Diagnosis and Management of External Penetrating Cervical Esophageal Injuries

Abstract

External penetrating injuries of the esophagus are more likely to cause serious morbidity and even mortality than those involving the pharynx. However, the cervical esophagus is extrathoracic in location, and controversy exists regarding the diagnosis and surgical management of penetrating injuries at this level. A retrospective review of 23 such injuries showed that contrast esophagography had only a 62% success rate in identification of cervical esophageal violations, compared to 100% for rigid esophagoscopy. Even large penetrations were successfully treated with limited debridement, primary repair when possible, muscle interposition flaps to separate common injuries of the tracheal wall, and, most important, external drainage of the adjacent neck spaces. Esophageal stricture occurred only when complex esophageal diversion procedures were performed, either as an unnecessary primary operation, or as a lifesaving secondary operation necessitated by infectious complications caused by delayed diagnosis and treatment of the esophageal violation. Penetrating injuries of the cervical esophagus can therefore be managed more as a pharyngeal injury if diagnosis and appropriate surgical treatment occur in a timely fashion.

Penetrating injuries to the cervical oesophagus: is routine exploration mandatory?

“…11,[13][14][15] A low index of suspicion as well as difficulties and delays in establishing the diagnosis of cervical oesophageal injuries are important contributing factors to morbidity and mortality. [5][6][7]16 Delay in treatment from 12-24 h allows enough leakage of saliva and bacteria, as well as refluxed acid, pepsin, and bile into the surrounding loose areolar tissues, to produce suppurative infection and an intense necrotising inflammatory response. 6,16 This inflammation may allow rapid spread of infection into the mediastinum under the force of gravity and negative intrathoracic pressure if the leakage is not drained away from the deep neck spaces.…”

“…[5][6][7]16 Delay in treatment from 12-24 h allows enough leakage of saliva and bacteria, as well as refluxed acid, pepsin, and bile into the surrounding loose areolar tissues, to produce suppurative infection and an intense necrotising inflammatory response. 6,16 This inflammation may allow rapid spread of infection into the mediastinum under the force of gravity and negative intrathoracic pressure if the leakage is not drained away from the deep neck spaces. 7,16 This increases morbidity and mortality and attempting repair in these patients is unlikely to succeed.…”

“…6,16 This inflammation may allow rapid spread of infection into the mediastinum under the force of gravity and negative intrathoracic pressure if the leakage is not drained away from the deep neck spaces. 7,16 This increases morbidity and mortality and attempting repair in these patients is unlikely to succeed.…”

“…2,7,17 Armstrong et al 16 showed that delay in treatment increases the incidence of prolonged leak from 20% for less than 12 h to 43% for longer. The longest delay in this series was 48 h due to late referral.…”

Penetrating Neck Injury: A Case Report and Review of Management

“…All patients who are stable must have a thorough evaluation of the vascular structures and of the aerodigestive tract prior to any surgical intervention [6].…”