A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation

Freeman, Richard K.; Herrera, Argenis; Ascioti, Anthony J.; Dake, Megan; Mahidhara, Raja S.

doi:10.1016/j.jtcvs.2015.01.066

Cited by 50 publications

(31 citation statements)

References 13 publications

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“…However comparisons can be made between the two treatment groups. In 2014, we reported a propensity matched comparison of patients treated at multiple institutions with either an esophageal stent or an operative repair following the recognition of an acute esophageal perforation (39). In these well matched groups, the esophageal stent cohort realized significant differences in morbidity (4% vs. 43%; P=0.02), mean length of stay (6 vs. 11 days; P=0.0007), time to oral intake (3 vs. 8 days; P=0.0004), and cost ($91,000 vs. $142,000; P<0.0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic management of esophageal leaks

Ong¹,

Freeman²

2017

J. Thorac. Dis.

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Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents.Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse J Thorac Dis 2017;9(Suppl 2):S135-S145 jtd.amegroups.com significantly less esophageal dilatation, a lower rate of migration and improved palliation for malignant esophageal strictures and malignant tracheo-esophageal fistulae (10,11). However, placement of these prostheses continued to be reserved only for the patient requiring palliative therapy for a malignancy because of the potential esophageal damage associated with extraction including reports of irreparable, sometimes life threatening, fistulae.To combat these complications, second generation metallic stent designs were developed incorporating a covering of silicone, polyurethane or other polymers (12). While offering the advantage of diminishing amount of tumor ingrowth and fixation to the esophageal wall, it came with the cost of higher migration rates. Later, the ends of these covered stents were modified to be partially covered with a margin of 1.5 cm on both proximal and distal ends to optimize purchase of the esophageal wall (13).Further evolution in esophageal stent biomaterials resulted in the development of an occlusive plastic prosthesis coated with silicone. This new design allowed ease of insertion, a minimal requirement for esophageal dilation and the ability to form an occlusive seal within the lumen of the esophagus (14). The distinctive advantage of these non-metallic endoprostheses was the ability for removal or replacement even after an extended period of time without damage to the esophagus. However, similar to the covered metallic stents, a higher incidence of migration was appreciated (15).These synergistic developments led to a crucial turning point in management of esophageal perforations. The ease in manipulation of high-quality covered, occlusive stents in the esophagus, led some investigators to implant these stents in select patients as a temporary measure to treat intrathoracic anastomotic leaks following esophagogastrostomy and acute perforations. Segalin et al. and Roy-Choudhury et al. were am...

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Section: Discussionmentioning

confidence: 99%

Endoscopic management of esophageal leaks

Ong¹,

Freeman²

2017

J. Thorac. Dis.

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“…In a prospective study of 24 patients with HH, Chen et al [29] have shown that the use of indwelling pleural catheters (IPCs) with a regimented drainage schedule of 1 L fluid removal on every other day may be a feasible and safe approach. Although IPCs are often used in the management and palliation of malignant pleural effusion [30][31][32], a growing body of literature proves their utility and safety in benign pleural effusions [29,[33][34][35]. However, this is paired with an overall higher complication rate and lower spontaneous pleurodesis rate in the HH population receiving IPCs compared to malignant pleural effusion [29,36].…”

Section: Discussionmentioning

confidence: 99%

Repeat Thoracentesis in Hepatic Hydrothorax and Non-Hepatic Hydrothorax Effusions: A Case-Control Study

et al. 2018

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Background: Repeat thoracentesis for symptom control is offered to patients with refractory hepatic hydrothorax (HH) but the risk profile for this management strategy remains unclear. Objectives: This study aimed to compare complication frequency and nature during repeat thoracentesis in patients with and without HH. Methods: Complication rates in patients undergoing repeat thoracentesis for symptom relief was compared between patients with HH and a control group (non-HH group) at a single center from 2010 to 2015. Records were reviewed for demographics, laboratory values, number of thoracentesis, and associated complications with each procedure. Results: 82 patients with HH (274 thoracenteses) and 100 control patients (188 thoracenteses) were included. A complication was noted in 17/462 (0.03%) procedures in the entire cohort. There was a higher overall complication rate with repeat thoracentesis in the HH group (8 vs. 0%, p = 0.016, 95% CI = 1.5–14.6). In the HH group, the cumulative risk of complications increased with sequential thoracenteses; a complication occurring in the preceding intervention was the strongest predictor for subsequent complication (OR = 17.1, p = 0.0013) and more than 1 previous complication was associated with a 15-fold increased risk of a subsequent complication (p < 0.001). In multivariate analysis within the HH group, the Model for End-Stage Liver Disease (MELD) score was an independent predictor of hemothorax (OR = 1.19, 95% CI = 1.03–1.36, p = 0.012). Conclusions: Repeat thoracentesis is an overall low-risk procedure, although a higher complication rate is observed in HH compared with non-HH patients. The presence of a previous complication significantly increases the risk of future complications in the HH population.

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“…10 Supporting this logic are several retrospective single-institution or single health-system observational studies that have reported excellent outcomes associated with esophageal stenting among both patients who were and were not candidates for surgical repair. 2,3,10,11 …”

Section: Commentmentioning

confidence: 99%

A Nationwide Rise in the Use of Stents for Benign Esophageal Perforation

Thornblade

Cheng

Wood

et al. 2017

The Annals of Thoracic Surgery

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BACKGROUND Surgical repair or drainage is the standard treatment for benign esophageal perforation. The Food and Drug Administration has approved the use of esophageal stents for the management of malignant esophageal stricture and/or fistula. We hypothesize that increasing enthusiasm and experience with esophageal stents has led to greater use of stents for the management of benign esophageal perforation. METHODS We performed a retrospective cohort study (2007–2014) of patients with benign esophageal perforation using MarketScan®—a commercial claims database. Subjects had six months of follow-up. Regression was used for risk-adjustment. RESULTS A total of 659 patients (mean 49 years, 41% women) were treated for benign esophageal perforation (surgical repair: n=449, 69%; surgical drainage: n=110, 17%; stent: n=100, 15%). Stent use increased from 7% in 2007 to 30% in 2014 (p-trend<0.001). Over the same period, surgical repair decreased from 71% to 53% (p-trend=0.001), while surgical drainage did not change (p=0.24). After adjustment for other factors that could vary over time, stent use increased by 28% per year (incidence rate ratio=1.28, 95% confidence interval 1.17–1.39). There were no significant changes in risk-adjusted deaths, discharges home, readmissions, or costs over the same period (all p-trend>0.05). CONCLUSIONS The use of stents for the management of benign esophageal perforation has increased by over four fold in just eight years, but short-term outcomes have not changed over time for this population of patients. A national registry for off-label use of esophageal stents may clarify the indications for and risks and benefits of stenting benign esophageal perforations.

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A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation

Cited by 50 publications

References 13 publications

Endoscopic management of esophageal leaks

Endoscopic management of esophageal leaks

Repeat Thoracentesis in Hepatic Hydrothorax and Non-Hepatic Hydrothorax Effusions: A Case-Control Study

A Nationwide Rise in the Use of Stents for Benign Esophageal Perforation

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