Overview of esophageal perforation due to blunt or penetrating trauma
- Daniel P Raymond, MD
Daniel P Raymond, MD
- Thoracic Surgeon
- The Cleveland Clinic
- Section Editors
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
Traumatic injuries of the esophagus due to blunt or penetrating mechanisms are rare, but life-threatening [1,2]. Despite the relative rarity, clinicians in multiple disciplines, including general surgery, emergency medicine, thoracic surgery, trauma surgery, otolaryngology, and spine surgery must be knowledgeable regarding their diagnosis and management.
Penetrating injuries are more common than blunt injuries. Injury to adjacent structures, such as the trachea, and a delay in diagnosis of 24 hours are associated with a poor outcome. For traumatic injuries, primary surgical repair is the generally preferred treatment approach, particularly for thoracic or abdominal injuries .
Most esophageal perforations are iatrogenic following esophageal instrumentation (table 1) [4,5]. The most common cause of non-iatrogenic esophageal perforation is spontaneous rupture, followed by foreign body ingestion (table 2), trauma, and malignancy (table 1) . Spontaneous (emetogenic) rupture (Boerhaave’s syndrome) and foreign body perforation of the esophagus are reviewed separately. (See "Boerhaave syndrome: Effort rupture of the esophagus" and "Ingested foreign bodies and food impactions in adults" and "Foreign bodies of the esophagus and gastrointestinal tract in children".)
PREVALENCE AND ETIOLOGY
Traumatic esophageal injuries are rare, with most large trauma centers treating only one to two cases per year. A two-year contemporary analysis of the National Trauma Database found 227 reported cases of penetrating esophageal trauma from 77 Level 1 and 20 Level 2 trauma centers . In addition, a review of the Scottish Trauma Audit Group (STAG) identified an annual incidence of esophageal trauma to be 0.95 per million per year .
The majority of the esophageal injuries are penetrating injuries. The incidence of blunt esophageal injuries was one-tenth that of penetrating injuries at one urban Level 1 trauma center . The most common penetrating etiology is gunshot wound (75 percent) in the United States studies, followed by stab wounds, and other mechanisms [1,9]. In a series of 1921 patients with transmediastinal gunshot wounds, less than 1 percent had an esophageal injury [10-12]. However, in the STAG study, 57 percent of esophageal perforations were due to blunt trauma and 43 percent from penetrating trauma .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- PREVALENCE AND ETIOLOGY
- CLINICAL FEATURES AND DIAGNOSIS
- Associated injuries
- Esophagoscopy and esophagography
- ANATOMY AND INJURY GRADING
- Injury grading
- INITIAL MANAGEMENT
- OPERATIVE MANAGEMENT
- Importance of early surgery
- Repair approach by injury grade
- Adjunctive esophageal stenting
- Special considerations for specific injury sites
- - Cervical esophagus
- - Thoracic esophagus
- - Abdominal esophagus
- CONSERVATIVE TREATMENT
- POSTOPERATIVE MANAGEMENT
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS