576661
research-article2015
TAG0010.1177/1756283X15576661Therapeutic Advances in GastroenterologyG-j Zhao, J-y Cheng
Therapeutic Advances in Gastroenterology
Letter to the Editor
Conservative management of esophageal perforation due to external air-blast injury: a case report and literature review
Ther Adv Gastroenterol 1–5 DOI: 10.1177/ 1756283X15576661 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Guang-ju Zhao, Jun-yan Cheng, Shao-ce Zhi, Xiao Jin and Zhong-qiu Lu
Background Esophageal perforation is a life-threatening clinical situation, timely diagnosis is difficult and scientific therapy experiences for this condition are lacking [Søreide and Viste, 2011]. Esophageal perforation caused by iatrogenic or other reasons has been reported frequently, however, barotraumatic injury caused by external air-blast is rare. Only four cases were found in the English literature when searched by Roan and Wu in 2010, and 11 cases were found in a perusal of the English and Chinese literature up to 2013 (Table 1) [Roan and Wu, 2010; Wu et al. 2011; Zhu et al. 2009; Zhou, 2007; Zhang et al. 2006; Li et al. 2000; Guth et al. 1991; Michel et al. 1981; Majeski and MacMillan, 1979; Volk et al. 1955]. Herein, we report a case of a patient with esophageal perforation following an injury caused by a gas-tank explosion who recovered satisfactorily after conservative management. The diagnosis and therapy strategy of this condition are discussed. Case presentation The patient was a fit and healthy 20-year-old woman who worked in a shoe company. On 31 August 2013, while she was working, a large tank containing high-pressure gas exploded in front of her. She immediately lost consciousness. About 2–3 min later, she regained consciousness and complained of severe chest pain and dizziness. The woman was brought to the emergency department of our hospital 1 h after the accident. Upon admission, the patient did not present with dyspnea or cyanosis. Her vital signs were stable, with a respiratory rate of 22 /min, blood pressure of 100/70 mmHg, heart rate of 100/min, and a body temperature of 36.7°C. However, her leftsided breath sounds were decreased remarkably.
A computed tomography (CT) scan was performed immediately and the diagnosis of pneumothorax with pneumomediastinum and subcutaneous emphysema was confirmed (Figure 1). Thus, an emergency left-tube thoracostomy was performed. In addition, esophageal perforation was strongly suspected but not shown on a methylene blue swallow. A contrast study of the esophagus was performed immediately with diatrizoate meglumine and no leakage of contrast material from the esophagus was observed (Figure 2). On 2 September 2013, an upper gastrointestinal (GI) tract endoscopy revealed an esophageal ulcer 25 cm from the incisors (Figure 3a), while bronchoscopy illustrated that there was no tracheal fistula. From these findings, it was thought that the esophageal perforation closed naturally soon after this condition occurred.
Correspondence to: Zhong-qiu Lu, PhD Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People’s Republic of China [email protected] Guang-ju Zhao, MD Jun-yan Cheng, PhD Shao-ce Zhi, PhD Xiao Jin, PhD Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
The patient was managed conservatively. Oral nutrition was prohibited and parenteral nutrition was used to maintain the patient’s nutritional status as soon as esophageal perforation was suspected. The proton-pump inhibitor, omeprazole, was given intravenously. Meropenem 1.0 g as a 3-h infusion every 8 h was used to treat infections until there was no fever and inflammatory markers (white blood cells, procalcitonin, and C-reactive protein) returned to normal levels. The patient was discharged 26 days after admission. On 15 October 2013, an upper GI endoscopy revealed a rent scar of 1.5 cm in the esophagus without esophageal stenosis (Figure 3b). A repeated CT scan was within normal limits (Figure 4). Conclusion A few cases of esophageal perforation have been reported as a result of a sudden release of highpressure air into the esophagus via the mouth
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Therapeutic Advances in Gastroenterology Table 1. Esophageal perforation or rupture caused by external air-blast injury. Reported year
Age (years)
Gender
Presentation
Chest radiography or computed tomography scan
Interval to diagnosis (h)
Location
Management
Outcome
References
This case
20
Remale
Chest pain
42
Middle
Conservative
