Trauma to the esophagus
Floyd D. Loop, M.D.
Department of Thoracic and Cardiovascular Surgery
All esophageal perforations, regardless of location or size, are potentially lethal. As with the rupture of any hollow viscus, an esophageal tear demands recognition without delay, for early diagnosis influences the patient’s hospital course more than any other single factor. Mediastinitis and its devastating sequelae progress rapidly, and any prolonged loss of time may eventually render the patient unresponsive to even the most aggressive treatment.
Before the era of antibiotics and incisional drainage, most patients died after cervical esophageal perforation and disruption of the thoracic esophagus was uniformly fatal. From the experiences reported by Jemerin,1 Pearse,2 Barrett,3 Samson,4 and others, the concept of operative treatment was introduced. In recent years, surgical intervention has become well established, and the prognosis for esophageal injury has greatly improved. It is the purpose in this paper to present the mechanisms of esophageal perforation, the methods that aid in preventing such injury, and the surgical principles involved in early and late stages of management.Upper esophageal perforation
Virtually all perforations of the cervical esophagus are caused by instrumentation or penetrating wounds. The upper end of the esophagus is the narrowest part, and the esophageal wall is compressed against the sixth or seventh cervical vertebra as the esophagoscope passes across the cricopharyngeus muscle.5 The endotracheal tube cuff should always be deflated, since it contributes to a further decreased lumen diameter. The crushing effect is increased by hyperextending the patient’s neck; perforation during diagnostic instrumentation is most likely to occur at this level. The surrounding buccopharyngeal fascia is lacerated, thus. . .