e present the case of a 40-year-old man with spontaneous esophageal perforation following an episode of ethanol intoxication. The diagnosis of perforation was delayed due to refusal of intervention. Endoscopic examination of the upper part of the esophagus revealed the tear above the gastroesophageal junction. A Polyflex self-expanding coated stent (Willy Ruesch GMBH, Kernen, Germany) was placed, isolating and sealing the area of perforation and restoring esophageal continuity. A left thoracoscopy was performed to drain and debride the mediastinum. The patient was discharged eating a regular diet and the Polyflex stent was removed 1 month later.This case is unique because a combined minimally invasive approach was used to manage a complex potentially fatal surgical emergency, which was previously handled through open thoracotomy. Because we combined video-assisted thoracic surgery and upper esophageal endoscopy, the patient experienced minimal morbidity and a short hospital stay with rapid return to activities of daily living. We believe this is the first reported case in which these combined modalities were used in the primary management of spontaneous esophageal perforation.
An 18-year-old driver in a high-speed motor vehicle accident sustained multiple life-threatening injuries, including partial transection of his descending aorta along with a linear tear of the distal trachea. Other significant injuries included closed-head shear injury and multiple bone fractures. Initial presentation revealed a pneumothorax and widening of the mediastinum. Bronchoscopy revealed a long, linear tear of the membranous trachea. Simultaneous exposure of both injuries for repair was not possible. A covered tracheal stent was placed, isolating and sealing the tracheal injury. The aorta was subsequently repaired during cardiopulmonary bypass at a later time. The tracheal stent was removed without sequelae after adequate healing of the membranous tracheal injury. (J Bronchol 2006;13:32-34) T his case describes the nonsurgical management of a blunt tracheal injury. Open surgical repair was not possible as a result of a concomitant extensive major vascular disruption. Proposed surgical repair of the tracheal injury would potentially have caused fatal uncontrollable exsanguination by disruption of a stable hematoma of the descending aorta. An Ultraflex (Boston Scientific, Natick, MA) covered tracheobronchial stent was placed to seal and isolate the tracheal injury, allowing eventual repair of the aortic disruption. We believe this is the first report of managing blunt tracheal injury by stent placement than by surgical repair because of the concomitant major aortic injury. CASE REPORTAn 18-year-old male, unrestrained driver was involved in a high-speed, head-on collision with a second car. On transfer to the emergency room, he was found to be somnolent but arouseable. Vital signs revealed a blood pressure of 90/70 mm Hg, heart rate 120 beats/min, with a SaO 2 of 90% on 4 L nasal cannula oxygen. Initial survey revealed absent left-sided breath sounds, normal heart sounds, and a soft abdomen. Plain x-rays revealed a widened mediastinum, multiple bilateral rib fractures, and a left pneumothorax. A chest tube was placed. A computed tomography scan was performed revealing mediastinal emphysema (Fig. 1) with a persistent left-sided pneumothorax. Aortic disruption with hematoma was noted adjacent to the origin of the left subclavian artery. There was no evidence of contrast extravasation.The patient was taken to the operating room for planned thoracotomy and interposition grafting of his aortic injury. Because the patient had a persistent pneumothorax with active air leak, bronchoscopic examination of the trachea and distal airways was performed through a single-lumen endotracheal tube. A long, linear, 4-cm tear of the membranous trachea-cartilaginous ring junction was seen on the left, distally, extending to the carinal spur.Initial surgical plans for aortic repair were abandoned because there were no surgical options for combined airway and vascular repair. Exposure for repair of the airway injury would have required contralateral thoracotomy with potential disruption of the aortic hematoma. Instead, after fl...
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