Factors impacting management of an esophageal injury:
(1) anatomic location
(2) time to diagnosis (while 12-18 hours is used as a benchmark, management should be determined by the extent of local inflammation and the ability to achieve a sound closure)
(3) manner of injury (blunt vs penetrating trauma) and associated injuries
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Anatomic Location of Injury
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Surgical Approach
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upper third
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right posterolateral thoracotomy in the 4th interspace
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middle third
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left posterolateral thoracotomy in 5th or 6th interspace
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lower third
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left posterolateral thoracotomy in 5th or 6th interspace
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If the injury is detected early (within 12-18 hours of injury), then a primary repair can occur using 1 or 2 layers. Richardson et al recommend use of a flap (vascularized muscle, pleura) to cover the site.
If the injury has gone undetected for more than 12-18 hours, then need to deal with complications associated with leakages:
(1) Insert a T-tube for drainage into the mediastinum.
(2) Divert flow from the esophagus (lateral cervical esophagostomy, gastrostomy and feeding jejunostomy).
(3) Close the injury with 2 layers, then cover the site with vascularized muscle (intercostal muscle, diaphragm, rhomboid muscle, etc.) or pleural flap