Survived
2011
28
Female
Chest pain dyspnea
Mediastinum pneumothorax and subcutaneous emphysema Pneumothorax
8
Lower
Operative
Survived
3
2010
31
Male
Pneumothorax
84
Lower
Operative
Survived
2
2009 2007
34 20
Male Male
Chest pain dyspnea Dyspnea Dyspnea
Pneumothorax Pneumomediastinum
72 96
Lower Middle
Operative Operative
Survived Died
4 5
2006
22
Male
Lower
Conservative
Survived
6
18
Male
Pneumothorax and pneumomediastinum Pneumothorax
120
2000
—
Lower
Operative
Survived
7
2000
36
Male
Pneumothorax
—
Lower
Operative
Survived
7
1991 1980 1979
35 _ 15
Male _ Male
Pneumothorax _ Pneumothorax
24 24 48
Middle Lower Lower
Operative Operative None
Survived Survived Died
8 9 10
1955
22
Female
Chest pain dyspnea Chest pain dyspnea Chest pain dyspnea Dyspnea _ Chest pain dyspnea Dysphagia neck pain and hemoptysis
Pneumothorax and subcutaneous emphysema
240
Cervical
Operative
Survived
11
Figure 1. Chest computed tomography scan of the patient shows a left pneumothorax and pneumomediastinum.
[Lee and Lim, 2005]. However, esophageal perforation caused by external air-blast injury is extremely rare with only 11 reported cases in the English and Chinese literature. The very low incidence of esophageal perforation by barotraumas makes it difficult for individual doctors to gain clinic experience to give a timely and accurate diagnosis [Roan et al.2010; Wu et al. 2011].
Symptoms of esophageal perforation vary depending on the cause, location, as well as the time of occurrence. As shown in Table 1, chest pain and dyspnea are the most common symptoms of esophageal perforation caused by external airblast injury. However, the common presenting symptoms are not specific for esophageal perforation. Diagnosis of an esophageal perforation mainly relies on radiographic evidence. The
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G-j Zhao, J-y Cheng et al. esophagogram is considered to be the gold standard examination with which to establish the diagnosis of esophageal lesions and can reveal a contrast leak in most cases of esophageal perforation [Hasimoto et al. 2013; Kiss, 2008]. It is important to mention that esophagograms can produce false negatives by up to 10–25% [Flynn et al. 1989]. In the case presented here, no leakage of contrast material from the esophagus was observed by CT with diatrizoate meglumine swallow. CT findings include esophageal wall thickening, extraluminal gas, and abscessed cavities adjacent to the esophagus highly suggestive of esophageal perforation [Wu et al. 2007]. All of the
Figure 2. No leakage of contrast material from the esophagus was observed by chest computed tomography scan with diatrizoate meglumine swallow.
11 reported esophageal perforations caused by external air-blast injury presented with pneumothorax or pneumomediastinum. In those patients, flexible endoscopy should be considered to provide additional information [Søreide et al. 2011]. In the case presented here, an upper tract GI endoscopy revealed a diagnosis of perforation of the esophagus. It should be noted that pneumomediastinum and pneumothorax can also be caused by lung injury after an external air-blast. The appropriate management of esophageal perforation is a controversial issue. Operative management was the mainstay of the treatment performed in 9 of the 11 cases of esophageal perforation caused by an external air-blast injury. However, there has been a recent trend toward more nonoperative management [Søreide et al. 2011]. According to the criteria defined by Cameron and colleagues [Cameron et al. 1979] and later modified by Altorjay and colleagues, conservative management can be applied to selected patients with suspected or limited perforation, perforation not in the abdomen, contained perforation in the mediastinum, content of the perforation draining back to the esophagus, perforation does not involve neoplasm or obstruction of the esophagus, there is an absence of sepsis symptoms and signs [Altorjay et al. 1997]. Our patient was managed conservatively although she had sepsis symptoms. She was treated with chest-tube drainage and intravenous broad-spectrum antibiotics until signs of inflammation disappeared. To maintain the patient’s nutritional status, parenteral nutrition or enteral tube feeding can be used until oral feedings can be initiated and effectively sustained. After conservative management for 26 days, the patient was discharged. A repeated endoscopic and CT scan revealed that this patient recovered satisfactorily.
