Esophageal transection is a life-threatening condition that requires early diagnosis and prompt surgical intervention to prevent serious morbidities or even mortality. There are different etiologies of esophageal injuries, including iatrogenic injury, spontaneous perforation , trauma, foreign body ingestion, and malignancy. Most esophageal injuries are iatrogenic, occurring especially during endoscopy or echocardiography. Intraoperative esophageal injury only accounts for a small proportion of the iatrogenic type. Esophageal transection during total thyroidectomy for thyroid carcinoma is an extremely rare condition, as experienced surgeons carefully dissect periesophageal soft tissues to avoid complications during the procedure.
The most common presenting complaints following esophageal injury include pain, fever, dysphagia, odynophagia, and subcutaneous emphysema; leakage of intraluminal content from the esophagus into the mediastinum causes a serious inflammatory reaction. A chest roentgenogram in such a patient will possibly demonstrate widened mediastinum, diffuse pneumomediastinum, pneumothorax, or pleural effusion. Chest CT scans are also usually obtained to survey the extent and location of esophageal injury, which may show mediastinal abscess, dilated esophagus, or pneumomediastinum. Modalities commonly used for direct evaluation by the surgeons are endoscopy and esophagography. Contrasts such as barium and water-soluble agents are used to evaluate extravasation of the intraluminal esophageal content. However, if esophageal transection is highly suspected, exploration is strongly recommended to visualize, to diagnose, and to control infection by placing drains around the injury site.
The treatment of esophageal injury mainly depends on the location and timing of symptoms. Nonoperative management may be successful in some patients who meet certain strict criteria. A hemodynamically stable patient with a new-onset local esophageal injury could be managed nonoperatively with antimicrobial agents and adequate drainage. However, emergency surgical intervention is given with the first sign of clinical deterioration. Most complications of esophageal surgeries can be immediately observed and managed during surgery by an experienced surgeon. Primary surgical repair of esophageal injury is usually performed with interrupted, absorbable sutures for the mucosal layer and nonabsorbable sutures for the muscular layer.
However, primary repair or anastomosis was not indicated in our case because
the distal stump of the esophagus could not be visualized. The space between the proximal and distal portions of the esophagus was significant; therefore, the two ends of esophagus could not be approximated. Surgical treatment of cervical esophageal transection includes a diversion procedure and esophagectomy, followed by esophageal reconstruction after 6 months. Diversion procedures involve proximal diversion of the esophagus with cervical esophagostomy, gastric diversion with gastrostomy, and jejunostomy for decompression, as well as nutritional support. In our patient, cervical esophagostomy for proximal diversion was extremely difficult to execute because of the friable nature and short length of the esophageal remnant. We adapted an alternative esophageal diversion, where we inserted a one-limb T-tube (the other limb was ligated) into the lumen of the remaining esophagus for drainage of saliva. We recommend early recognition of mediastinitis and prompt mediastinotomy for drainage of mediastinal abscesses, to prevent sepsis and to enhance postoperative recovery. Esophageal reconstruction is typically conducted half a year later, and the gastric conduit is commonly used for alimentary reconstruction owing to its sufficient length and blood supply. The colon, jejunum or even forearm free flap may be used for reconstruction if the stomach is unavailable owing to a previous gastric surgery [2, 3].