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 .
- Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma 2001; 50:289.
- Onat S, Ulku R, Cigdem KM, et al. Factors affecting the outcome of surgically treated non-iatrogenic traumatic cervical esophageal perforation: 28 years experience at a single center. J Cardiothorac Surg 2010; 5:46.
- Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: new perspectives and treatment paradigms. J Trauma 2007; 63:1173.
- Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004; 77:1475.
- Richardson JD. Management of esophageal perforations: the value of aggressive surgical treatment. Am J Surg 2005; 190:161.
- Patel MS, Malinoski DJ, Zhou L, et al. Penetrating oesophageal injury: a contemporary analysis of the National Trauma Data Bank. Injury 2013; 44:48.
- Skipworth RJ, McBride OM, Kerssens JJ, Paterson-Brown S. Esophagogastric trauma in Scotland. World J Surg 2012; 36:1779.
- Biffl WL, Moore EE, Feliciano DV, et al. Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries. J Trauma Acute Care Surg 2015; 79:1089.
- Weiman DS, Walker WA, Brosnan KM, et al. Noniatrogenic esophageal trauma. Ann Thorac Surg 1995; 59:845.
- Cornwell EE 3rd, Kennedy F, Ayad IA, et al. Transmediastinal gunshot wounds. A reconsideration of the role of aortography. Arch Surg 1996; 131:949.
- Degiannis E, Benn CA, Leandros E, et al. Transmediastinal gunshot injuries. Surgery 2000; 128:54.
- Plott E, Jones D, McDermott D, Levoyer T. A state-of-the-art review of esophageal trauma: where do we stand? Dis Esophagus 2007; 20:279.
- Dertsiz L, Arici G, Arslan G, Demircan A. Acute tracheobronchial injuries: early and late term outcomes. Ulus Travma Acil Cerrahi Derg 2007; 13:128.
- Hamid UI, Jones JM. Combined tracheoesophageal transection after blunt neck trauma. J Emerg Trauma Shock 2013; 6:117.
- Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma 2008; 64:1392.
- Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg 2013; 75:936.
- Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003; 54:61.
- Kazi M, Junaid M, Khan MJ, et al. Utility of clinical examination and CT scan in assessment of penetrating neck trauma. J Coll Physicians Surg Pak 2013; 23:308.
- Stassen NA, Lukan JK, Spain DA, et al. Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma 2002; 53:635.
- Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury 2007; 38:48.
- Grossman MD, May AK, Schwab CW, et al. Determining anatomic injury with computed tomography in selected torso gunshot wounds. J Trauma 1998; 45:446.
- Hanpeter DE, Demetriades D, Asensio JA, et al. Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds. J Trauma 2000; 49:689.
- Defore WW Jr, Mattox KL, Hansen HA, et al. Surgical management of penetrating injuries of the esophagus. Am J Surg 1977; 134:734.
- Srinivasan R, Haywood T, Horwitz B, et al. Role of flexible endoscopy in the evaluation of possible esophageal trauma after penetrating injuries. Am J Gastroenterol 2000; 95:1725.
- Weigelt JA, Thal ER, Snyder WH 3rd, et al. Diagnosis of penetrating cervical esophageal injuries. Am J Surg 1987; 154:619.
- Wood J, Fabian TC, Mangiante EC. Penetrating neck injuries: recommendations for selective management. J Trauma 1989; 29:602.
- Stanley RB Jr, Armstrong WB, Fetterman BL, Shindo ML. Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel. J Trauma 1997; 42:675.
- Flowers JL, Graham SM, Ugarte MA, et al. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma 1996; 40:261.
- Arantes V, Campolina C, Valerio SH, et al. Flexible esophagoscopy as a diagnostic tool for traumatic esophageal injuries. J Trauma 2009; 66:1677.
- Inci I, Ozcelik C, Nizam O, et al. Traumatic oesophageal perforation. Scand Cardiovasc J 1997; 31:97.
- James AE Jr, Montali RJ, Chaffee V, et al. Barium or gastrografin: which contrast media for diagnosis of esophageal tears? Gastroenterology 1975; 68:1103.
- Buecker A, Wein BB, Neuerburg JM, Guenther RW. Esophageal perforation: comparison of use of aqueous and barium-containing contrast media. Radiology 1997; 202:683.
- Moore EE, Jurkovich GJ, Knudson MM, et al. Organ injury scaling. VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary. J Trauma 1995; 39:1069.
- Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg 2011; 92:209.
- Ivatury RR, Moore FA, Biffl W, et al. Oesophageal injuries: Position paper, WSES, 2013. World J Emerg Surg 2014; 9:9.
- Wu CH, Chen CM, Chen CC, et al. Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary? AJR Am J Roentgenol 2013; 201:977.
- Nesbitt JC, Sawyers JL. Surgical management of esophageal perforation. Am Surg 1987; 53:183.
- Linden PA, Bueno R, Mentzer SJ, et al. Modified T-tube repair of delayed esophageal perforation results in a low mortality rate similar to that seen with acute perforations. Ann Thorac Surg 2007; 83:1129.
- Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation: emphasis on management. Ann Thorac Surg 1996; 61:1447.
- Dasari BV, Neely D, Kennedy A, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg 2014; 259:852.
- Ben-David K, Behrns K, Hochwald S, et al. Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm. J Am Coll Surg 2014; 218:768.
- Grabowski G, Cornett CA, Kang JD. Esophageal and vertebral artery injuries during complex cervical spine surgery--avoidance and management. Orthop Clin North Am 2012; 43:63.
- Qadeer MA, Dumot JA, Vargo JJ, et al. Endoscopic clips for closing esophageal perforations: case report and pooled analysis. Gastrointest Endosc 2007; 66:605.
- Losken A, Rozycki GS, Feliciano DV. The use of the sternocleidomastoid muscle flap in combined injuries to the esophagus and carotid artery or trachea. J Trauma 2000; 49:815.
- Feliciano DV, Bitondo CG, Mattox KL, et al. Combined tracheoesophageal injuries. Am J Surg 1985; 150:710.
- Kuppusamy MK, Hubka M, Felisky CD, et al. Evolving management strategies in esophageal perforation: surgeons using nonoperative techniques to improve outcomes. J Am Coll Surg 2011; 213:164.
- Madiba TE, Muckart DJ. Penetrating injuries to the cervical oesophagus: is routine exploration mandatory? Ann R Coll Surg Engl 2003; 85:162.
- Yugueros P, Sarmiento JM, Garcia AF, Ferrada R. Conservative management of penetrating hypopharyngeal wounds. J Trauma 1996; 40:267.
- Makhani M, Midani D, Goldberg A, Friedenberg FK. Pathogenesis and outcomes of traumatic injuries of the esophagus. Dis Esophagus 2014; 27:630.
- 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