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

Abstract

Background Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave's syndrome (BS). Methods We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. Results Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8-5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2-7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2-6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1-3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1-3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. Conclusions This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome. Keywords Esophageal rupture • Individual patient data meta-analysis • Time of diagnosis Abbreviations TOD Time of diagnosis IEP Iatrogenic esophageal perforation BS Boerhaave's syndrome IPDMA Individual patient data meta-analysis LOS Length of hospital stay ICU Intensive care unit CI Confidence interval OR Odds ratio SD Standard deviation and Other Interventional Techniques Results of the current manuscript are (partly) presented as poster during the Digestive Disease Week 2019 (San Diego) and the European Society of Gastrointestinal Endoscopy Days 2019 (Prague). The members of the Benign Esophageal Perforation Collaborative Group are listed in "Acknowledgements".

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

“…Stents are usually removed 6-8 weeks after insertion and repeated stent placement is needed in 11 % of patients [114][115][116]. In patients who are endoscopically treated for benign esophageal perforations, early diagnosis (< 24 hours) has been shown to be associated with a lower need for re-intervention and intensive care admission, and a shorter hospital stay [123].…”

Endoscopic negative pressure therapy (ENPT) of a spontaneous oesophageal rupture (Boerhaave’s syndrome) with peritonitis – a new treatment option

“…The immediate diagnosis and rapid initiation of treatment measures can be lifesaving. An essential prognostic factor is the time interval between the occurrence of the first symptoms and the first treatment measure [ 8 ].…”

Atypical chest pain: A case report of Boerhaave syndrome

“…Even though there is no standardized care, studies agree that the first 24 hours (golden 24-hours) are crucial for the prognosis [6]. Recent meta-analysis of 2020 regrouping 384 patients among 25 studies confirms that an early diagnosis (<24 hours) correlates with a better clinical outcome [7]. The management is more complicated in community hospitals where the diagnosis and therapeutic tools, as well as the specialists are not easily available.…”