After a motor vehicle accident a 19-year-old man was transferred to our trauma department from a local hospital. The car driven by the victim had rolled over at a high speed; seat belts were used. At admission the patient presented with unconsciousness (Glasgow Coma Scale 9), shock (systolic blood pressure 60 mm Hg), and tachycardia (140 beats/min.). Both pleural cavities were drained in the emergency department because of haemopneumothorax caused by ribs fractures. No further examination of the obtained fluid has been performed as there was no suspicion of oesophageal rupture, and ribs fractures seemed to be the cause of haemopneumothorax. Nevertheless, testing for amylase would have been of value. Computed tomography (CT) scans confirmed the diagnosis in the thorax and showed some fluid in the peritoneal cavity and pelvic fracture. Laparotomy was performed which revealed 500 ml of blood in the peritoneal cavity and a grade II (American Association for the Surgery of Trauma) spleen injury. The spleen was preserved after the haemorrhaging was stopped. A left sided retroperitoneal haematoma was found and not explored.
After surgery the patient was admitted to the intensive care unit. Broad spectrum antibiotics and fluids were given intravenously. However, the patient remained unstable and drugs such as inotropes and colloids were needed. The next day (18 h after admission) another CT scan with contrast administered through a gastric catheter showed some fluid around the spleen. Leakage of the oesophagus to the left pleural cavity was shown. The patient had leucocytosis and fever, and a procalcitonin test was positive.
The patient was taken to the operating room where a posterolateral thoracotomy was performed. In patients with multiple trauma, especially after traffic accidents, an inspection of the abdominal cavity is required even if preoperative diagnosis suggests particular organ damage. That is why even if the diagnosis has been made preoperatively, a posterolateral thoracotomy together with a laparotomy would have been undertaken in order to gain full access to the abdominal cavity and check all the organs. A 15 cm long traumatic rupture of the diaphragm that affected the oesophageal hiatus was found. The diaphragmatic rupture was filled by pressure from the stomach. The conjunction area showed two perforations situated opposite each other; a longer one (10 cm) starting from the lower oesophagus and extending to the stomach fundus by a greater curvature, and a shorter perforation (5 cm) extending from the oesophagus to the gastric cardia by a lesser stomach curvature. The left pleural cavity contained 1000 ml of blood, mixed with some food which was evacuated. The oesophagus and stomach were sutured (two layers) and the diaphragm was reconstructed by single sutures (). Drains were put into the mediastinal and pleural spaces. No contamination or blood in the peritoneal cavity was found during regular re-laparotomy.
Upper panels: computed tomography scans revealing leakage of contrast from the lower part of the oesophagus to the left pleural cavity. Lower panels: intraoperative photographs showing primary reconstruction of oesophagus and stomach perforations.