Transmural injury to the esophagus is not common, but when it occurs the mortality may be high, either due to failure to diagnose the injury or because of associated visceral injuries. Once diagnosed care is taken to eliminate leakage and to ensure a good closure of he defect.


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

Anatomic Location of Injury

Surgical Approach

upper third

right posterolateral thoracotomy in the 4th interspace

middle third

left posterolateral thoracotomy in 5th or 6th interspace

lower third

left posterolateral thoracotomy in 5th or 6th interspace


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


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