Esophageal injuries: Principles of management

Esophageal injuries, while uncommon, mandate a high degree of suspicion especially for penetrating injuries to the neck or thorax. The predominant mechanism responsible for esophageal trauma injury is gunshot wounds and many patients incur concomitant vascular, airway, or intraabdominal injuries that often require emergent operative intervention. The cervical esophagus represents the most common site of injury followed by thoracic and abdominal esophageal injuries. The morbidity associated with cervical esophageal injuries has been estimated as high as 16%, with most complications related to the duration of diagnostic delay and subsequent contamination from esophageal contents. Most trauma centers now practice selective management of neck wounds using some type of study to exclude esophageal injury in stable patients. We routinely begin with a water-soluble contrast esophagogram followed by dilute barium if no injury is visualized initially. Because contrast studies yield a false-negative rate of up to 25%, these may be followed by esophagoscopy in patients still regarded as high risk for injury. Several principles should be kept in mind regardless of the location of the esophageal injury. The first principle is the importance of preservation of esophageal function with attempted primary repair and buttressing given the lack of a serosa and the likelihood of early inflammation. Given the high incidence esophageal repair leak, the area should be widely drained. Finally, consider the need for possible nutritional support and the placement of enteral access at the initial operation.