Penetrating injuries to the esophagus are relatively uncommon, and blunt injuries to the esophagus are rare. In patients not undergoing surgical exploration of a penetrating wound, the diagnosis of esophageal injury can be made using radiographic studies or endoscopy. A combination of esophagography and rigid esophagoscopy appears to be the most sensitive technique for identifying these injuries. However, frequently only one of these studies is performed unless there is a very high clinical suspicion of an esophageal injury.
In general, esophageal injuries are managed operatively. Most of these injuries can be directly repaired, particularly if they are diagnosed and treated within 24 h. If the injury is more than 24 h old, mediastinal inflammation may make it impossible to close the perforation. In those circumstances, drainage, with or without diversion, may be the only option.
There have been a few case reports in which esophageal injuries have been successfully managed non-operatively in a manner similar to that employed for certain iatrogenic esophageal perforations. The general guidelines for non-operative management of iatrogenic esophageal injuries are that the perforation is small, the area of extravasation is contained and has free communication back to the esophagus, and the patient exhibits no clinical signs and symptoms of ongoing infection. Whether or not these guidelines can be safely extended to allow non-operative management of patients with traumatic esophageal injuries awaits a more definitive study.
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