Perforations of the esophagus from gunshot wounds

Fifteen cases of gunshot wounds of the esophagus seen between the years 1970 and 1978 were reviewed, eight involving the cervical esophagus and seven involving the thoracic portion. Most common symptoms were pain, neck tenderness, dyspnea, and dysphagia. Signs observed were subcutaneous emphysema, crepitations, fever, and leukocytosis. Plain X-rays showed pneumomediastinum, hydrothorax, and pneumothorax. Perforations were confirmed by barium studies in 12 patients. Injuries in the cervical portion were treated by prompt exploration, closure of the defect, and drainage. There were no deaths in this group. Thoracic injuries were treated by prompt thoracotomy except in one patient, for whom the diagnosis was not made until 22 hours after the injury; his was the only death in this series. Because of the extensive tissue involvement in gunshot wounds, primary repairs of thoracic esophageal perforations have a high incidence of failure. Defunctionalization of the esophagus, through ligation of the distal esophagus, gastrostomy, and cervical esophagostomy, has provided a safer method. Use of a double strand of absorbable Dexon to ligate the distal esophagus made a second thoracotomy for removal of the ligature unnecessary. We have adopted routine use of hyperalimentation, avoiding the need for feeding jejunostomy.