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Gunshot wounds of the esophagus
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.
Julio Popovsky, M.D., F.A.C.S., F . A . C . C , Y. C. Lee, M.D., and James L. Berk, M.D., F.A.C.S.,* Cleveland, Ohio
v J u n s h o t wounds of the esophagus have been considered to be an uncommon cause of esophageal perforations, as they constitute a very small percentage of the total causes in most reports. 7 ' 8 ' 12 A review of the patients treated during the period between 1970 and 1974 revealed 11 patients with gunshot wounds of the esophagus, which represents 52 per cent of the total 21 patients with perforations of the esophagus. This experience represents a change in the pattern of esophageal trauma and very likely reflects the increased incidence of gunshot wounds in the civilian population. 1 ' 4 Patients and methods There were 9 men and 2 women in this group with a mean age of 30 years. Six perforations were in the From the Department of Surgery, The Mt. Sinai Hospital of Cleveland, Cleveland, Ohio. Received for publication June 24, 1976. Accepted for publication June 30, 1976. Address for reprints: Julio Popovsky, M.D., The Mt. Sinai Hospital of Cleveland, University Circle, Cleveland, Ohio 44106. ♦Professor of Surgery, Case Western Reserve University School of Medicine; Director of Surgery, Mt. Sinai Hospital.
cervical portion and five in the thoracic portion of the esophagus. The over-all mortality rate was 9 per cent (Tables I and II). In the group with cervical injuries the primary symptoms were pain and tenderness in the neck. Dyspnea and dysphagia were present in one patient each. Physical examination revealed crepitus in 5 patients; roentgenograms of the neck showed subcutaneous emphysema in all. Three patients had minimal leukocytosis, 2 had temperature elevation, the highest being 101° F . , and one had an ipsilateral pneumothorax. Associated injuries included perforation of the internal jugular vein in one, the trachea and the apex of the right lung in another, fracture of the fifth and sixth cervical bodies in a third, and a fracture of the right mandible in a fourth. All patients had varying amounts of hematomas of the neck. The diagnosis was confirmed by barium swallow in all 6. In one the perforation was also observed by means of the esophagoscope. There was an average interval of 3 hours from injury to operation. All patients were treated by exploration of the cervical esophagus through a longitudinal incision located anterior to the sternocleidomastoid muscle. Primary re609
The Journal of Thoracic and Cardiovascular Surgery
6 1 0 Popovsky, Lee, Berk
Table I. Age, site of injury, interval from injury to surgery, surgical procedure, and outcome of 11 patients with gunshot wounds of the esophagus Case No.
Level of injury
Interval, injury to surgery (hr.)
Outcome
Procedure
c c c c
Low T Upper T
3 10 2.5 4 3 3 2 2
Survived Survived Survived Survived Survived Survived Survived Survived
M
Upper T
22
Died
30
F
Upper T
12
Survived
22
F
MidT
3
Survived
Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage 1. Repair, drainage 2. Drainage, posterior paravertebral approach 1. Repair, drainage 2. Repair with pleural wrapping, drainage 1. Cervical esophagostomy, repair, drainage 2. Colon interposition 1. Ligation of lower esophagus, cervical esophagostomy, gastrostomy, repair, drainage 2. Removal of ligature, closure esophagostomy
Age (yr.)
Sex
1 2 3 4 5 6 7 8
17 17 20 20 37 44 33 51
M M M M M M M M
9
48
10 11
C C
Legend, C, Cervical portion of esophagus. T, Thoracic portion of esophagus.
