Comparative Surgical Strategies for Esophageal Injuries Following Penetrating Thoracoabdominal Gunshot Wounds: Two Case Reports and Literature Review

Background: Esophageal injuries following penetrating thoracoabdominal gunshot wounds are rare (<1% of trauma admissions) and carry substantial morbidity if diagnosis and treatment are delayed. We describe two patients with similar injury patterns who were managed with different surgical strategies and summarize the recent literature to contextualize decision-making. Case Presentations: Case 1 involved a 28-year-old male with thoracoabdominal gunshot trauma, right hemopneumothorax, and distal esophageal leak. Following initial abdominal repair of the diaphragm and esophagus with jejunostomy, a persistent esophageal fistula was detected on postoperative day 5. Endoscopic stent placement achieved complete resolution within 4 weeks. Follow-up at 1, 3, and 6 months revealed normal swallowing with no late fistula. Case 2 concerned an 11-year-old male with hemodynamic instability after a trans-thoracic gunshot wound causing bilateral diaphragmatic, gastric, and hepatic injuries. A right thoracotomy with primary esophageal repair was performed. Recovery was uneventful. At 3 and 6 months, oral intake was well tolerated with no fistula or stricture. These cases emphasize tailoring the surgical approach to hemodynamic status and imaging findings. A stepwise strategy with delayed thoracic intervention and endoscopic stenting can limit initial invasiveness in stable patients, whereas immediate thoracotomy is lifesaving in unstable cases. Contemporary series support early diagnosis, selective use of endoscopy/stenting, and structured nutritional support to reduce leak risk and mortality. Conclusions: Individualized timing and modality of surgical intervention, combined with multidisciplinary coordination, are pivotal to optimizing outcomes in penetrating esophageal trauma.