann Surg 1997; 225: 415-21. | CrossRef | PubMed |

Shaffer HA Jr, Valenzuela G, Mittal RK. Esophageal perforation: a reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med 1992; 152: 757-62. | CrossRef | PubMed |