Table II. Symptoms, signs, and findings Pain Dyspnea Dysphagia Fever Neck tenderness Crepitations Subcutaneous emphysema Leukocytosis Hydrothorax Pneumomediastinum Pneumothorax
Cervical
Thoracic
6 1 1 2 6 5 5 3
5 4 1 2
-
1
-
2 2 2 5 4 5
pair with drainage was accomplished in all. All patients survived, and the average hospitalization time was 13 days. Barium swallow was performed in all prior to discharge, and there was no evidence of leakage. The 5 patients with wounds of the thoracic esophagus included 3 men and 2 women. Four had associated injuries to the lung and one also had an injury of the trachea. In 3 patients the perforation was located above the aortic arch, one had a midesophageal injury, and one an injury to the lower third of the esophagus. The presenting symptoms in the group with the
thoracic injuries were pain in 5, dyspnea in 4, and dysphagia in 2. Temperature elevation to 102° F. and moderate leukocytosis occurred in 2 patients. The chest x-ray film showed hydropneumothorax in all 5 patients and pneumomediastinum in 4. The diagnosis was confirmed by barium swallow in 4 patients. The average interval from injury to operation was less than 2lA hours in 3 patients. In a fourth it was 22 hours. The latter sustained a gunshot wound of the left side of the chest lateral to the midclavicular line, and because of the location an esophageal injury was not suspected. A chest x-ray film did not show pneumomediastinum, but there was a hemopneumothorax which was attributed to a pulmonary injury. The following day oral feeding was observed to drain from the chest tube. An esophagogram revealed a perforation in the midthoracic esophagus. The fifth patient was admitted with a gunshot wound of the left side of the chest with a hemopneumothorax; a chest tube was inserted which drained about 1,000 c.c. of blood with clearing of the chest x-ray film. After a period of stabilization, blood again began draining from the chest tube. At exploration, 12 hours after the injury, a perforation of the thoracic esophagus was found. Three of the patients underwent left thoracotomy with primary repair and drainage. One (Case 7) had an
Volume 72 Number 4 October, 1976
uneventful postoperative course. Another (Case 8) developed a fistula with a localized abscess which required posterior paravertebral drainage. The fistula subsequently closed spontaneously in 6 weeks. The third patient (Case 9), the one with an interval of 22 hours between injury and operation, developed a fistula requiring secondary closure and wrapping with pleura along with drainage. The fistula recurred and the patient died 3 weeks after the injury with empyema and septic shock. A fourth patient (Case 10), who had a tracheoesophageal perforation, had defunctionalization of the esophagus with a cervical esophagostomy and gastrostomy. Reconstruction was accomplished 6 weeks later by colon interposition. The fifth patient (Case 11) was treated by the method recommended by Urschel and associates,14 which combines ligation of the lower esophagus over a Teflon strip with repair of the perforation, a feeding gastrostomy, and a cervical esophagostomy. This patient did well and 2'/2 months following the injury was readmitted for ligature removal and esophagostomy closure. No repair was required at the site of the esophageal ligation. Discussion The increasing incidence of gunshot wounds in the civilian population has resulted in a greater number of esophageal gunshot wounds. Successful management of these injuries depends on early diagnosis and prompt surgical repair. A high index of suspicion must be exercised with injuries of the neck or chest because, as is well known but occasionally forgotten, the pathway of a bullet is frequently erratic and the expected trajectory from the site of entrance to exit may be misleading. The usual symptoms of esophageal perforations6 such as pain or tenderness, frequently diagnostic of perforations from other causes, are not specific in a patient with a bullet wound. Fever is uncommon if the diagnosis is made promptly. Roentgenograms of the neck and chest must be obtained in these patients to detect air in the neck or mediastinum. If present, a contrast study should be obtained to determine the site and the extent of the injury.2 We have used barium sulfate because the contrast quality is superior to that of water-soluble agents. We have found no untoward effects attributable to the barium, perhaps because all of the patients were treated surgically and all extra-esophageal barium was removed. Contrast studies are also obtained in the absence of free air in the neck or mediastinum if, because of the location, there is any possibility of esophageal injury.
Gunshot wounds of esophagus
61 1
All patients with gunshot wounds of the esophagus are treated promptly by surgery to avoid further mediastininal contamination. Preoperatively, intravenous fluids and a broad-spectrum parenteral antibiotic are begun. A nasogastric tube is inserted and connected to low suction to prevent further soilage. Protrusion of the tube through the perforation rarely may occur, but this has caused no problems and the tube may be repositioned at surgery. Because oral feeding will not be resumed for several days, intravenous hyperalimentation is begun early in the postoperative period as soon as the patient's condition is stable. We believe this to be an important factor in recovery.10 The surgical repair varies with the location of the injury. In the cervical region,3 exploration is is carried out on the side of the injury or, if the laceration is extensive, bilaterally to facilitate closure and permit better drainage. The esophageal perforation is sutured with two layers of nonabsorbable material and a drain is always placed. The nasogastric tube remains on suction for 5 to 7 days. A barium swallow is repeated and if there is no fistula the tube is removed and the patient started on a soft diet. All patients with cervical injuries survived without major complications. Injuries to the thoracic esophagus are a much more serious and difficult problem. Primary repairs have a tendency to fail because of the extensive tissue damage, as described by Symbas and associates.13 They found severe histologic changes in the tissue debrided from the edges of the esophageal wound, including diffuse hemorrhage of all layers, acute coagulation necrosis, and acute inflammation. This seems to account for the high incidence of fistulization after primary repair and emphasizes the need for adequate debridement. Leakage from these repairs causes contamination of the mediastinum and pleural cavity and frequently results in empyema and sepsis, even if adequate pleural drainage has been carried out. Delay in repair contributes to the incidence of failure,9, n as demonstrated by the fact that the only patient in our series who died was operated upon 22 hours after injury. In addition, primary closure failed in 2 patients operated upon within a reasonable time. Both survived, but further procedures were required to control the resulting fistulas. Two patients were managed by complete defuntionalization of the esophagus. The method of Urschel's group14 has the advantage of not requiring esophageal replacement. Based on the experience of Urschel and our patient, no plastic procedure is required at the site of the ligature. Although complete defunctionalization requires
6 12
The Journal of Thoracic and Cardiovascular Surgery
Popovsky, Lee, Berk
more than one operation, we believe it is the safest method and the procedure of choice for gunshot wounds of the thoracic esophagus with extensive tissue damage. Use of this technique should contribute to lowering the high mortality rate associated with gunshot wounds of the thoracic esophagus.
REFERENCES 1 Bombeck, C. T., Boyd, D. R., and Nyhus, L. M.: Esophageal Trauma, Surg. Clin. North Am. 52: 219, 1972. 2 Berry, B. E., and Ochsner, J. L.: Perforation of the Esophagus: A 30 Year Review, J. THORAC. CARDIOVASC. SURG. 65: 1,
1973.
3 Briggs, J. N., and Germann, T. D.: Traumatic Perforations of the Esophagus, Surg. Clin. North Am. 48: 1297, 1968. 4 Foster, J. H., Jolly, P. C , Sawyers, J. L., et al.: Esophageal Perforation: Diagnosis and Treatment, Ann. Surg. 161: 701, 1965. 5 Hardin, W. J., Hardy, J. D., and Conn, J. H.: Esophageal Perforations, Surg. Gynecol. Obstet 124: 325, 1967. 6 Hardy, J. D., Tompkins, W. C , Jr., Ching, E. C , et. al.: Esophageal Perforations and Fistulas: Review of 36
7 8 9 10 11 12
Cases With Operative Closure of Four Chronic Fistulas, Ann. Surg. 177: 788, 1973. Hix, W. R., and Mills, M.: The Management of Esophageal Wounds, Ann. Surg. 172: 1002, 1970. Jones, R. J., and Samson, P. C : Esophageal Injury, Ann. Thorac. Surg. 19: 216, 1975. Loop, F. D., and Groves, L. K.: Esophageal Perforations, Ann. Thorac. Surg. 10: 571, 1970. Rea, W. J., Gallivan, G. J., Ecker, R. R., et al.: Traumatic Esophageal Perforation, Ann. Thorac. Surg. 14: 671, 1972. Sawyers, J. L., Lane, C. E., Foster, J. H., et. al.: Esophageal Perforation: An Increasing Challenge, Ann. Thorac. Surg. 19: 233, 1975. Sommer, G. N. J., Jr., and O'Brien, C. E.: War Wounds Of the Esophagus, J. THORAC. SURG. 17: 393,
1948.
13 Symbas, P. N., Tyras, D. H., Hatcher, C. R., Jr., et al.: Penetrating Wounds of the Esophagus, Ann. Thorac. Surg. 13: 552, 1972. 14 Urschel, H. C , Jr., Razzuk, M. A., Wood, R. E.,etal.: Improved Management of Esophageal Perforation: Exclusion and Diversion in Continuity, Ann. Surg. 179: 587, 1974. 15 Williams, J. W., and Sherman, R. T.: Penetrating Wounds of the Neck: Surgical Management, J. Trauma 13: 435, 1973.
Julio Popovsky, M.D., F.A.C.S., F . A . C . C , Y. C. Lee, M.D., and James L. Berk, M.D., F.A.C.S.,* Cleveland, Ohio
v J u n s h o t wounds of the esophagus have been considered to be an uncommon cause of esophageal perforations, as they constitute a very small percentage of the total causes in most reports. 7 ' 8 ' 12 A review of the patients treated during the period between 1970 and 1974 revealed 11 patients with gunshot wounds of the esophagus, which represents 52 per cent of the total 21 patients with perforations of the esophagus. This experience represents a change in the pattern of esophageal trauma and very likely reflects the increased incidence of gunshot wounds in the civilian population. 1 ' 4 Patients and methods There were 9 men and 2 women in this group with a mean age of 30 years. Six perforations were in the From the Department of Surgery, The Mt. Sinai Hospital of Cleveland, Cleveland, Ohio. Received for publication June 24, 1976. Accepted for publication June 30, 1976. Address for reprints: Julio Popovsky, M.D., The Mt. Sinai Hospital of Cleveland, University Circle, Cleveland, Ohio 44106. ♦Professor of Surgery, Case Western Reserve University School of Medicine; Director of Surgery, Mt. Sinai Hospital.
cervical portion and five in the thoracic portion of the esophagus. The over-all mortality rate was 9 per cent (Tables I and II). In the group with cervical injuries the primary symptoms were pain and tenderness in the neck. Dyspnea and dysphagia were present in one patient each. Physical examination revealed crepitus in 5 patients; roentgenograms of the neck showed subcutaneous emphysema in all. Three patients had minimal leukocytosis, 2 had temperature elevation, the highest being 101° F . , and one had an ipsilateral pneumothorax. Associated injuries included perforation of the internal jugular vein in one, the trachea and the apex of the right lung in another, fracture of the fifth and sixth cervical bodies in a third, and a fracture of the right mandible in a fourth. All patients had varying amounts of hematomas of the neck. The diagnosis was confirmed by barium swallow in all 6. In one the perforation was also observed by means of the esophagoscope. There was an average interval of 3 hours from injury to operation. All patients were treated by exploration of the cervical esophagus through a longitudinal incision located anterior to the sternocleidomastoid muscle. Primary re609
The Journal of Thoracic and Cardiovascular Surgery
6 1 0 Popovsky, Lee, Berk
Table I. Age, site of injury, interval from injury to surgery, surgical procedure, and outcome of 11 patients with gunshot wounds of the esophagus Case No.
Level of injury
Interval, injury to surgery (hr.)
Outcome
Procedure
c c c c
Low T Upper T
3 10 2.5 4 3 3 2 2
Survived Survived Survived Survived Survived Survived Survived Survived
M
Upper T
22
Died
30
F
Upper T
12
Survived
22
F
MidT
3
Survived
Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage Repair, drainage 1. Repair, drainage 2. Drainage, posterior paravertebral approach 1. Repair, drainage 2. Repair with pleural wrapping, drainage 1. Cervical esophagostomy, repair, drainage 2. Colon interposition 1. Ligation of lower esophagus, cervical esophagostomy, gastrostomy, repair, drainage 2. Removal of ligature, closure esophagostomy
Age (yr.)
Sex
1 2 3 4 5 6 7 8
17 17 20 20 37 44 33 51
M M M M M M M M
9
48
10 11
C C
Legend, C, Cervical portion of esophagus. T, Thoracic portion of esophagus.
Table II. Symptoms, signs, and findings Pain Dyspnea Dysphagia Fever Neck tenderness Crepitations Subcutaneous emphysema Leukocytosis Hydrothorax Pneumomediastinum Pneumothorax
Cervical
Thoracic
6 1 1 2 6 5 5 3
5 4 1 2
-
1
-
2 2 2 5 4 5
pair with drainage was accomplished in all. All patients survived, and the average hospitalization time was 13 days. Barium swallow was performed in all prior to discharge, and there was no evidence of leakage. The 5 patients with wounds of the thoracic esophagus included 3 men and 2 women. Four had associated injuries to the lung and one also had an injury of the trachea. In 3 patients the perforation was located above the aortic arch, one had a midesophageal injury, and one an injury to the lower third of the esophagus. The presenting symptoms in the group with the
thoracic injuries were pain in 5, dyspnea in 4, and dysphagia in 2. Temperature elevation to 102° F. and moderate leukocytosis occurred in 2 patients. The chest x-ray film showed hydropneumothorax in all 5 patients and pneumomediastinum in 4. The diagnosis was confirmed by barium swallow in 4 patients. The average interval from injury to operation was less than 2lA hours in 3 patients. In a fourth it was 22 hours. The latter sustained a gunshot wound of the left side of the chest lateral to the midclavicular line, and because of the location an esophageal injury was not suspected. A chest x-ray film did not show pneumomediastinum, but there was a hemopneumothorax which was attributed to a pulmonary injury. The following day oral feeding was observed to drain from the chest tube. An esophagogram revealed a perforation in the midthoracic esophagus. The fifth patient was admitted with a gunshot wound of the left side of the chest with a hemopneumothorax; a chest tube was inserted which drained about 1,000 c.c. of blood with clearing of the chest x-ray film. After a period of stabilization, blood again began draining from the chest tube. At exploration, 12 hours after the injury, a perforation of the thoracic esophagus was found. Three of the patients underwent left thoracotomy with primary repair and drainage. One (Case 7) had an
Volume 72 Number 4 October, 1976
uneventful postoperative course. Another (Case 8) developed a fistula with a localized abscess which required posterior paravertebral drainage. The fistula subsequently closed spontaneously in 6 weeks. The third patient (Case 9), the one with an interval of 22 hours between injury and operation, developed a fistula requiring secondary closure and wrapping with pleura along with drainage. The fistula recurred and the patient died 3 weeks after the injury with empyema and septic shock. A fourth patient (Case 10), who had a tracheoesophageal perforation, had defunctionalization of the esophagus with a cervical esophagostomy and gastrostomy. Reconstruction was accomplished 6 weeks later by colon interposition. The fifth patient (Case 11) was treated by the method recommended by Urschel and associates,14 which combines ligation of the lower esophagus over a Teflon strip with repair of the perforation, a feeding gastrostomy, and a cervical esophagostomy. This patient did well and 2'/2 months following the injury was readmitted for ligature removal and esophagostomy closure. No repair was required at the site of the esophageal ligation. Discussion The increasing incidence of gunshot wounds in the civilian population has resulted in a greater number of esophageal gunshot wounds. Successful management of these injuries depends on early diagnosis and prompt surgical repair. A high index of suspicion must be exercised with injuries of the neck or chest because, as is well known but occasionally forgotten, the pathway of a bullet is frequently erratic and the expected trajectory from the site of entrance to exit may be misleading. The usual symptoms of esophageal perforations6 such as pain or tenderness, frequently diagnostic of perforations from other causes, are not specific in a patient with a bullet wound. Fever is uncommon if the diagnosis is made promptly. Roentgenograms of the neck and chest must be obtained in these patients to detect air in the neck or mediastinum. If present, a contrast study should be obtained to determine the site and the extent of the injury.2 We have used barium sulfate because the contrast quality is superior to that of water-soluble agents. We have found no untoward effects attributable to the barium, perhaps because all of the patients were treated surgically and all extra-esophageal barium was removed. Contrast studies are also obtained in the absence of free air in the neck or mediastinum if, because of the location, there is any possibility of esophageal injury.
Gunshot wounds of esophagus
61 1
All patients with gunshot wounds of the esophagus are treated promptly by surgery to avoid further mediastininal contamination. Preoperatively, intravenous fluids and a broad-spectrum parenteral antibiotic are begun. A nasogastric tube is inserted and connected to low suction to prevent further soilage. Protrusion of the tube through the perforation rarely may occur, but this has caused no problems and the tube may be repositioned at surgery. Because oral feeding will not be resumed for several days, intravenous hyperalimentation is begun early in the postoperative period as soon as the patient's condition is stable. We believe this to be an important factor in recovery.10 The surgical repair varies with the location of the injury. In the cervical region,3 exploration is is carried out on the side of the injury or, if the laceration is extensive, bilaterally to facilitate closure and permit better drainage. The esophageal perforation is sutured with two layers of nonabsorbable material and a drain is always placed. The nasogastric tube remains on suction for 5 to 7 days. A barium swallow is repeated and if there is no fistula the tube is removed and the patient started on a soft diet. All patients with cervical injuries survived without major complications. Injuries to the thoracic esophagus are a much more serious and difficult problem. Primary repairs have a tendency to fail because of the extensive tissue damage, as described by Symbas and associates.13 They found severe histologic changes in the tissue debrided from the edges of the esophageal wound, including diffuse hemorrhage of all layers, acute coagulation necrosis, and acute inflammation. This seems to account for the high incidence of fistulization after primary repair and emphasizes the need for adequate debridement. Leakage from these repairs causes contamination of the mediastinum and pleural cavity and frequently results in empyema and sepsis, even if adequate pleural drainage has been carried out. Delay in repair contributes to the incidence of failure,9, n as demonstrated by the fact that the only patient in our series who died was operated upon 22 hours after injury. In addition, primary closure failed in 2 patients operated upon within a reasonable time. Both survived, but further procedures were required to control the resulting fistulas. Two patients were managed by complete defuntionalization of the esophagus. The method of Urschel's group14 has the advantage of not requiring esophageal replacement. Based on the experience of Urschel and our patient, no plastic procedure is required at the site of the ligature. Although complete defunctionalization requires
6 12
The Journal of Thoracic and Cardiovascular Surgery
Popovsky, Lee, Berk
more than one operation, we believe it is the safest method and the procedure of choice for gunshot wounds of the thoracic esophagus with extensive tissue damage. Use of this technique should contribute to lowering the high mortality rate associated with gunshot wounds of the thoracic esophagus.
REFERENCES 1 Bombeck, C. T., Boyd, D. R., and Nyhus, L. M.: Esophageal Trauma, Surg. Clin. North Am. 52: 219, 1972. 2 Berry, B. E., and Ochsner, J. L.: Perforation of the Esophagus: A 30 Year Review, J. THORAC. CARDIOVASC. SURG. 65: 1,
1973.
3 Briggs, J. N., and Germann, T. D.: Traumatic Perforations of the Esophagus, Surg. Clin. North Am. 48: 1297, 1968. 4 Foster, J. H., Jolly, P. C , Sawyers, J. L., et al.: Esophageal Perforation: Diagnosis and Treatment, Ann. Surg. 161: 701, 1965. 5 Hardin, W. J., Hardy, J. D., and Conn, J. H.: Esophageal Perforations, Surg. Gynecol. Obstet 124: 325, 1967. 6 Hardy, J. D., Tompkins, W. C , Jr., Ching, E. C , et. al.: Esophageal Perforations and Fistulas: Review of 36
7 8 9 10 11 12
Cases With Operative Closure of Four Chronic Fistulas, Ann. Surg. 177: 788, 1973. Hix, W. R., and Mills, M.: The Management of Esophageal Wounds, Ann. Surg. 172: 1002, 1970. Jones, R. J., and Samson, P. C : Esophageal Injury, Ann. Thorac. Surg. 19: 216, 1975. Loop, F. D., and Groves, L. K.: Esophageal Perforations, Ann. Thorac. Surg. 10: 571, 1970. Rea, W. J., Gallivan, G. J., Ecker, R. R., et al.: Traumatic Esophageal Perforation, Ann. Thorac. Surg. 14: 671, 1972. Sawyers, J. L., Lane, C. E., Foster, J. H., et. al.: Esophageal Perforation: An Increasing Challenge, Ann. Thorac. Surg. 19: 233, 1975. Sommer, G. N. J., Jr., and O'Brien, C. E.: War Wounds Of the Esophagus, J. THORAC. SURG. 17: 393,
1948.
13 Symbas, P. N., Tyras, D. H., Hatcher, C. R., Jr., et al.: Penetrating Wounds of the Esophagus, Ann. Thorac. Surg. 13: 552, 1972. 14 Urschel, H. C , Jr., Razzuk, M. A., Wood, R. E.,etal.: Improved Management of Esophageal Perforation: Exclusion and Diversion in Continuity, Ann. Surg. 179: 587, 1974. 15 Williams, J. W., and Sherman, R. T.: Penetrating Wounds of the Neck: Surgical Management, J. Trauma 13: 435, 1973.