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Tex Heart Inst J. 2010; 37(6): 683–684.
PMCID: PMC3014123

The Injured Esophagus

Joseph S. Coselli, MD, Section Editor

Injury to the esophagus, although not often seen, is an intolerable condition in the absence of early detection and appropriate surgical intervention. The cause can be penetrating or blunt injury, iatrogenic injury, laceration from ingestion of a sharp object, or tissue destruction secondary to swallowing a caustic substance. Ingestion of alkaline or acid liquids can be accidental or purposeful. In Southeast Asia, this method of attempting suicide is more common than in North America. Iatrogenic injury—especially during endoscopy, tube insertion, forceful dilation, and balloon insertion or inflation—is the most common cause. Spontaneous rupture of the esophagus is relatively rare but can be as devastating as any of the causes described above.

A patient who has an esophageal injury may present with a variety of symptoms, ranging from relatively minor (at first) to severe sepsis, mediastinal abscess, and empyema. On physical examination, a patient with an established esophageal leak usually has signs of acute infection, chest pain, and a mediastinal “crunch” heard on auscultation of the chest. The examining physician can also palpate cervical subcutaneous emphysema.

No single examination, test, or imaging technique is always diagnostic; therefore, multiple and combined tests are often required to confirm the esophageal injury. Imaging of the esophagus can be confusing and is overrated. The chest radiograph can show signs of mediastinal air or of pleural empyema. A computed tomographic scan is often either under-or over-read and rarely adds more than what is seen on chest radiography. Contrast studies of the esophagus should be performed with barium, rather than with water-soluble contrast substances. A Gastrografin swallow esophagogram has too high a false-positive rate, and the contrast material, if aspirated during the procedure, is more toxic to the lungs than is barium.

Esophagostomy procedures (using rigid scopes) might show an injury, but false-negative results do occur. The use of flexible esophagoscopes is discouraged when esophageal injury is suspected. The best diagnostic yield occurs when multiple techniques supplement the physician's judgment of the patient's clinical signs.

Surgical procedures to repair an injured esophagus range from simple closure to total esophageal resection with later reconstruction. Thoracic esophageal injuries must always be approached via a posterolateral thoracic incision. The “safe” surgical option is the best for these injuries, and drainage of the esophageal injury or the infected mediastinum is always safe. In some instances, long-term conduit reconstruction might be required.

The surgeon and the treating team should follow several governing principles:

  • Use a combination of diagnostic methods.
  • Do not depend on the nonspecific computed tomographic scan of the chest.
  • For contrast esophagoscopy, use barium, not water-soluble material.
  • The approach to the cervical esophagus is through a cervical incision.
  • The approach to the thoracic esophagus is through a posterolateral incision.– Right 4th interspace for the upper esophagus– Left 5th or 6th interspace for the lower esophagus
  • Consider creating a vascularized muscle flap during the initial incision, to reinforce the ultimate repair.
  • Do not attempt repair of an esophageal injury discovered via an anterior incision, as the dehiscence rate is 50%—with 50% of these breakdowns resulting in death.
  • For extensive injury and contamination of the esophagus, consider an esophagectomy and secondary conduit reconstruction.
  • Do not “burn bridges” during initial damage-control procedures.

Footnotes

Address for reprints: Kenneth L. Mattox, MD, FACS, the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, 390, Houston, TX 77030

E-mail: moc.loa@tratsder

Presented at the Joint Session of the Denton A. Cooley Cardiovascular Surgical Society and the Michael E. DeBakey International Surgical Society; Austin, Texas, 10–13 June 2010

Further Reading

1. Ahmed N, Massier C, Tassie J, Whalen J, Chung R. Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient. J Trauma 2009;67(1):152–4. [PubMed]
2. Asaoka M, Usami N, Sasaki M, Masumoto H, Kajiyama M, Seki A. Combined rupture of trachea and esophagus following blunt trauma–a case report [in Japanese]. Jpn J Thorac Cardiovasc Surg 1998;46(2):215–9. [PubMed]
3. Carter MP, Long RF, Pellegrini RA, Wynn RA. Traumatic esophageal rupture: unusual cause of acute mediastinal widening. South Med J 1991;84(6):767–9. [PubMed]
4. Chilimindris CP. Rupture of the thoracic esophagus from blunt trauma. J Trauma 1977;17(12):968–71. [PubMed]
5. Defore WW Jr, Mattox KL, Hansen HA, Garcia-Rinaldi R, Beall AC Jr, DeBakey ME. Surgical management of penetrating injuries of the esophagus. Am J Surg 1977;134(6):734–8. [PubMed]
6. Feliciano DV, Bitondo CG, Mattox KL, Romo T, Burch JM, Beall AC Jr, Jordan GL Jr. Combined tracheoesophageal injuries. Am J Surg 1985;150(6):710–5. [PubMed]
7. Horwitz B, Krevsky B, Buckman RF Jr, Fisher RS, Dabezies MA. Endoscopic evaluation of penetrating esophageal injuries. Am J Gastroenterol 1993;88(8):1249–53. [PubMed]
8. Sheely CH 2nd, Mattox KL, Beall AC Jr, DeBakey ME. Penetrating wounds of the cervical esophagus. Am J Surg 1975; 130(6):707–11. [PubMed]
9. Shin DD, Wall MJ Jr, Mattox KL. Combined penetrating injury of the innominate artery, left common carotid artery, trachea, and esophagus. J Trauma 2000;49(4):780–3. [PubMed]
10. Sokolov VV, Bagirov MM. Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae. Eur J Cardiothorac Surg 2001;20(5):1025–9. [PubMed]
11. Sotnichenko BA, Makarov VI, Stepura AP, Rybakovskii EL. The diagnosis and surgical procedure in penetrating neck wounds [in Russian]. Vestn Khir Im I I Grek 1997;156(5):38–40. [PubMed]
12. Szentkereszty Z, Trungel E, Posan J, Sapy P, Szerafin T, Sz Kiss S. Current issues in the diagnosis and treatment of penetrating chest trauma [in Hungarian]. Magy Seb 2007;60(4): 199–204. [PubMed]
13. Weigelt JA, Thal ER, Snyder WH 3rd, Fry RE, Meier DE, Kilman WJ. Diagnosis of penetrating cervical esophageal injuries. Am J Surg 1987;154(6):619–22. [PubMed]
14. van Heijl M, Saltzherr TP, van Berge Henegouwen MI, Goslings JC. Unique case of esophageal rupture after a fall from height. BMC Emerg Med 2009;9:24. [PMC free article] [PubMed]

Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute