Esophageal Injuries

MECHANICAL TRAUMA Lacerations of the esophagus occur most frequently during endoscopic biopsy or dilatation of a narrowed or obstructed esophagus. The esophagus can also be injured by swallowed foreign bodies. Injury to the thoracic esophagus is seen only rarely in patients who reach the hospital alive.

If esophageal injury is suspected, an esophagogram should be obtained. The initial study should be performed using water-soluble contrast, since extravasation of barium into the mediastinum can complicate mediastinitis. However, a negative water-soluble contrast study should always be confirmed with a barium study owing to the former's relatively high false-negative rate.

Flexible esophagoscopy is being performed increasingly for diagnosis but may miss more than 20 percent of injuries, even if combined with an esophagogram. Some prefer rigid esophagoscopy in combination with bronchoscopy to rule out associated tracheobronchial injuries.

If treatment is delayed beyond 24 h, primary closure of a torn esophagus is usually not advisable because local edema, tissue necrosis, and infection make secure suturing and primary healing unlikely. If mediastinitis develops, it may be rapidly fatal unless the site is drained early and completely. Even if an esophageal repair is not attempted, continuous complete drainage of the stomach (preferably with a gastrostomy tube) and the adjacent mediastinum (with chest tubes) is important and may be necessary for up to several weeks.

In spite of all our technical and nutritional advances in recent years, the mortality rate for esophageal injuries ranges from 5 to 25 percent for those treated definitively within 12 h and 25 to 66 percent for those treated after 24 h.

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