Panagiotis N. Symbas, M.D., Denis H. Tyras, M.D., Charles R. Hatcher, Jr., M.D., and Byron Perry, M.D. ABSTRACT The histories of 22 patients with perforation of the esophagus from bullet or stab wounds who were treated at Grady Memorial Hospital between August, 1964, and July, 1971, were reviewed. The presenting symptoms, signs, and plain roentgenographic findings in this group of patients, because of the frequent existence of injuries to other organs, were not diagnostic for esophageal perforation. The routine use of esophagography in all patients who have a penetrating wound close to the esophagus or in whom the bullet or weapon may have traversed the mediastinum has been of great value in diagnosing esophageal injury resulting from such wounds. The treatment of choice for these patients is surgical repair of the esophageal wound with wide drainage of the soiled mediastinum as soon as the diagnosis is made. T raumatic perforation of the esophagus from knife and gunshot wounds constitutes a small percentage of esophageal injuries in most reported series [2, 6,8]. The purpose of the present study is to review the patients with knife or gunshot wounds of the esophagus who were diagnosed and treated at Grady Memorial Hospital between August, 1964, and July, 1971, and to consider the unique problems that arose during their management. Clinical Material During this seven-year period, 22 patients were diagnosed and treated for bullet or knife wounds shown to involve esophageal injury (12 to the cervical, 7 to the thoracic, and 3 to the abdominal portion). Their ages ranged from 16 to 49 years, and in all but 1 of them the injury was due to a gunshot wound. The admission history and physical findings included, in addition to the presence of one or more penetrating wounds: bleeding from the mouth (4 patients); hoarseness (1 patient); subcutaneous cervical emphysema (5 patients); rigid and tender abdomen (5 patients); shock (4 patients); stridor (1 patient); and mediastinal crunch (1 patient). The initial chest roentgenograms were reported to have shown pneumothorax or hemothorax (8 patients), foreign body in close proximity to the esophagus (6 patients), subcutaneous emphysema (5 patients), widening of the mediastinurn (3 pa- From the Joseph B. Whitehead Department of Surgery, Thoracic and Cardiovascular Surgery Division, Emory University School of Medicine, Atlanta, Ga. Supported in part by National Institutes of Health Training Grant No. HE 05861. Presented at the Eighteenth Annual Meeting of the Southern Thoracic Surgical Association, Tampa, Fla., Nov. 4-6, 1971. Address reprint requests to Dr. Symbas, 69 Butler St., S.E., Atlanta, Ga. 30303. 552 THE ANNALS OF THORACIC SURGERY
tients), and cervical vertebral fracture (2 patients). The diagnosis of esophageal perforation was made by extravasation of radiopaque material at esophagography (12 patients): at the time of emergency surgical exploration for suspected internal injuries (9 patients); or after a bullet initially thought to be in the hilum of the left lung traversed the gastrointestinal tract and passed through the rectum (1 patient). Of the 22 patients with esophageal perforation, 5 had three or more associated organ injuries, 5 patients had two, and 5 patients had one (Fig. 1). A nasogastric tube was inserted, oral intake discontinued, and antibibiotics administered in all patients as soon as the diagnosis of esophageal perforation was suspected. The administered antibiotics were either chloramphenicol, carbenicillin, or sodium cephalothin with or without kanamycin sulfate or streptomycin sulfate. All patients but 1 were treated surgically 6.2 hours, mean, arter the injury, although delays of as long as 14, 16, and 24 hours occurred. Time lapses of this magnitude were most often due to delay in transporting the patient to a medical facility. The operative procedures performed included wide drainage of the area adjacent to the perforation, with or without suture of the perforation and with or without debridement of the traumatized margins of the esophageal wound. The procedure most commonly performed was drainage of the area adjacent to the esophagus and suture closure of the FIG. 1. Esophagogram performed shortly after admission showing (A) esophagopericardial communication in a patient with a bullet wound of the right chest and (B) the missile located in the left chest. VOL. 13, NO. 6, JUNE, 1972 553
SYMBAS ET AL. wound. One patient with a tangential high-velocity-bullet wound at the cardioesophageal junction with complete destruction of about 6 cm. of the esophageal wall and bullet wounds of several other organs had exteriorization of the proximal end of the injured esophagus through the posterior chest wall, closure of the cardioesophageal junction, gastrostomy, and pyloroplasty. Debridement of the esophageal wound edges was performed in only 3 patients, operated upon 2,4, and 24 hours, respectively, after the injury. Only 1 patient was treated nonoperatively. This patient had no signs, symptoms, or plain roentgenographic evidence of esophageal perforation. The diagnosis was suspected 48 hours after the injury, when the bullet, which initially was thought to be in the hilum of the left lung based on the admission anteroposterior portable chest roentgenogram, was found to have migrated to the abdomen. The esophagogram obtained