Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

Objective: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morb idity and mortality. The outcome study is intended to correlate time with d eath from esophageal causes, overall complications, esophageal related comp lications, and surgical intensive care unit length of stay. Methods: This was a retrospective multicenter study involving 34 trauma cen ters in the United Status, under the auspices of the American Association f or the Surgery of Trauma Multi-institutional Trials Committee over a span o f 10.5 years. Patients surviving to reach the operating room (OR) were divi ded into two groups: those that underwent diagnostic studies to identify th eir injuries (preoperative evaluation group) and those that went immediatel y to the OR (no preoperative evaluation group). Statistical methods include d Fisher's exact test, Student's t test, and logistic regression analysis. Results: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean In jury Severity Score was 28, and the mean time interval to the OR was 6.5 ho urs. There were associated injuries in 356 patients (88%), and an overall c omplication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hun dred forty-six patients survived to reach the OR: 171 in the preoperative e valuation group and 175 in the no preoperative evaluation group. No statist ically significant differences were noted in the two groups in the followin g parameters: number of patients, age, Injury Severity Score, admission blo od pressure, anatomic location of injury (cervical or thoracic), surgical m anagement (primary repair, resection and anastomosis, resection and diversi on, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus I hour in the no preoperative evaluation group (p < 0.001). Overall complicat ions occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal relat ed complications occurred in the preoperative evaluation group versus 32 (1 9%) in the no preoperative evaluation group (p = 0.003). Mean surgical inte nsive care unit length of stay was II days in the preoperative evaluation g roup versus 7 days in the no preoperative evaluation group (p = 0.012). Log istic regression analysis identified as independent risk factors for the de velopment of esophageal related complications included time delays in preop erative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection an d diversion (odds ratio, 4.47). Conclusion: Esophageal injuries carry a high morbidity and mortality. Incre ased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practici ng selective management of penetrating neck injuries and transmediastinal g unshot wounds, rapid diagnosis and definitive should be made a high priorit y.