Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment

Abstract

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis

“…First, as mentioned above, studies generally consist of small case series (range 27-119 patients [5,[9][10][11][12][13]24]) from one center, which allows authors to perform only univariable analyses without accounting for type of perforation and treatment strategy. Second, treatment options selected for the management of esophageal perforation in these studies vary considerably within and between studies, which also causes heterogeneity (Supplementary Table 5) [25,26]. In an effort to overcome these shortcomings, we pooled individual data from almost a thousand patients and performed multivariable regression analysis.…”

Esophageal emergencies: WSES guidelines

“…The initial clinical and biological presentation of EP has no specific patterns; late stages are characterized by signs of inflammation and sepsis. To avoid delay in diagnosis (> 50% of cases) and allow timely management, a high degree of suspicion is required at presentation [68, 75, 76].…”

Boerhaave’s syndrome: case report and review

“…Хирургическое лечение в настоящее время считается «золотым стандартом» при разрывах пищевода, диагностированных в течение 24 часов от появления клинических симптомов, и позволяет добиться полного выздоровления в 75% случаев [37,38]. Это связано с тем, что разрыв возникает в области здоровых тканей с хорошим кровоснабжением, способствующим быстрому заживлению после операции и низкой частоте инфекционных осложнений [36]. Хирургический подход включает в себя дренирование плевральной полости и ушивание перфорированного участка пищевода через открытый торакотомический или лапаротомический доступ [24,28].…”

“…По мнению ряда авторов, данная методика связана с высокой частотой периоперационных осложнений и высокой смертностью [43][44][45]. Несмотря на то, что эндоскопическое стентирование пищевода является малоинвазивной процедурой, оно не связано с уменьшением частоты повторных хирургических вмешательств [36].…”