then showed no extravasation of radiopaque material. The diagnosis of esophageal perforation in this patient was established four days later, when the migrating bullet passed per rectum. R esu 1 ts Sixteen of the 22 patients with esophageal perforation survived. Of the 6 deaths, 2 occurred in the group of 12 patients with perforation of the cervical esophagus and 4 in the group of 7 patients with perforation of the thoracic esophagus. Three of the 6 fatal perforations were diagnosed between 12 and 23 hours after the injury, and 3 were diagnosed earlier than 12 hours. Four patients had associated severe multiple organ injuries. The 2 patients with perforation of the cervical esophagus who died had coincidental spinal cord transection. In 1 of the 12 patients with perforation of the cervical esophagus, localized infection with esophagocutaneous fistula occurred nine days after injury. This closed spontaneously within one week without residual defect. In the remaining 11 patients, the repaired wound healed primarily. Of the 6 surgically treated patients who had perforation of the endothoracic esophagus, 4 deveioped leakage of the suture line and pleural empyema 4, 6,7, and 10 days, respectively, after repair. Only 1 of these 4 patients survived the injury, after prolonged open drainage of the chest (Fig. 2). The 2 other surviving patients from those with perforation of the thoracic esophagus were the patient who was initially treated with exteriorization of the proximal end of the injured esophagus and the nonsurgically treated patient in whom the bullet migrated through the gastrointestinal tract. The perforations of the abdominal esophagus all healed per primam, and all these patients recovered from their injuries. In all 3 patients who underwent debridement of the edges of the esophageal wound, the suture line disrupted postoperatively; 2 of these patients, operated upon 4 and 24 hours, respectively, after injury, died; whereas the 554 THE ANNALS OF THORACIC SURGERY
FIG. 2. (A) Chest roentgenogram in a patient with bullet wound of the right chest. The missile is located in the left chest. (B) Admission esophagogram shows extravasation of radiopaque material into the right chest. third patient recovered after prolonged treatment for pleural empyema and a pleuroesophageal fistula. Histological examination of the debrided esophageal tissue showed diffuse hemorrhage involving all layers of the esophageal wall, acute coagulation necrosis of the muscle fibers, and acute inflammatory cell reaction. Comment Traumatic perforation of the esophagus due to knife or gunshot wounds forms a small percentage of all esophageal perforations reported [Z, 6, 81. The incidence of this form of esophageal injury, however, is greater in institutions treating large numbers of trauma patients, and, with the increase in volume of injured patients, the incidence of traumatic esophageal perforation may be expected to increase also. Pain has been found to be the most common symptom of perforation of the esophagus from all causes [71. Its intensity and location are dependent upon the site of perforation. Fever is next in frequency [7] (in more than 90% of patients), and dysphagia, respiratory distress, and hoarseness are less frequently observed. The signs of esophageal perforation from all causes have been found to depend upon the location of the injury. Perforations of the cervical esophagus are accompanied by local tenderness and subcutaneous emphysema as well as by resistance of the neck to passive motion. Injury of the intrathoracic esophagus may include, in addition to subcutaneous emphysema of the neck, mediastinal crunch, splinting of the chest wall, respiratory distress, and shock. Abdominal tenderness and rigidity are the most VOL. 13, NO. 6, JUNE, 1972 555
SYMBAS ET AL. common symptoms and signs of perforation of the abdominal esophagus, and not infrequently of the lower thoracic esophageal segment, and may be mistaken for a perforated peptic ulcer [GI. Widening of the superior mediastinal shadow, subcutaneous emphysema in the neck (Fig. 3A), and increased distance between trachea and vertebrae (prevertebral shadow) are the chief roentgenographic signs of cervical esophageal perforation. In addition, widening of the whole mediastinal shadow, mediastinal emphysema, and hydrothorax or pneumothorax are the main signs of perforation of the thoracic esophagus [7] (see Fig. 2A). Although the symptoms, signs, and plain roentgenographic findings in perforation of the esophagus from a stab or gunshot wound are almost identical to those observed in patients with esophageal perforation from other causes, these same findings from wounds inflicted on other organs may frequently mask those of the esophageal injury (see Fig. 1). The routine use of esophagography in all patients who have a penetrating wound close to the esophagus or in whom the bullet or weapon may have traversed the mediastinum has been of great value in diagnosing esophageal perforation from such wounds (see Figs. 1 and 3). This test should be performed with either absorbable or nonabsorbable radiopaque material as soon as the patient s condition is stable following the initial resuscitative measures. The use of cinefluorography within the first 24 hours after injury, with films obtained both during and after the radiopaque material has been swallowed, has resulted thus far in no false-positive or false-negative examinations. Although the management of esophageal perforation from other causes has been somewhat controversial [l, 3, 41, it is our belief that all patients with perforation of the esophagus from stab or bullet wounds should be FIG. 3. (A) Chest roentgenogram showing swelling, subcutaneous emphysema, and a missile in the lower neck region in a patient with bullet wound of the lower neck. (B) Admission esophagogram shows extrauasation of the radiopaque material. 556 THE ANNALS OF THORACIC SURGERY
