The injured esophagus.

Injury to the esophagus, although not often seen, is an intolerable condition in the absence of early detection and appropriate surgical intervention. The cause can be penetrating or blunt injury, iatrogenic injury, laceration from ingestion of a sharp object, or tissue destruction secondary to swallowing a caustic substance. Ingestion of alkaline or acid liquids can be accidental or purposeful. In Southeast Asia, this method of attempting suicide is more common than in North America. Iatrogenic injury—especially during endoscopy, tube insertion, forceful dilation, and balloon insertion or inflation—is the most common cause. Spontaneous rupture of the esophagus is relatively rare but can be as devastating as any of the causes described above. A patient who has an esophageal injury may present with a variety of symptoms, ranging from relatively minor (at first) to severe sepsis, mediastinal abscess, and empyema. On physical examination, a patient with an established esophageal leak usually has signs of acute infection, chest pain, and a mediastinal “crunch” heard on auscultation of the chest. The examining physician can also palpate cervical subcutaneous emphysema. No single examination, test, or imaging technique is always diagnostic; therefore, multiple and combined tests are often required to confirm the esophageal injury. Imaging of the esophagus can be confusing and is overrated. The chest radiograph can show signs of mediastinal air or of pleural empyema. A computed tomographic scan is often either under-or over-read and rarely adds more than what is seen on chest radiography. Contrast studies of the esophagus should be performed with barium, rather than with water-soluble contrast substances. A Gastrografin swallow esophagogram has too high a false-positive rate, and the contrast material, if aspirated during the procedure, is more toxic to the lungs than is barium. Esophagostomy procedures (using rigid scopes) might show an injury, but false-negative results do occur. The use of flexible esophagoscopes is discouraged when esophageal injury is suspected. The best diagnostic yield occurs when multiple techniques supplement the physician's judgment of the patient's clinical signs. Surgical procedures to repair an injured esophagus range from simple closure to total esophageal resection with later reconstruction. Thoracic esophageal injuries must always be approached via a posterolateral thoracic incision. The “safe” surgical option is the best for these injuries, and drainage of the esophageal injury or the infected mediastinum is always safe. In some instances, long-term conduit reconstruction might be required. The surgeon and the treating team should follow several governing principles: Use a combination of diagnostic methods. Do not depend on the nonspecific computed tomographic scan of the chest. For contrast esophagoscopy, use barium, not water-soluble material. The approach to the cervical esophagus is through a cervical incision. The approach to the thoracic esophagus is through a posterolateral incision.– Right 4th interspace for the upper esophagus– Left 5th or 6th interspace for the lower esophagus Consider creating a vascularized muscle flap during the initial incision, to reinforce the ultimate repair. Do not attempt repair of an esophageal injury discovered via an anterior incision, as the dehiscence rate is 50%—with 50% of these breakdowns resulting in death. For extensive injury and contamination of the esophagus, consider an esophagectomy and secondary conduit reconstruction. Do not “burn bridges” during initial damage-control procedures.