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

Alberto Aiolfi,Luigi Bonavina,Desmond Khor,Demetrios Demetriades,Gustavo Recinos,Elizabeth R Benjamin,Kenji Inaba,Emanuele Asti,Lydia Lam,Aaron Strumwasser

doi:10.1186/s13017-017-0131-8

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

Highlights

Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality
Variables extracted from the National Trauma Data Bank (NTDB) included demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Organ Injury Scale (OIS), and vital signs in the emergency department
During the study period, a total of 1603 patients were identified from the NTDB as having a traumatic esophageal injury, with an overall prevalence of 0.02% (1603/ 5,774,836)

Summary

Introduction

Non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. 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. The management of iatrogenic and spontaneous perforations of the esophagus has well-established risk factors and treatment guidelines. In this setting, thoracic perforations are associated with poor outcomes because of the association with systemic sepsis and multi-organ failure [1,2,3,4,5]. Traumatic esophageal injury is associated with a significant morbidity and mortality burden. Only a few small series are available in the literature addressing management and outcomes with contrasting results. Our current understanding of the optimal treatment for these injuries is unclear

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