Version May 2024
INTRODUCTION — Noniatrogenic traumatic injuries of the esophagus due to blunt or penetrating mechanisms are rare causes of esophageal perforation but can be 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 [3].
An overview of the management of noniatrogenic traumatic injury is reviewed. Management of other esophageal conditions leading to perforation are reviewed separately.
●Iatrogenic injury can occur following esophageal instrumentation, but they may also result from percutaneous ablation procedures for cardiac arrythmias [4-7]. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Complications' and "Surgical management of esophageal perforation" and "Atrial fibrillation: Catheter ablation", section on 'Other'.)
●The most common cause of noniatrogenic esophageal perforation is spontaneous rupture, followed by foreign body ingestion and malignancy (table 1) [4]. (See "Boerhaave syndrome: Effort rupture of the esophagus" and "Ingested foreign bodies and food impactions in adults" and "Surgical management of resectable esophageal and esophagogastric junction cancers".)
PREVALENCE AND ETIOLOGY — Noniatrogenic traumatic esophageal injuries are rare, with most large trauma centers treating only one to two cases per year. A five-year analysis of the National Trauma Database reported an incidence of traumatic esophageal injury as 37 per 100,000 trauma patients [8]. It occurred 16 times more frequently in penetrating compared with blunt trauma. In addition, in a review of the Scottish Trauma Audit Group (STAG), the annual incidence of esophageal trauma was 0.95 per million per year [9].
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 [10]. The most common penetrating etiology is gunshot wound (75 percent) in the United States studies, followed by stab wounds, and other mechanisms [1,11]. In a series of 1921 patients with transmediastinal gunshot wounds, less than 1 percent had an esophageal injury [12-14]. However, in the STAG study, 57 percent of esophageal perforations were due to blunt trauma and 43 percent from penetrating trauma [9].
In a 10 year, single-center retrospective review of noniatrogenic esophageal trauma, 19 esophageal injuries were identified [11]. The mechanism of injury was gunshot wound in 18 and blunt injury in 1 patient. The cervical esophagus was most commonly involved, with less than 5 percent of injuries involving more than one anatomic location (eg, neck and thorax) [1]. The most common adjacent site involved was the trachea (75 percent), although all nearby structures are at risk for injury with penetrating trauma to any portion of the esophagus [11]. Concomitant esophageal and tracheal perforation is an uncommon but potentially life-threatening injury. Most patients probably die at the scene of the accident or from the penetrating injury [15]. Of those who survive and are transported to a hospital, no deaths were reported in one review of 27 patients who had emergency surgical management [16].
CLINICAL FEATURES AND DIAGNOSIS — The diagnosis of traumatic esophageal injury poses some unique challenges. As with esophageal perforation in general, timeliness of diagnosis remains a cornerstone of management. In a multivariate analysis, time delays in diagnosis were a significant predictor of esophageal-related complications following penetrating esophageal injury (odds ratio 3.13, 95% CI 1.72-5.89) (see 'Morbidity and mortality' below). The clinician must therefore maintain a high degree of suspicion based upon mechanism of injury (eg, gunshot, stab), site of injury (eg, neck, chest, abdomen), and the proximity of the esophagus to other identified injuries (often identified on computed tomography [CT]), particularly given that clinical symptoms and signs of esophageal injury (eg, dysphagia, neck pain, neck swelling, hypersalivation, retrosternal fullness, hematemesis, odynophagia, subcutaneous emphysema) are not reliably present. In a review of 405 patients, dysphagia was present in only 7 percent and subcutaneous emphysema was identified in 19 percent [1].
The initial trauma evaluation of neck or chest injury is based upon the mechanism of injury, location, and clinical condition of the patient [17,18] and often includes CT of the neck or chest, which may identify immediately life-threatening injury (eg, aortic injury), or injury to structures (eg, vascular, laryngotracheal, spinal injury) in proximity to the esophagus; however, the overall sensitivity of CT for esophageal injury is low [19,20]. In a retrospective review of 42 patients with penetrating zone II neck injuries, CT scan missed two of the four perforations [19]. CT has also proven useful for identifying the trajectory of transmediastinal missiles, which may or may not have a path that involves the esophagus [21-24]. Findings on CT that suggest the esophageal injury include periesophageal air or fluid. (See "Penetrating neck injuries: Initial evaluation and management" and "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)
Associated injuries — Penetrating trauma at the esophageal hiatus is often associated with injuries to the liver, spleen, aorta, vena cava, pancreas, stomach, colon, lung, heart, and spine, which can be identified by CT scan [1,11,25].
