Gunshot wounds of the esophagus

During a 4 year period between 1970 and 1974 there were eleven esophageal gunshot wounds representing 52 per cent of the total esophageal perforations. The increased incidence of esophageal gunshot wounds reflects the higher rate of civilian gunshot injuries. There were six perforations in the cervical portion of the esophagus and five in the thoracic portion, with three located above the aortic arch, one in the midesophagus, and one in the lower third. Symptoms are less diagnostic than in esophageal perforations from other causes because the gunshot wound tends to mask the complaints related to mediastinitis. The signs are similar. In 9 patients free air was present in the neck or mediastinum and in 10 patients the diagnosis was confirmed by barium swallow. Of the 2 patients without free air, one had a lateral thoracic wound and esophageal injury was not suspected; the diagnosis was made by drainage of oral feeding through a thoracostomy and confirmed by barium swallow. In the other patient the perforation was found during surgery for hemothorax. Primary repair with drainage was done in the group with cervical injuries. All survived with no serious complications. In the group with thoracic injuries, fistulas developed in 2 of 3 patients who had primary repair with drainage. Two patients with extensive injuries of the esophagus treated by defunctionalization did well but required a second procedure. It is concluded that gunshot wounds of the cervical esophagus, if treated promptly by suture and drainage, will do well. Thoracic injuries represent a more difficult problem and it is suggested that defunctionalization of the esophagus is the safest procedure, particularly if damage is extensive.