OPERATIVE MANAGEMENT OF AERODIGESTIVE INJURIES: IMPROVED SURVIVAL OVER TWO DECADES

Objectives: Non-iatrogenic aerodigestive injuries are rare but consequential. Mortality and morbidity are substantial and associated injuries are frequent. We hypothesize that advances in trauma management and the adoption of innovative therapies resulted in improved survival.

Methods: Trauma registry review at a large urban university Level 1 trauma center from 2000 to 2020, identifying adults with non-iatrogenic aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted and compared by decade. Univariate analysis was performed, p< 0.05 was statistically significant.

Results: 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined tracheoesophageal). Mean age was 30.9 (+/- 14) years, 87.4% were male, 82.1% penetrating, 28.4% major vascular injuries, and 29.5% were transfers. Median ISS, chest AIS, admission systolic blood pressure, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, 0.8 (0.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. CTA, bronchoscopy and esophagoscopy were routinely performed in hemodynamically stable patients. Of the 68 tracheal injuries, 67.2% were cervical, 32.8% thoracic, and 76.4% had a preoperative airway established, including 30.8% prior to arrival. Five (5.3%) patients with airway injuries presented in profound respiratory distress requiring VV ECMO prior to surgery, and four survived. 61 (96.8%) patients with an airway injury had an operative repair, and endobronchial stents were placed for definitive management in 2 patients with severe TBI. Of the 37 esophageal injuries; 63% cervical, 27.6% thoracic, 7.4% abdominal, all primarily repaired. Combined tracheoesophageal injuries were individually repaired with a muscle buttress interposed. 5.9% of airway injuries had complications (stenosis and tracheoesophageal fistula), all successfully managed. 29.7% of esophageal injuries had complications including 2 strictures and 9 leaks managed with conservative therapy, stents or resection. Overall mortality was 9.6%, with half secondary to intraoperative hemorrhage. Injury-specific mortality was tracheobronchial 8.8%, esophageal 10.8%, and 20% for combined injury. Mortality was significantly associated with higher ISS (p=0.01), blunt mechanism (p=0.01), bronchial injury (p=0.01), vascular injury (p=0.007), and years 2000-2010 (p=0.03), but not combined tracheobronchial injury.

Conclusion: Non-iatrogenic aerodigestive injuries are infrequent, even at a busy urban, academic trauma center. Mortality is associated with several variables, including concomitant vascular trauma, but not combined tracheoesophageal injury. Use of innovative therapies such as ECMO and endoluminal stents in highly selective patients, institutional experience and precise operative repair may account for 97.7% survival over the past decade.