Esophagoscopy and esophagography — Given the limitations of CT, esophagoscopy and esophagography are used to directly visualize esophageal injury and perforation [26,27]. Flexible esophagoscopy using modern instrumentation is highly accurate for a diagnosis of esophageal perforation when performed by experienced operators, with sensitivities ranging from 96 to 100 percent, and specificities of 92 to 100 percent [10,26,28-31].
●For patients who are clinically stable, we suggest flexible esophagoscopy to establish a diagnosis of esophageal perforation, provided a skilled, experienced endoscopist is available. If endoscopy is not possible, or the results are equivocal, then esophagography can be performed. Compared with esophagoscopy, esophagography has a higher rate of false negatives, ranging from 10 to 43 percent, but may be more accurate in the thoracic compared with cervical esophagus [10,25,26,32]. Esophagography should initially be performed with water-soluble contrast (eg, diatrizoate meglumine/diatrizoate sodium solution [ie, Gastrografin]), to avoid the negative effects of barium spillage into the mediastinum. If no leak is identified, a follow-up study using thinned barium should be performed [33]. In one study, 4 of 18 patients (22 percent) had unremarkable findings at esophagography using a water-soluble contrast, but a perforation was subsequently detected using barium [34].
●For patients who are clinically unstable or intubated, flexible esophagoscopy should be performed in the intensive care unit or operating room. In one retrospective review, 55 patients with a suspected penetrating esophageal injury underwent emergency flexible endoscopy at a median time of three hours after presentation [26]. No perforations were missed, and endoscopic findings altered management in 38 patients.
ANATOMY AND INJURY GRADING — The esophagus is located in the posterior mediastinum and extends from the level of the 7th cervical vertebra to the 11th thoracic vertebra. It is divided into regions including the cervical esophagus (figure 1A-B), thoracic esophagus (figure 2A-B), and intra-abdominal esophagus (figure 3), which have a bearing on the diagnosis and treatment of esophageal injury. The esophagus is composed of the mucosa, submucosa, muscularis externa, and adventitia (image 1).
The arterial supply includes the inferior thyroid artery (cervical esophagus), bronchial arteries and the aorta (thoracic esophagus), and branches of the left gastric artery and inferior phrenic artery (abdominal esophagus) (figure 4). The venous drainage is through the inferior thyroid vein (cervical esophagus); the azygous vein, the hemiazygous vein, or the bronchial veins (thoracic esophagus); and the coronary vein (abdominal esophagus) (figure 5).
Injury grading — Esophageal injury is graded according to the American Association for the Surgery of Trauma (AAST) injury severity scoring (table 2) [35]. The extent of injury has a bearing on the nature of the repair. (See 'Repair approach by injury grade' below.)
INITIAL MANAGEMENT — When esophageal injury is diagnosed by esophagoscopy or esophagography, or strongly suspected in the hemodynamically unstable patient, the patient will require urgent surgical exploration and repair. However, due to the multiplicity of associated injuries in this patient population, the injuries should be triaged according to severity and the surgical approach should be planned accordingly. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)
Initial management includes securing the airway, appropriate fluid resuscitation, laboratory evaluation, and type and crossmatch. (See "Initial management of trauma in adults" and "Approach to shock in the adult trauma patient".)
Given the association of esophageal injury and airway injury, endoscopic assessment of the airway is necessary if the mechanism of injury potentially involved the airway there. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)
The patient should remain nil per os (NPO), and at the time of esophagoscopy, a nasogastric tube should be placed under direct vision to provide gastrointestinal decompression, if possible. Blind insertion of a nasogastric tube should never be attempted in a patient with suspicion for esophageal injury.
