Lauren A Raff1, Eric A Schinnerer, Rebecca G Maine, Jan Jansen, Matthew R Noorbakhsh, Zachary Spigel, Eric Campion, Julia Coleman, Syed Saquib, Joseph T Carroll, Lewis E Jacobson, Jamie Williams, Andrew Joseph Young, Jose Pascual, Sigrid Burruss, Darnell Gordon, Bryce R H Robinson, Jeffry Nahmias, Matthew E Kutcher, Nikolay Bugaev, Kokila Jeyamurugan, Patrick Bosarge. 1. From the Division of Acute Care Surgery, Department of Surgery (L.A.R.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Ascension St. John Medical Center Trauma Services (E.A.S.), Tulsa, Oklahoma; Department of Surgery (R.G.M., B.R.H.R.), Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington; Division of Acute Care Surgery, Department of Surgery (J.J.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (M.R.N., Z.S.), Allegheny General Hospital, Pittsburgh, Pennsylvania; Department of General Surgery (E.C., J.C.), Denver Health Medical Center, Denver, Colorado; University of Nevada at Las Vegas School of Medicine (S.S., J.T.C.), Las Vegas, Nevada; Department of Trauma (L.E.J., J.W.), St. Vincent Indianapolis Hospital, Indianapolis, Indiana; Department of Surgery (A.J.Y., J.P.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (S.B., D.G.), Loma Linda Medical Center, Loma Linda, California; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (J.N.), University of California at Irvine, Orange, California; Department of Surgery (M.E.K.), University of Mississippi Medical Center, Jackson, Mississippi; Division of Trauma and Acute Care Surgery, Department of Surgery (N.B., K.J.), Tufts Medical Center, Boston, Massachusetts; and Division of Acute Care Surgery, Department of Surgery (P.B.), Banner University Medical Center, University of Arizona College of Medicine, Phoenix, Arizona.
Abstract
BACKGROUND: Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting. METHODS: This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications. RESULTS: Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management. CONCLUSION: Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed. LEVEL OF EVIDENCE: Therapeutic, level IV.
BACKGROUND: Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting. METHODS: This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patientmortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications. RESULTS: Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management. CONCLUSION: Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed. LEVEL OF EVIDENCE: Therapeutic, level IV.
Authors: Austin Rogers; Rob Allman; Fernando Brea; Dean Yamaguchi; Aundrea Oliver; James Speicher; Mark Iannettoni; Carlos Anciano Journal: JTCVS Tech Date: 2022-05-21