外伤性颈胸段食管穿孔的现代治疗：东部创伤外科学会多机构研究的结果。

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study.

机构信息

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.

出版信息

J Trauma Acute Care Surg. 2020 Oct;89(4):691-697. doi: 10.1097/TA.0000000000002841.

DOI:10.1097/TA.0000000000002841

PMID:32590561

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.

摘要

背景

外伤性食管穿孔较为罕见，但与显著的发病率和死亡率相关。诊断和治疗方法存在很大差异。食管支架已越来越多地用于非外伤性穿孔；然而，外伤性穿孔的支架置入尚未成为标准治疗方法。本研究的目的是评估外伤性食管穿孔的当前治疗方法，以评估食管支架置入的频率和相关并发症。

方法

这是一项东部创伤外科学会多机构回顾性研究，纳入了 2011 年至 2016 年间，11 家参与创伤中心之一收治的外伤性颈段或胸段食管损伤患者。收集患者的人口统计学、损伤特征、初始治疗、并发症和患者死亡率等数据，并发送至一家单中心进行分析。主要结局为死亡率；次要结局为初始治疗、食管漏和相关并发症。

结果

共分析了 51 例患者。食管损伤位于颈段者占 69%，胸段者占 31%。大多数患者最初接受手术一期修复（61%），其次是无干预（19%）、食管支架置入（10%）和广泛局部引流（10%）。与接受手术一期修复的患者相比，接受食管支架置入的患者食管漏的发生率更高（22.6% vs. 80.0%，p = 0.02）。尽管损伤严重度评分和颈/胸/腹损伤严重度评分相似，但钝性损伤比穿透性机制的并发症发生率更高（100% vs. 31.8%，p = 0.03）。总体死亡率为 9.8%，与损伤部位、损伤机制或初始治疗方法无关。