Broad-spectrum intravenous antibiotics should be administered covering aerobes and anaerobes. If the patient has been on a longstanding therapy with a proton pump inhibitor, antifungal therapy should also be administered, particularly for lower esophageal injuries. (see "Surgical management of esophageal perforation", section on 'Initial management' and "Overview of gastrointestinal tract perforation", section on 'Antibiotics')
OPERATIVE MANAGEMENT — Open surgery remains the mainstay of treatment of traumatic esophageal perforation. The approach to traumatic esophageal perforation depends upon the location of the injury (eg, neck, chest, abdomen), severity of damage (grade of injury), hemodynamic status of the patient, and nature and severity of associated injuries. (See 'Conservative treatment' below.)
Hemodynamically unstable patients are brought to the operating room because of a positive focused abdominal sonography for trauma (FAST) scan or hemothorax with bleeding from the chest tube site. The operative management of traumatic esophageal perforation is entertained only after bleeding has been controlled and hemodynamics have stabilized. It is important during the intraoperative trauma evaluation that the involved surgeons think of the potential for esophageal injury and use endoscopy, which can be performed regardless of patient positioning.
The principles of esophageal repair include debridement of contaminated and necrotic material, closure of the esophageal defect, and liberal drainage around the site of contamination and repair. When feasible, using vascularized tissue such as a muscle flap, thymic flap, or pericardial flap to buttress the esophageal repair is desirable. Primary repair is preferable within 24 hours from perforation; however, repair can be entertained after 24 hours depending on the degree of contamination and devitalized tissue [3,5,36,37]. If there is significant contamination, placement of a closed-suction drain is advisable and may help prevent postoperative abscess formation [10]. (See "Surgical management of esophageal perforation", section on 'Principles of surgical management'.)
Importance of early surgery — Prompt surgical intervention remains the cornerstone of effective management. In a multicenter review of patients with penetrating neck trauma, 346 patients survived to reach the operating room, and 175 patients had immediate surgical intervention with no preoperative evaluation [1]. Immediate intervention patients had a higher rate of intra-abdominal esophageal injury (26 versus 10 percent) and a lower mean Revised Trauma Score (6.7 versus 7.3). In those undergoing preoperative evaluation, the mean time that elapsed in the emergency department was 13 hours, with a mean of 1.7 procedures performed per patient, including esophagoscopy (73 percent), contrast studies (61 percent), and computed tomography (CT) scans (43 percent). The rate of postoperative esophageal complications was significantly higher for patients who had preoperative evaluation in the emergency department compared with those taken directly to the operating room (41 versus 19 percent, odds ratio [OR] 3.13, 95% CI 1.72-5.89).
Repair approach by injury grade — Primary repair of esophageal injuries can be performed whenever healthy tissue can be approximated without tension [5,36-38].
Most low-grade (grade I through III) (table 2) traumatic esophageal perforations can be repaired primarily, or repaired over a drain [3,39]. If primary repair is not possible because of contamination or hemodynamic instability, but there is only a small amount of tissue loss, an effective strategy is to repair the esophagus around a large T-tube. This creates a controlled esophageal-cutaneous fistula, which may close spontaneously after edema resolves and the T-tube is removed. Alternatively, an esophageal stent could be used to cover the defect [10,40,41]. However, drainage of the contaminated space remains essential. (See 'Adjunctive esophageal stenting' below.)
The esophagus should be debrided to healthy tissue and the mucosal defect should be completely exposed, even if this requires enlarging the muscular defect. Failure to close the mucosa will most assuredly result in failure of the repair. Intraoperative endoscopy can be helpful for identifying the extent of the defect. The mucosal defect should be closed first, followed by a second-layer closure of the muscularis layer. There are no studies comparing the techniques [5,37]. Some recommend absorbable suture with knots on the outside to avoid granuloma formation, but this has not been subjected to rigorous evaluation [37].
Larger defects or those involving significant devascularization (grade IV, V) require more challenging surgical management. Typically in the traumatic circumstance, esophagectomy with reconstruction is not indicated due to the length and technical nature of the procedure as well as the patient's hemodynamic status [10]. Rather, esophageal diversion may be required. This includes creation of an end cervical esophagostomy and division of the esophagus at the gastroesophageal junction to exclude the site of injury. If the patient is hemodynamically stable, removal of the thoracic esophagus should be performed. In the unstable patient, the thoracic esophagus may be left in situ with removal later once the patient is stable. It should be noted that a blind-ended esophagus is at high risk for spontaneous rupture with time due to the force of esophageal peristalsis, even with a nasogastric tube in place.
