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.
Pulmonary arteriography was performed in 22 patients with penetrating injury of the lung(s) within the first 72 post-injury hours and no vascular lesion directly attributable to the injury was found. Pulmonary arteriovenous fistula or pulmonary artery aneurysm secondary to penetrating pulmonary injury, are extremely rare lesions, but they should be suspected in a patient with penetrating wound of the chest with signs and symptoms of pulmonary arteriovenous fistula or with chronic residual well circumscribed density on chest roentgenogram. The treatment of these lesions should be excision of the lesion with preservation of the lung, whenever possible, or resection of the involved lobe.
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