Figure 3. (a) gastrointestinal tract endoscopy revealed an esophageal ulcer 25 cm from the incisors; (b) a repeated upper gastrointestinal tract endoscopy revealed a rent scar of 1.5 cm in the esophagus. http://tag.sagepub.com 3
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Therapeutic Advances in Gastroenterology
Figure 4. Repeated chest computed tomography scan was within normal limits.
In conclusion, esophageal perforation caused by external air-blast injury is a rare and life-threatening clinical situation. Considering esophagograms have a significant rate of false-negative results, other technologies including flexible endoscopy should be considered to provide additional information. Conservative management is a safe and effective strategy for an esophageal perforation which has closed naturally.
Cameron, J., Kieffer, R., Hendrix, T., Mehigan, D., Baker, R. (1979) Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 275: 404–408.
Consent The patient gave her consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Hasimoto, C., Cataneo, C., Eldib, R., Thomazi, R., Pereira, R., Minossi, J. et al. (2013) Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies. Acta Cir Bras 28: 266–271.
Funding This work was supported, in part, by the grant of key construction academic subject (medical innovation) of Zhejiang Province (11-CX26). Conflict of interest statement The authors state that they have no conflict of interest.
Flynn, A., Verrier, E., Way, L., Thomas, A. and Pellegrini, C. (1989) Esophageal perforation. Arch Surg 124: 1211–1214. Guth, A., Gouge, T. and Depan, H. (1991) Blast injury to the thoracic esophagus. Ann Thorac Surg 51: 837–839.
Kiss, J. (2008) Surgical treatment of oesophageal perforation. Br J Surg 95: 805–806. Lee, J. and Lim, S. (2005) Barotraumatic perforation of pharyngoesophagus by explosion of a bottle into the mouth. Yonsei Med J 46: 724–728. Li, G and Li, H. (2000) Esophageal rupture caused by blast injury: two case reports. Chin J Thorac Cardiovasc Surg 16: 121. Majeski, J. and MacMillan, B. (1979) Acute esophageal perforation in an adolescent burn patient. J Trauma 19: 288–289.
References
Michel, L., Grillo, H. and Malt, R. (1981) Operative and nonoperative management of esophageal perforations. Ann Surg 194: 57–63.
Altorjay, A., Kiss, J., Vörös, A. and Bohák, A. (1997) Nonoperative management of esophageal perforations. Is it justified? Ann Surg 225: 415–421.
Roan, J. and Wu, M. (2010) Esophageal perforation caused by external air-blast injury. J Cardiothorac Surg 5: 130.
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G-j Zhao, J-y Cheng et al. Søreide, J. and Viste, A. (2011) Esophageal perforation: diagnostic work-up and clinical decisionmaking in the first 24 hours. Scand J Trauma Resusc Emerg Med 19: 66. Volk, H., Storey, C. and Marrangoni, A. (1955) Tracheo-esophageal fistula due to blast injury. Ann Surg 141: 98–104. Wu, J., Mattox, K. and Wall, M. (2007) Esophageal perforations: new perspectives and treatment paradigms. J Trauma 63: 1173–1184. Wu, Y., Tang, B., Chen, W., Lai, C. and Chen, H. (2011) Combination of a free jejunal flap and a
Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report. Microsurgery 31: 331–334. Zhang, D., Jing, K. and Zhang, D. (2006) An esophageal rupture caused by blast injury. Chin J Trauma 22: 271. Zhou, Q. (2007) An esophageal rupture caused by blast injury. Chin J Misdiagn 7: 2930. Zhu, J., Cui, L., Song, J. and Ren, Y. (2009) Successful management of an esophageal rupture caused by blast injury: case report. Chin J Trauma 25: 957.