While in the abdomen, a gastrostomy is recommended but should be placed strategically so as to not damage the subsequent formation of a gastric tube for reconstruction of the gastrointestinal tract. Feeding jejunostomy is also recommended, although only in stable patients [5,10,37,38]. Delayed esophageal reconstruction is planned months later.
In one review, the types and frequencies of repairs of 346 penetrating traumatic injuries included [1]:
●Primary repair: 82 percent
●Drainage alone: 11 percent
●Resection and diversion: 4 percent
●Resection and anastomosis: 3 percent
●Drainage as an adjunct procedure: 62 percent
Adjunctive esophageal stenting — A number of studies have described the placement of an esophageal stent, or use of endoscopically placed clips to seal or close small nontraumatic esophageal perforations [42-45]. No comparisons have been made with surgical repair. Although there is minimal experience in the trauma population, temporary esophageal stenting may be an alternative to open surgical repair among those patients who, at least initially, are not deemed fit for surgery or who have multiple other injuries that take precedent. When elected, stent placement should only be attempted by an experienced endoscopist. Drainage of the contaminated field is a necessary adjunct to stent placement for source control of extraluminal infection. This may be accomplished thoracoscopically. Additional concerns include obtaining a route for enteral nutrition and remaining wary of potential stent migration. Endoscopic stent placement for patients with an esophageal perforation is discussed in more detail elsewhere. (See "Surgical management of esophageal perforation", section on 'Endoscopic stent placement' and "Endoscopic stenting for palliation of malignant esophageal obstruction".)
Special considerations for specific injury sites — The approach to open surgical repair depends upon the level of the perforation and may involve a neck incision and/or thoracotomy, and for lower esophageal perforation, potentially an upper abdominal incision as well.
Cervical esophagus — The general principles of surgical management of cervical esophageal perforation are discussed separately. Specific issues pertaining to cervical esophageal perforation due to blunt or penetrating trauma are discussed below. (See "Surgical management of esophageal perforation", section on 'Cervical perforation'.)
The cervical esophagus is generally approached via an incision along the medial border of the left sternocleidomastoid; a right-sided or, if bilateral access is required (eg, coexistent tracheal injury), a transverse incision can be used [10]. However, the chest should also be prepped into the field in case broader exposure is required. Violation of the platysma by a penetrating object predicts deeper injury of vital neck structures 24 to 33 percent of the time. This includes a 10.8 to 12.6 percent rate of esophageal injury [14].
Due to the anatomic confines of the neck, cervical esophageal injuries can often be managed with drainage alone. First and foremost is the identification of associated injuries including the airway, major vessels, and spine. Dissection should begin along the lateral edge of the sternocleidomastoid muscle with judicious use of cautery. The omohyoid muscle is then divided and the lateral aspect of the esophagus is exposed. Care must be taken to avoid injury to the recurrent laryngeal nerve, which includes careful retraction of the deeper structures (a finger on the trachea is best), minimal use of cautery, and, if cautery is used, bipolar rather than monopolar cautery. The retroesophageal space should be opened sharply. If an injury is readily identified, it may be closed in two layers without tension. Otherwise, closed-suction drains may be simply placed behind the esophagus and in any potentially contaminated space with subsequent wound closure. The patient should be kept nil per os (NPO) and restudied with barium esophagram in approximately one week based on drain output.
If a coexistent airway injury is identified, repair of both injuries is indicated with rotation of a muscle flap between the repairs to avoid development of a tracheoesophageal fistula.
Other considerations in the context of trauma include the following:
●Given the anatomic proximity of the cervical esophagus to the trachea and other vital structures (figure 1B), the surgeon must evaluate for possible coexistent injuries to prevent complications such as tracheoesophageal fistula. Further investigation for injury to the upper airway and upper gastrointestinal tract can then be undertaken in the operating room using bronchoscopy, laryngoscopy, and esophagoscopy.