placed on constant nasogastric suction, should have oral alimentation suspended, and should have intravenous fluids and broad-spectrum antibiotics administered as soon as the diagnosis is suspected. After the diagnosis is established, the patient should be operated upon as soon as feasible. The wound should be sutured, if possible, and the adjacent area widely drained. For cervical esophageal perforations, drainage is achieved with Penrose drains placed in the contralateral and ipsilateral mediastinum and brought out through a separate skin incision. For endothoracic esophageal injuries, drainage is accomplished by widely opening the mediastinal pleura from the diaphragm to the neck, after which the pleural space is drained by two large chest tubes. For perforations of the esophagus located below the aortic arch, a concomitant gastrostomy and feeding jejunostomy should be performed. For perforations above the aortic arch, nasogastric drainage suffices. In a patient who has significant loss of the thoracic esophageal wall and injuries to other organs, pyloroplasty and gastrostomy appear to be the procedures of choice in addition to drainage of the mediastinum, exteriorization of the proximal end of the injured esophagus, and closure of the distal end. Esophageal continuity in these patients is established at a later date, preferably after all other wounds have healed. In our series, debridement of the esophageal wound edges before repair did not appear to influence wound healing; but this technique was used in only 3 patients, all of whom had perforation of the thoracic segment of the esophagus. The observed histological changes in the resected specimens suggest, however, that debridement of the wound before suturing might yield a higher incidence of primary healing. Further evaluation of this technique is needed before its value is defined. Following repair of the wound, the previously inserted nasogastric tube -which provides gastric decompression and facilitates identification and mobilization of the esophagus during operation-is removed in patients with perforation below the aortic arch. Antibiotics are continued postoperatively and may be altered as dictated by the sensitivity of the organisms cultured from the wound at the time of operation. Oral alimentation usually is begun on the fourth or fifth postoperative day if a preceding esophagogram has shown no extravasation of radiopaque material. If an esophagocutaneous fistula occurs following repair of a cervical esophageal perforation, it is usually easily handled by drainage of the area and by feeding the patient through the nasogastric tube. The fistula usually closes without narrowing of the esophageal lumen. However, an esophagopleural fistula and pleural empyema are far more difficult to manage. In these patients, administration of proper antibiotics, alimentation through the previously inserted feeding jejunostomy (or intravenous hyperalimentation), and careful investigation and prompt drainage of intrathoracic purulent loculations are mandatory for a successful outcome. The single patient who was treated nonoperatively because the esopha- VOL. 13, NO. 6, JUNE, 1972 557
SYMBAS ET AL. geal perforation was not suspected during the first 48 hours after injury had a 0.22 caliber bullet wound of the esophagus. The missile in this case had lost its velocity when it reached the esophagus, since it barely managed to perforate one esophageal wall before falling into the esophageal lumen. The esophageal wound, being small in size and presumably without significant damage of the adjacent esophageal tissue, most likely sealed quickly without significant mediastinal contamination and healed primarily with the help of supportive treatment that included massive intravenous doses of antibiotics, parenteral alimentation, and gastric suction. References 1. 2. 3. 4. 5. 6. 7. 8. Briggs, J. N., and Germann, T. D. Traumatic perforations of the esophagus. Surg. Clin. North Am. 48:1297, 1968. Hardin, W. J., Hardy, J. D., and Conn, J. H. Esophageal perforations. Surg. Gynecol. Obstet. 124:325, 1967. Jemerin, E. E. Results of treatment of perforation of the esophagus. Ann. Surg. 128:971, 1948. Mathewson, C., Jr., Cohn, R., and Shaupp, W. C. Perforation of the esophagus. Ann. Otol. Rhinol. Laryngol. 67:1141, 1958. Mathewson, C., Jr., Dozier, W. E., Hamill, J. P., and Smith, M. Clinical experiences with perforation of the esophagus. Am. J. Surg. 104:257, 1962. Overstreet, J. W., and Ochsner, A. Traumatic rupture of the esophagus. J. Thoruc. Surg. 30: 164, 1955. Seybold, W. D., Johnson, M. A., 111, and Leary, W. V. Perforation of the esophagus. Surg. Clin. North Am. 30: 1155, 1950. Wichern, W. A., Jr. Perforation of the esophagus. Am. J. Surg. 119:534, 1970. 558 THE ANNALS OF THORACIC SURGERY