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research-article2015
TAG0010.1177/1756283X15576661Therapeutic Advances in GastroenterologyG-j Zhao, J-y Cheng
Therapeutic Advances in Gastroenterology
Letter to the Editor
Conservative management of esophageal perforation due to external air-blast injury: a case report and literature review
Ther Adv Gastroenterol 1–5 DOI: 10.1177/ 1756283X15576661 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Guang-ju Zhao, Jun-yan Cheng, Shao-ce Zhi, Xiao Jin and Zhong-qiu Lu
Background Esophageal perforation is a life-threatening clinical situation, timely diagnosis is difficult and scientific therapy experiences for this condition are lacking [Søreide and Viste, 2011]. Esophageal perforation caused by iatrogenic or other reasons has been reported frequently, however, barotraumatic injury caused by external air-blast is rare. Only four cases were found in the English literature when searched by Roan and Wu in 2010, and 11 cases were found in a perusal of the English and Chinese literature up to 2013 (Table 1) [Roan and Wu, 2010; Wu et al. 2011; Zhu et al. 2009; Zhou, 2007; Zhang et al. 2006; Li et al. 2000; Guth et al. 1991; Michel et al. 1981; Majeski and MacMillan, 1979; Volk et al. 1955]. Herein, we report a case of a patient with esophageal perforation following an injury caused by a gas-tank explosion who recovered satisfactorily after conservative management. The diagnosis and therapy strategy of this condition are discussed. Case presentation The patient was a fit and healthy 20-year-old woman who worked in a shoe company. On 31 August 2013, while she was working, a large tank containing high-pressure gas exploded in front of her. She immediately lost consciousness. About 2–3 min later, she regained consciousness and complained of severe chest pain and dizziness. The woman was brought to the emergency department of our hospital 1 h after the accident. Upon admission, the patient did not present with dyspnea or cyanosis. Her vital signs were stable, with a respiratory rate of 22 /min, blood pressure of 100/70 mmHg, heart rate of 100/min, and a body temperature of 36.7°C. However, her leftsided breath sounds were decreased remarkably.
A computed tomography (CT) scan was performed immediately and the diagnosis of pneumothorax with pneumomediastinum and subcutaneous emphysema was confirmed (Figure 1). Thus, an emergency left-tube thoracostomy was performed. In addition, esophageal perforation was strongly suspected but not shown on a methylene blue swallow. A contrast study of the esophagus was performed immediately with diatrizoate meglumine and no leakage of contrast material from the esophagus was observed (Figure 2). On 2 September 2013, an upper gastrointestinal (GI) tract endoscopy revealed an esophageal ulcer 25 cm from the incisors (Figure 3a), while bronchoscopy illustrated that there was no tracheal fistula. From these findings, it was thought that the esophageal perforation closed naturally soon after this condition occurred.
Correspondence to: Zhong-qiu Lu, PhD Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People’s Republic of China [email protected] Guang-ju Zhao, MD Jun-yan Cheng, PhD Shao-ce Zhi, PhD Xiao Jin, PhD Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
The patient was managed conservatively. Oral nutrition was prohibited and parenteral nutrition was used to maintain the patient’s nutritional status as soon as esophageal perforation was suspected. The proton-pump inhibitor, omeprazole, was given intravenously. Meropenem 1.0 g as a 3-h infusion every 8 h was used to treat infections until there was no fever and inflammatory markers (white blood cells, procalcitonin, and C-reactive protein) returned to normal levels. The patient was discharged 26 days after admission. On 15 October 2013, an upper GI endoscopy revealed a rent scar of 1.5 cm in the esophagus without esophageal stenosis (Figure 3b). A repeated CT scan was within normal limits (Figure 4). Conclusion A few cases of esophageal perforation have been reported as a result of a sudden release of highpressure air into the esophagus via the mouth
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Therapeutic Advances in Gastroenterology Table 1. Esophageal perforation or rupture caused by external air-blast injury. Reported year
Age (years)
Gender
Presentation
Chest radiography or computed tomography scan
Interval to diagnosis (h)
Location
Management
Outcome
References
This case
20
Remale
Chest pain
42