●Testing can include endoscopic insufflation of the cervical esophagus while the wound is irrigated to identify air leaking into the wound, which would be indicative of injury to the trachea or esophagus. Endoscopy can also aid in identifying a perforation that might be obscured by hematoma, to evaluate the opposite side to help identify a through-and-through injury, and to insufflate air following repair to assess for a leak [10].
●Interposition of a muscle flap between the repaired esophagus and other structures is essential in combined repairs (esophagus-trachea, esophagus-carotid artery) [37,46,47]. This can be accomplished using typically a strap muscle, but the sternocleidomastoid muscle can be detached and rotated at either end to buttress the esophageal repair [10]. The wound should be irrigated and well drained (closed-suction).
●Care must be taken to avoid injury to the recurrent laryngeal nerve running in the tracheoesophageal groove. This includes careful identification of anatomy, avoidance of monopolar cautery near the tracheoesophageal groove, and the use of soft retractors. Based on the mechanism of trauma, if bilateral nerve injury is suspected, tracheostomy may be necessary. Laryngoscopy can be performed at bedside for extubated patients to identify vocal cord immobility indicating a recurrent nerve injury.
●Extensive injury to the cervical spine may result in an esophageal injury being overlooked. Subspecialists dealing with spine injury must remain wary of these events given the proximity of the esophagus to the spinal column.
●The wound should be irrigated with isotonic saline and drained well with closed-suction drains (eg, Jackson-Pratt drains) placed in the periesophageal space and brought out through counter incisions in the lateral neck. Neck drainage alone is acceptable if the injury cannot be identified after an extensive surgical and endoscopic evaluation of the hypopharynx, airway, and esophagus.
Thoracic esophagus — The general principles of surgical management of thoracic esophageal perforation are discussed separately. Specific issues pertaining to thoracic esophageal perforation due to blunt or penetrating trauma are discussed below. (See "Surgical management of esophageal perforation", section on 'Thoracic perforation'.)
The hemodynamically stable patient in whom the diagnosis has been confirmed by endoscopy should undergo posterolateral thoracotomy [10]. The proximal esophagus (upper and middle third) is approached via right lateral thoracotomy incision (fifth to eighth interspace depending on the suspected site of injury) and the distal esophagus (lower third) via a left thoracotomy (seventh or eighth interspace).
Special considerations in the context of trauma include the following:
●For patients requiring immediate transport to the operating room, without time for radiologic or preoperative endoscopic assessment, endoscopy and bronchoscopy can be performed intraoperatively. Intraoperative endoscopy aids in identifying the site(s) of perforation, and to assess for a leak following repair. Following endoscopy, place a nasogastric tube under direct vision if an injury is identified.
●Primary thoracic esophageal repairs should be buttressed with pleura, pericardium, intercostal muscle, or diaphragm. The stomach should not be pulled up into the chest to buttress a distal esophageal injury, as this tends to create severe gastroesophageal reflux due to the disruption of the gastroesophageal junction.
●Wide chest drainage using closed-suction drains is necessary following repair.
Abdominal esophagus — The general principles of surgical management of abdominal esophageal perforation are discussed separately. Specific issues pertaining to abdominal esophageal perforation due to blunt or penetrating trauma are discussed below. (See "Surgical management of esophageal perforation", section on 'Abdominal perforation'.)
The perforated abdominal esophagus is approached through a standard trauma midline incision. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury", section on 'Damage control laparotomy'.)
Special considerations in the context of trauma include the following:
●Hemodynamically unstable patients with penetrating abdominal wounds are brought directly to the operating room. During exploration, maintain a high degree of suspicion for abdominal esophageal injury, particularly when upper abdominal injuries are identified during exploration (eg, liver, spleen, proximal aorta, pancreas, stomach, transverse colon, heart).
●Intraoperative endoscopy should be used whenever abdominal esophageal injury is suspected. Insufflate the esophagus to observe for air leak. Following endoscopy, place a nasogastric tube under direct vision if an injury is identified.
●Perform a primary repair when possible, which can be buttressed using the stomach (Dor fundoplication or Nissen fundoplication). Copiously irrigate the perforation site with isotonic saline.
