Approaches to Repair of Penetrating Injuries of the Proximal,Mid,and Distal Esophagus

Traumatic esophageal injuries represent less than 10% of traumatic injuries. Penetrating injuries represent an even smaller but more lethal percentage, but blunt injuries are harder to diagnose and tend to have delayed recognition and treatment. ¹ Esophageal injuries can be cervical, thoracic, or abdominal with decreasing frequency. In contrast to their higher frequency, cervical and thoracic esophageal injuries represent >80% of these injuries and are more morbid. ² Morbidity and mortality are increased with delayed identification. Although diagnosis can be hard, management is similar despite location.

A 21-year-old (yo) male transferred from outside hospital with a single gunshot wound (GSW) to anterior midline neck in Zone 1 of the neck. He had been intubated at the outside hospital and a left pigtail had been placed. On arrival, his airway was intact, he had a #7 endotracheal tube (ETT) in place, he was normotensive with a Glasgow coma score (GCS) 11T, and had no focal neurologic deficits. Air was coming through the anterior neck wound so he was taken to the operating room for esophagogastroscopy (EGD), and primary esophageal repair in 2 layers with wide drainage, sternocleidomastoid patch (SCL), and nasogastric (NG) tube placement. His postoperative course was unremarkable (Figure 1).

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Figure 1.

CT scans showing subcutaneous emphysema due to esophageal perforation.

A 33-year-old female Uber driver sustained GSWs to the posterior neck, shoulder, and back with subsequent motor vehicle collision (MVC). Her airway was intact and she had bilateral breath sounds. She was hypotensive but responded to fluid resuscitation and had a GCS of 15. She was also noted to have absent motor and sensation in bilateral lower extremities. Computerized tomography (CT) scan showed thoracic spine ballistic fractures, pneumomediastinum, right lung laceration, and right hemopneumothorax (Figure 1). She was taken to the operating room for an EGD, right thoracotomy, and esophageal repair in 2 layers with a pleural patch and drains. She had a prolonged hospital course which was due to sequelae of her spinal cord injury but was eventually discharged on postoperative day (POD) 55.

A 33-year-old male presented with a trans-thoracoabdominal GSW. Despite his mild hypotension and tachycardia, his airway was intact, oxygen saturations were normal, and his GCS was 15. He went straight to the operating room and underwent exploratory laparotomy with repair of gastric laceration. Esophagogastroscopy identified a distal esophageal injury that was repaired in 2 layers with Thal patch including wide drainage and J-tube (Figure 2). Postoperative imaging showed a contained leak which was managed nonoperatively (Figure 2). He was eventually discharged on POD 42 and his J-tube and drains were all removed in the clinic by POD 70.

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Figure 2.

Picture of esophageal perforation at gastroesophageal junction and fluoroscopic imaging of leak at same location.

Our cases highlight a few key points. First, in all 3 cases, we identified the injuries early and all patients had appropriate repairs. Early intervention is what helped lead to positive outcomes for all patients. With flaps, wide drainage, and enteral access, we were able to progress patients through and after discharge.

Despite low incidence of penetrating esophageal injuries, morbidity and mortality is extremely high, especially with associated injuries. ² Early identification and treatment is paramount. Anatomical knowledge is necessary for successful surgical management. Incision planning is paramount. For cervical injuries, a vertical incision on the left, just anterior to the sternocleidomastoid (SCM) is used. For mid-thoracic injuries, a right thoracotomy is performed, and for more distal injuries, an exploratory laparotomy or combination with left thoracotomy may be needed. ³ Primary repair in 2 layers should be attempted whenever possible including musical closure with absorbable suture. Repair over a bougie in order to help prevent stricture formation. Flaps, diversions, wide drainage, and feeding tube access should always be key surgical considerations. Feeding tubes can be nasogastric (NG), small bore “dobhoff,” gastric, or jejunal tubes based on location of injury and duration of need. ⁴ Gastric and jejunal tubes have increasing risk of complications including leaks, so should be used for more distal injuries and when enteral access is suspected to be prolonged. Flaps can include sternocleidomastoid muscle for cervical injuries, intercostal muscle, diaphragm, pericardium, and pleural flaps for thoracic injuries, and “Thal” gastric or omental flaps for gastroesophageal junction and abdominal injuries. ^{3 ,4} Successful identification and management can lead to increased survival.