Middle
Conservative
Survived
2011
28
Female
Chest pain dyspnea
Mediastinum pneumothorax and subcutaneous emphysema Pneumothorax
8
Lower
Operative
Survived
3
2010
31
Male
Pneumothorax
84
Lower
Operative
Survived
2
2009 2007
34 20
Male Male
Chest pain dyspnea Dyspnea Dyspnea
Pneumothorax Pneumomediastinum
72 96
Lower Middle
Operative Operative
Survived Died
4 5
2006
22
Male
Lower
Conservative
Survived
6
18
Male
Pneumothorax and pneumomediastinum Pneumothorax
120
2000
—
Lower
Operative
Survived
7
2000
36
Male
Pneumothorax
—
Lower
Operative
Survived
7
1991 1980 1979
35 _ 15
Male _ Male
Pneumothorax _ Pneumothorax
24 24 48
Middle Lower Lower
Operative Operative None
Survived Survived Died
8 9 10
1955
22
Female
Chest pain dyspnea Chest pain dyspnea Chest pain dyspnea Dyspnea _ Chest pain dyspnea Dysphagia neck pain and hemoptysis
Pneumothorax and subcutaneous emphysema
240
Cervical
Operative
Survived
11
Figure 1. Chest computed tomography scan of the patient shows a left pneumothorax and pneumomediastinum.
[Lee and Lim, 2005]. However, esophageal perforation caused by external air-blast injury is extremely rare with only 11 reported cases in the English and Chinese literature. The very low incidence of esophageal perforation by barotraumas makes it difficult for individual doctors to gain clinic experience to give a timely and accurate diagnosis [Roan et al.2010; Wu et al. 2011].
Symptoms of esophageal perforation vary depending on the cause, location, as well as the time of occurrence. As shown in Table 1, chest pain and dyspnea are the most common symptoms of esophageal perforation caused by external airblast injury. However, the common presenting symptoms are not specific for esophageal perforation. Diagnosis of an esophageal perforation mainly relies on radiographic evidence. The
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G-j Zhao, J-y Cheng et al. esophagogram is considered to be the gold standard examination with which to establish the diagnosis of esophageal lesions and can reveal a contrast leak in most cases of esophageal perforation [Hasimoto et al. 2013; Kiss, 2008]. It is important to mention that esophagograms can produce false negatives by up to 10–25% [Flynn et al. 1989]. In the case presented here, no leakage of contrast material from the esophagus was observed by CT with diatrizoate meglumine swallow. CT findings include esophageal wall thickening, extraluminal gas, and abscessed cavities adjacent to the esophagus highly suggestive of esophageal perforation [Wu et al. 2007]. All of the
Figure 2. No leakage of contrast material from the esophagus was observed by chest computed tomography scan with diatrizoate meglumine swallow.
11 reported esophageal perforations caused by external air-blast injury presented with pneumothorax or pneumomediastinum. In those patients, flexible endoscopy should be considered to provide additional information [Søreide et al. 2011]. In the case presented here, an upper tract GI endoscopy revealed a diagnosis of perforation of the esophagus. It should be noted that pneumomediastinum and pneumothorax can also be caused by lung injury after an external air-blast. The appropriate management of esophageal perforation is a controversial issue. Operative management was the mainstay of the treatment performed in 9 of the 11 cases of esophageal perforation caused by an external air-blast injury. However, there has been a recent trend toward more nonoperative management [Søreide et al. 2011]. According to the criteria defined by Cameron and colleagues [Cameron et al. 1979] and later modified by Altorjay and colleagues, conservative management can be applied to selected patients with suspected or limited perforation, perforation not in the abdomen, contained perforation in the mediastinum, content of the perforation draining back to the esophagus, perforation does not involve neoplasm or obstruction of the esophagus, there is an absence of sepsis symptoms and signs [Altorjay et al. 1997]. Our patient was managed conservatively although she had sepsis symptoms. She was treated with chest-tube drainage and intravenous broad-spectrum antibiotics until signs of inflammation disappeared. To maintain the patient’s nutritional status, parenteral nutrition or enteral tube feeding can be used until oral feedings can be initiated and effectively sustained. After conservative management for 26 days, the patient was discharged. A repeated endoscopic and CT scan revealed that this patient recovered satisfactorily.