●Drain pleural spaces that may have been contaminated or subject to sympathetic effusions following an upper abdominal esophageal injury.
●Perform a feeding jejunostomy if extensive esophageal injury is identified and the patient is otherwise stable.
●Use closed-suction drains.
CONSERVATIVE TREATMENT — Conservative, nonoperative management of other etiologies of esophageal perforation (iatrogenic, foreign body, emetogenic) is an alternative for minimal injuries; however, the generally more extensive nature of blunt or penetrating esophageal injury precludes nonoperative management for the majority of patients. For those in whom nonoperative management is attempted, restricted oral intake and intravenous broad-spectrum antibiotics are recommended during healing. (See "Overview of gastrointestinal tract perforation", section on 'Conservative care'.)
Cervical perforation is most commonly considered for nonoperative management but, for blunt or penetrating traumatic injury, is usually managed operatively. The available data pertaining to management of nontraumatic cervical esophageal perforations are few and low quality [42,43,48]. One small study in a series of trauma patients suggested that nonoperative management could be safe and effective [49]. Given the low rate of complications with neck exploration, it would be difficult to justify any complications related to a nonoperative approach [10].
Injuries to the hypopharynx may often be safely managed nonoperatively. The low intraluminal pressure and the overlapping middle and inferior pharyngeal constrictor muscles facilitate a rapid, spontaneous seal of stab and small gunshot wounds [29,50]. In the lower hypopharynx (ie, below the tips of the arytenoid cartilages), or in the setting of extensive tissue damage, operative intervention is often necessary [50].
Perforation into the pleural or peritoneal cavity is a relative contraindication to nonoperative management due to the difficulties of controlling spillage. A patient with a very small, contained thoracic perforation and no signs of sepsis may be managed nonoperatively. Published series have reported good outcomes following nonoperative management of small, contained iatrogenic thoracic esophageal perforations [43,48], but a major distinction between traumatic and nontraumatic perforations is that trauma may disrupt the tissue planes and thereby the potential containment of the esophageal leak. If nonoperative management of traumatic esophageal perforation is attempted, it should only be done with the guidance of a multidisciplinary team experienced in the care of complex esophageal pathology [10].
POSTOPERATIVE MANAGEMENT — For patients who are managed nonoperatively, the decision about when to start feeding after an injury depends upon the extent of the injury, underlying esophageal pathology, general condition of the patient, and reliability of the patient in following instructions regarding oral intake. (See 'Conservative treatment' above.)
Following repair, most recommend nil per os (NPO) status for several days. A decompressive nasogastric tube is not required for cervical injury but should be placed under direct vision for identified thoracic and abdominal esophageal injuries. It is reasonable to obtain an esophagogram in the absence of any complications on postoperative day 7, before initiating oral intake.
Nutritional support may be necessary if the postoperative course becomes complicated. This may require a surgically placed feeding tube; a fluoroscopically or endoscopically placed feeding tube (ie, percutaneous endoscopic gastrostomy [PEG]) is contraindicated and should not be performed after identification of an esophageal injury. (See "Surgical management of esophageal perforation", section on 'Postoperative management'.)
For patients with combined airway and cervical esophageal trauma, the patient should be monitored carefully for evidence of an esophageal fistula.
Any patient with clinical signs of postoperative aspiration or pneumonia should be evaluated bronchoscopically.
MORBIDITY AND MORTALITY — Mortality from traumatic esophageal trauma is related to multiple factors, including injury severity, concomitant injuries, and underlying comorbidities. As an example, given the proximity of the thoracic esophagus to major vascular structures, injuries in this region are often fatal. In a six-year retrospective review, esophageal trauma occurred in 0.14 percent of 231,694 trauma patients; the presence of esophageal trauma was an independent predictor of mortality (odds ratio 3.42, 95% CI 2.50-4.71) [51]. In a National Trauma Data Bank review of 944 noniatrogenic esophageal injuries, mortality was significantly lower for cervical injuries compared with thoracic or abdominal esophageal injuries (7.9 versus 13.5 percent). Logistic regression identified age >50, thoracic injury, high grade esophageal injury (organ injury scale IV to V), hypotension, and Glasgow coma scale (GCS)< 9 as independent risk factors for mortality [52].
