Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review

Abstract

Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368...

Outcome after stenting and débridement for spontaneous esophageal rupture

“…In our study the ultimate leak occlusion rate and treatment success were 87%, in line with an overall success rate of 88% reported in a meta-analysis of 371 patients stented for iatrogenic and spontaneous esophageal rupture [2]. In the surgical-based treatment [2] the data were similar with an overall success rate of 83% and an in-hospital mortality of 17% based on 368 patients. However, presumably the patients who underwent surgery probably were more severely afflicted compared with patients who underwent stent-based treatment.…”

“…Spontaneous esophageal perforation, effort rupture (Boerhaave syndrome) is a lifethreatening condition with high morbidity and mortality [2], regardless of the treatment.…”

“…Surgery has been and still is the most common treatment for spontaneous rupture of the esophagus [1] but the use of initial stenting has gradually increased as shown in meta-analysis from 2000-2012 [3] and 2005 -2015 [2]. Moreover, there has been a tendency that the mortality after stent-based treatment was lower compared to surgical based treatment of iatrogenic and spontaneous perforations with pooled mortalities of 7.5 % versus 17% [2].…”

“…During the past 15 years, sealing of the perforation by placement of a self expanding metal stent (SEMS) has increasingly been used [2,3] with promising results. The main goals of stent-based treatment are to seal and close the perforation effectively, to drain all fluid collections in the pleura and the mediastinum, primarily percutaneously, and perform surgical débridement in selected patients.…”

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

“…In a systematic review that compared SEMS insertion (371 patients) versus surgery (368 patients) for esophageal leaks, success/mortality rates were 88 %/7.5 % and 83 %/17 %, respectively [94]. These data should be interpreted with caution as no study was randomized or even comparative, implying a high risk of bias.…”