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Bullet embolization into the systemic and the pulmonary circulation is a rare complication of penetrating wounds. From 1966 to 1975 10 patients with bullet embolus (5 in the systemic and 5 in the pulmonary arteries) were treated at Grady Memorial Hospital. The embolization occurred shortly after the initial injury in all cases except for two in which it occurred within two weeks. The patients with bullet embolus were either asymptomatic or some of those with systemic arterial embolization had symptoms and signs of acute arterial occlusion and some of the patients with pulmonary embolization had symptoms and signs of pulmonary embolus. The diagnosis was suspected in all cases because there was no wound of exit and because of the plain regional xray studies, the missile was not present in the expected area. The diagnosis was strengthened when, on screening xray studies of the rest of the body, the missile was found in a remote area and it was confirmed by arteriography. Embolectomy was performed in all cases of both groups except one with pulmonary embolus, and all patients did well and have no residual disability related to the embolus. This study suggests that bullet embolization to the systemic or pulmonary circulation occasionally occurs following bullet wound injury. The diagnosis should be strongly suspected when there is no exit wound and when roentgenographically the missile is not found in the suspected area. In such cases, screening xray pictures of the rest of the body should be obtained, and, if the bullet is found in a remote area, arteriography should be performed to confirm the diagnosis. Embolectomy should be done as soon as feasible and it usually affords very good results.

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During a 15-year period from August 1964 to August 1979, 48 patients with gunshot wound of the esophagus (24 of the cervical, 17 of the thoracic, and seven of the abdominal) were treated at Grady Memorial Hospital. In the majority of the patients, the initial history, physical findings, and chest roentgenograms were nondiagnostic for esophageal injury. Esophageal perforation was mainly suspected because the bullet tract was in close proximity to the esophagus or the bullet had traversed the mediastinum. The diagnosis of esophageal perforation was made by esophagography (29 patients), at the time of emergency surgical exploration for suspected other organ injuries (17 patients), or by esophagoscopy (one patient). All but one patient were treated surgically. The surgical procedure most commonly used was primary repair of the esophageal wound with wide drainage of the mediastinum. Thirty-eight (79.2%) of the 48 patients survived, 21 (87.5%) of the 24 patients with cervical, 11 (64.7%) of the 17 patients with thoracic, and six (85.7%) of the seven patients with abdominal esophageal wounds. Ten patients died, three with cervical wound, six with thoracic wound, and one with abdominal esophageal wound. Three patients died intraoperatively from major bleeding and the remaining seven died from the esophageal and/or other associated injuries, four to eight days after surgery. None of the seven patients who underwent primary repair with wide drainage and plication of the suture line with pleural flap or other tissue, died or developed leak at the suture line. This study suggests that the physical and roentgenographic findings in patients with esophageal injury are often nondiagnostic and frequently are masked by coincidental injury to other organs. Hence, a high index of suspicion is required for the diagnosis of esophageal injury from gunshot wounds and esophagography should be performed as soon as the patient's condition is stable in all patients who present with a missile wound in close proximity to the esophagus or traversing the mediastinum. All patients with perforation of the esophagus from bullet wounds should be operated upon as soon as possible after the diagnosis is made. Wide drainage of the mediastinum and primary repair of the esophageal wound and plication of the suture line with parietal pleura or gastric fundus provide the best possible results.

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