Penetrating esophageal injuries: Time interval of safety for preoperative evaluation - How long is safe?

Objectives: This study was performed to assess the experience with penetrating esophageal injuries of an urban Level I trauma center and to attempt to correlate the time to establish a diagnosis with outcome including death, surgical intensive care unit length of stay, and esophageal-related complications. Methods: Retrospective study over a 72-month period at a single institution comparing age, admission blood pressure, Revised Trauma Score (RTS), Injury Severity Score (ISS), mechanism and anatomic location of injury, and time interval from admission to the operating room (OR) between nonsurvivors and survivors. Patients who survived to reach the operating room were divided into two groups: those who went immediately to the operating room (no preoperative evaluation) and those who underwent diagnostic studies to identify their injuries (preoperative evaluation). Data analysis was done of the same parameters plus average number of associated injuries, complications, and intensive care unit length of stay. Statistical methods used univariate analysis (Fisher's exact test and Student's t test). Results: Forty-three patients were identified with penetrating esophageal injuries and had the following characteristics: 36 males (84%) and 7 females and (16%); mean RTS, 9.39; mean ISS, 28.1; mean time interval to OR, 9.8 hours. Associated injuries occurred with 42 patients (98%). The overall complication rate was 14 of 32 (44%), and the overall mortality was 11 of 43 (26%). Corrected mortality was 22%. Differences were noted between nonsurvivors and survivors in the following parameters: admission blood pressure <90, 11 of 11 versus 3 of 29 (p <0.001); RTS, 2.364 versus 11.406 (p <0.001); ISS, 45 versus 21 (p <0.001); time interval from admission to OR, 18.3 minutes versus 9.8 hours (p <0.05). Thirty-six patients survived to reach the operating room, 18 in the no preoperative evaluation group and 17 in the preoperative evaluation group. No statistically significant differences were noted between these two groups in the following parameters: age, RTS, ISS, admission blood pressure, anatomic location of injury, number of associated injuries, or intensive care unit length of stay. Average length of time to the operating room was 16.7 hours in the preoperative evaluation group and 1.4 hours in the no preoperative evaluation group (p <0.001). Twelve complications (all esophageal-related) occurred among seven patients in the preoperative evaluation group, and seven complications (five esophageal- related) occurred among seven patients in the no preoperative evaluation group. Because of the small sample size, this failed to reach a statistical difference (p <0.05). Conclusions: Esophageal injuries carry a high morbidity and mortality. Although no definite conclusion can be drawn because of the small sample size, there does appear to be an increased morbidity associated with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, the rapid diagnosis and definitive repair of esophageal injury should be made a high priority.