CHAPTER 42 TREATMENT OF ESOPHAGEAL INJURY
The treatment of esophageal perforations remains controversial, with uncertainty surrounding several aspects of surgical management: the preferred method of surgical repair, the management of injuries recognized late, and the role of cervical esophagostomy for diversion, among others. Much of this controversy stems from the uncommon nature of these injuries. The relative infrequency of esophageal injury may be attributed to the deep location of this collapsed structure that is surrounded by vital organs. Many penetrating wounds injure the heart or aorta and result in death at the scene. Blunt injuries to the esophagus are very unusual. Anatomic features, with the lack of serosa, contribute to the difficulty in treatment. Given the frequency of delay in diagnosis and the complexity of operative treatment, injuries of the esophagus remain among the most difficult injuries to manage without major morbidity or mortality. Even the busiest trauma centers often encounter fewer than five esophageal injuries per year.
INCIDENCE
The incidence of esophageal injuries is low with most resulting from penetrating trauma. Esophageal trauma received little notice until the completion of World War II, with only 18 esophageal injuries recorded in the military records reviewed from that war and the Korean and Vietnam Wars combined. Numerous reports in the literature document the incidence of esophageal trauma to be less than 1% with the most common cause being penetrating injuries sustained from stab and gunshot wounds. The cervical esophagus represents the most common site of injury followed by thoracic and abdominal esophageal injuries. While these wounds occur relatively infrequently, they continue to be associated with high mortality ranging from 20% to 30%. Virtually all patients who sustain an esophageal injury also incur associated injuries to other respiratory, gastrointestinal, and vascular injuries. As a result, surgeons must maintain a high index of suspicion so that untoward diagnostic delays may be avoided.
SURGICAL TREATMENT
Most injuries of the esophagus can be primarily repaired if promptly diagnosed. Small injuries may be closed transversely, whereas injuries larger than 2–3 cm can be closed longitudinally in order to avoid undue tension. Unfortunately, diagnostic delay often creates a situation associated with significant mediastinal inflammation and sepsis. Furthermore, the lack of a serosal layer complicates primary reapproximation as the esophageal tissues are extremely friable especially under these circumstances. Numerous strategies have been proposed including non-operative management with drainage, esophageal resection, and diversion with exclusion. The use of pleural and pericardial flaps has been widely described for buttressing primary repairs. More recently, various muscle flaps have been advocated for primary repair of esophageal defects. However, adequate esophageal tissue debridement, tension-free repairs, and effective drainage remain the mainstays of successful operative management.
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