Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

Abstract

BackgroundTraumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality.MethodsThis National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications.ResultsA total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p = 0.008), 30-day mortality (4.2 vs. 9.3%, p = 0.005), and overall mortality (7.9 vs. 13.5%, p = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV–V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148–0.546; p < 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06–2.53; p = 0.026).ConclusionsDespite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival.Trial registrationiStar, HS-16-00883

Esophageal emergencies: WSES guidelines

“…Mortality of TIE is high with most deaths occurring within 24 h because of severe associated injuries [105]. Trauma to the thoracic esophagus is especially associated with high mortality rates [110]. Early diagnosis of TIE is mandatory to improve outcomes and requires a high level of suspicion.…”

Blunt Esophageal Injury and Importance of Early Diagnosis: A National Trauma Data Bank Analysis

“…Blunt esophageal injury is uncommon and carries a high morbidity and mortality. 8 Due to its low prevalence, there is a paucity of data, and most studies are mainly case reports. The purpose of this study was to examine a population of patients with traumatic blunt esophageal injury, specifically with regards to early vs delayed (>24 hours) surgical intervention and the associated management, outcomes, and risk factors for mortality.…”

“…A recent study involving 994 cases from the NTDB determined that early surgical intervention within the first 24 hours is associated with improved survival. 8 Due to the rarity of blunt traumatic esophageal injury, limited data are available. For this reason, the NTDB was queried to obtain a large sample population.…”

A Review of “Options in Management of Trauma to the Esophagus” (1982) “Submitted for the Literary Festschrift in Honor of J. David Richardson, MD”

“…Penetrating and blunt injuries to the esophagus remain rare, with the majority of injuries being iatrogenic or endoluminal in origin. [2][3][4][5][6][7] Penetrating trauma causes more esophageal injuries than blunt trauma, though these still occur in only .7% of patients with penetrating chest wounds. 9 Several reviews from both the National Trauma Data Bank and the Trauma Quality Improvement Program have noted a high percentage of additional organs injured, such as ribs and lungs, depending on the mechanism and due to the location of the esophagus deep in the thorax.…”

“…A high index of clinic suspicion is important for the early diagnosis of an esophageal injury, as a delay significantly increases morbidity and mortality. 6 The symptoms and signs of an esophageal injury include the following: odynophagia, dysphagia, hematemesis, oropharyngeal blood, cervical crepitus, pain and tenderness in the neck or chest, dyspnea, hoarseness, bleeding, cough, stridor, subcutaneous emphysema, abdominal tenderness, and mediastinal crunching sounds (Hamman sign). 8,9 If concerning findings are present on history and physical examination, initial evaluation of the esophagus can be accomplished through diagnostic imaging, endoscopy, or surgical exploration.…”