The following retrospective reviews illustrate morbidity and mortality rates based upon the severity of injury or location of injury [1,4]:
●In a review of 433 traumatic esophageal injuries, the overall mortality rate was 19 percent [1]. Mortality in the emergency department and operating room were 6 and 9 percent, respectively. The mortality rate directly correlated with the American Association for the Surgery of Trauma-Organ Injury Severity Score (AAST-OIS). Mortality for grade I injuries was 8 percent, and the mortality for grade V injuries was 67 percent. Over 75 percent of postoperative deaths were due to exsanguination. Postoperative morbidity was also high within this study, with 33 percent of patients having at least one postoperative complication and 25 percent with at least one esophageal complication. Most of the esophageal complications were related to postoperative infections, including abscess, mediastinitis, and empyema, and 1.4 percent developed a tracheoesophageal fistula. Independent risk factors for the development of esophageal-related complications included time delays incurred in preoperative evaluation (see 'Importance of early surgery' above), esophageal injury grade >2 (table 2), and need for esophageal resection and diversion.
●In a two-year review of the National Trauma Database that included 227 penetrating esophageal traumas, the overall mortality rate was 44 percent [53]. Of the 99 deaths, 73 were pronounced in the emergency department, 18 died <24 hours from admission, and 8 died >24 hours after admission. For patients who survived >24 hours after admission, mortality was 5.9 percent. In those surviving >24 hours from admission, 83 percent had complications, including 32 percent with an esophageal-related complication. Significant risk factors for complications included older age and abbreviated injury score (AIS) ≥3.
●A 10 year review of the Scottish Trauma Audit Group identified 30 patients with esophageal trauma [9]. The overall hospital mortality rate was 70 percent, including 30 percent who died in the emergency department. A high percentage of these patients (82 percent) had an AIS >15, consistent with severe trauma. Concomitant head or orthopedic injuries were associated with a 100 percent mortality rate.
Complications of surgery for repair of esophageal perforation are mainly related to breakdown of the repair with ensuing esophageal leak and infection. Complications related to esophageal resection and reconstruction are discussed separately. (See "Complications of esophageal resection".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Thoracic trauma" and "Society guideline links: Gastrointestinal perforation" and "Society guideline links: Penetrating neck injury".)
SUMMARY AND RECOMMENDATIONS
●Esophageal injury – Traumatic blunt or penetrating esophageal injuries are rare and life-threatening. Maintaining a high level of suspicion, expedient diagnosis, and rapid surgical intervention are critical components in managing patients with penetrating esophageal injuries. (See 'Special considerations for specific injury sites' above.)
●Approach to management – The approach to management of penetrating esophageal injuries depends on the patient's clinical stability and coexisting injuries. (See 'Special considerations for specific injury sites' above.)
•Patients who are unstable or intubated, or who have a penetrating intra-abdominal injury, should be transported directly to the operating room for further evaluation. This evaluation includes intraoperative bronchoscopy, laryngoscopy, and esophagoscopy once more acute life-threatening injuries have been addressed. (See 'Clinical features and diagnosis' above and 'Operative management' above.)
•Patients who are stable, such as those who may have no violation of the platysma muscle or peritoneum, should undergo preoperative evaluation with flexible esophagoscopy by an experienced endoscopist in the emergency department. (See 'Clinical features and diagnosis' above.)
●Esophageal repair
•Surgical repair – Primary repair is the optimal surgical procedure to restore the integrity of the esophagus. (See 'Operative management' above and "Surgical management of esophageal perforation", section on 'Primary surgical repair'.)
•Role of esophageal stenting – Esophageal stenting may be an option for unstable patients with numerous injuries but should not preclude subsequent attempts at surgical intervention once the patient has stabilized. (See 'Repair approach by injury grade' above.)
●Mortality and complications – The overall mortality rate is high, depending on severity of injury and other associated injuries. Most esophageal complications are related to infections (eg, abscess, mediastinitis, empyema). (See 'Morbidity and mortality' above.)
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