Esophageal Gunshot Injuries

Abstract

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.

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

“…There was an average of 4-5 oesophageal injuries per year, which falls within the rate of 2-9 cases per year reported by most busy trauma centres. 6,7 . These 28 patients constituted 13% of patients with odynophagia associated with neck injuries.…”

“…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.…”

“…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.…”

“…Delay increases morbidity and mortality and attempting repair in these patients is unlikely to succeed; 17 these patients should ideally undergo debridement and drainage without attempted repair. 2,7,9,17,21 Although some authors use double-layer repair, 1,8,22 other studies have shown that repair with a single layer is safe and effective both in traumatic 16,23 and non-traumatic situations. 24,25 Our policy is to use a single layer suture.…”

“…The problem with these series is that they report multifactorial causes of oesophageal perforation or injuries including many cases with preexisting disease. [5][6][7] The debate over selective versus mandatory neck exploration continues because of lack of data showing conclusively that one approach is superior to, or more cost effective than, the other. 8 This study was undertaken to establish whether conservative management of cervical oesophageal injuries is safe and effective.…”