Cooley /DeBakey

Joint Session The Injured Esophagus

I
Kenneth L. Mattox, MD, FACS njury 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 meth- od of attempting suicide is more common than in North
America. Iatrogenic injury especially during endoscopy, tube insertion, forceful
dilation, and balloon insertion or inf lationis the most common cause.
Spontaneous rupture of the esophagus is rela-
tively 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 f irst) to severe sepsis, mediastinal
abscess, and empy- ema. On physical examination, a patient with an established
esophageal leak usually has signs of acute infection, chest pain, and a mediastinal
crunch heard on auscul- tation 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 conf irm the
esophageal injury. Im- aging 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 radi- ography. Contrast studies of the esophagus
should be performed with barium, rather than with water-soluble contrast
substances. A Gastrograf in swallow esophagogram has too high a false-positive
rate, and the contrast material, if aspirated during the pro- cedure, is more toxic to
the lungs than is barium.
Presented at the Joint Institute, Houston
Session of the Denton
A. Cooley
Cardiovascular Surgical
Society and the Michael
E. DeBakey International
Surgical Society; Austin,
Texas,
1013 June 2010

Section Editor:
Joseph S. Coselli, MD

From: Division of Surgery,

the Michael E. DeBakey
Department of Surgery,
Baylor College of
Medicine, Houston, Texas
77030

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: redstart@aol.com

2010 by the Texas Heart

Texas Heart Institute Journal The Injured Esophagus 683
 Esophagostomy
procedures (using rigid
scopes) might show an
injury, but false-
negative results do
occur. The use of f
lexible esophagoscopes
is discouraged when
esophageal injury is
suspected. The best
diagnostic yield occurs
when multiple tech-
niques supplement the
physicians judgment of
the patients clinical
signs.
Surgical procedures to
repair an injured
esophagus range from
simple closure to total
esophageal resection
with later
reconstruction.
Texas Heart Institute Journal
Thoracic esophageal injuries must al- ways 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 me- diastinum 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 nonspecif ic 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 f lap during the initial incision, to
re- inforce 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
esophagec- tomy and secondary conduit reconstruction.
Do not burn bridges during initial damage-control procedures.
The Injured Esophagus 683
 Further Reading
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Diagno- sis of penetrating injuries of the pharynx and
esophagus in the severely injured patient. J Trauma
2009;67(1):152-4.
2. Asaoka M, Usami N, Sasaki M, Masumoto H, Kajiyama
M, Seki A. Combined rupture of trachea and esophagus
follow- ing blunt trauma--a case report [in Japanese]. Jpn
J Thorac Cardiovasc Surg 1998;46(2):215-9.
3. Carter MP, Long RF, Pellegrini R A, Wynn R A.
Traumatic esophageal rupture: unusual cause of acute
mediastinal wid- ening. South Med J 1991;84(6):767-9.
4. Chilimindris CP. Rupture of the thoracic esophagus
from blunt trauma. J Trauma 1977;17(12):968-71.
5. Defore WW Jr, Mattox KL, Hansen HA, Garcia-Rinaldi
R, Beall AC Jr, DeBakey ME. Surgical management of
penetrat- ing injuries of the esophagus. Am J Surg
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JM, Beall AC Jr, Jordan GL Jr. Combined
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1993;88(8):1249-53.
684 The Injured Esophagus
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Volume 37, Number 6,
2010