Figure 3. (a) gastrointestinal tract endoscopy revealed an esophageal ulcer 25 cm from the incisors; (b) a repeated upper gastrointestinal tract endoscopy revealed a rent scar of 1.5 cm in the esophagus. http://tag.sagepub.com 3
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Therapeutic Advances in Gastroenterology
Figure 4. Repeated chest computed tomography scan was within normal limits.
In conclusion, esophageal perforation caused by external air-blast injury is a rare and life-threatening clinical situation. Considering esophagograms have a significant rate of false-negative results, other technologies including flexible endoscopy should be considered to provide additional information. Conservative management is a safe and effective strategy for an esophageal perforation which has closed naturally.
Cameron, J., Kieffer, R., Hendrix, T., Mehigan, D., Baker, R. (1979) Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 275: 404–408.
Consent The patient gave her consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Hasimoto, C., Cataneo, C., Eldib, R., Thomazi, R., Pereira, R., Minossi, J. et al. (2013) Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies. Acta Cir Bras 28: 266–271.
Funding This work was supported, in part, by the grant of key construction academic subject (medical innovation) of Zhejiang Province (11-CX26). Conflict of interest statement The authors state that they have no conflict of interest.
Flynn, A., Verrier, E., Way, L., Thomas, A. and Pellegrini, C. (1989) Esophageal perforation. Arch Surg 124: 1211–1214. Guth, A., Gouge, T. and Depan, H. (1991) Blast injury to the thoracic esophagus. Ann Thorac Surg 51: 837–839.
Kiss, J. (2008) Surgical treatment of oesophageal perforation. Br J Surg 95: 805–806. Lee, J. and Lim, S. (2005) Barotraumatic perforation of pharyngoesophagus by explosion of a bottle into the mouth. Yonsei Med J 46: 724–728. Li, G and Li, H. (2000) Esophageal rupture caused by blast injury: two case reports. Chin J Thorac Cardiovasc Surg 16: 121. Majeski, J. and MacMillan, B. (1979) Acute esophageal perforation in an adolescent burn patient. J Trauma 19: 288–289.
References
Michel, L., Grillo, H. and Malt, R. (1981) Operative and nonoperative management of esophageal perforations. Ann Surg 194: 57–63.
Altorjay, A., Kiss, J., Vörös, A. and Bohák, A. (1997) Nonoperative management of esophageal perforations. Is it justified? Ann Surg 225: 415–421.
Roan, J. and Wu, M. (2010) Esophageal perforation caused by external air-blast injury. J Cardiothorac Surg 5: 130.
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G-j Zhao, J-y Cheng et al. Søreide, J. and Viste, A. (2011) Esophageal perforation: diagnostic work-up and clinical decisionmaking in the first 24 hours. Scand J Trauma Resusc Emerg Med 19: 66. Volk, H., Storey, C. and Marrangoni, A. (1955) Tracheo-esophageal fistula due to blast injury. Ann Surg 141: 98–104. Wu, J., Mattox, K. and Wall, M. (2007) Esophageal perforations: new perspectives and treatment paradigms. J Trauma 63: 1173–1184. Wu, Y., Tang, B., Chen, W., Lai, C. and Chen, H. (2011) Combination of a free jejunal flap and a
Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report. Microsurgery 31: 331–334. Zhang, D., Jing, K. and Zhang, D. (2006) An esophageal rupture caused by blast injury. Chin J Trauma 22: 271. Zhou, Q. (2007) An esophageal rupture caused by blast injury. Chin J Misdiagn 7: 2930. Zhu, J., Cui, L., Song, J. and Ren, Y. (2009) Successful management of an esophageal rupture caused by blast injury: case report. Chin J Trauma 25: 957.
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