Esophageal Perforation: Clinical Patterns and Outcomes from a Patient Cohort of Western Norway

Abstract

Background: Esophageal perforation is a rare, often life-threatening condition, and management remains challenging. Methods: Retrospective review of consecutive patients with esophageal perforation treated at two university hospitals between 2000 and 2010. Pertinent data from hospital records were retrieved for statistical calculations and evaluation of perforation score. Results: Forty-seven patients [47% female, median age 62 years (range 15–88)] were included. The annual incidence was 4.7/1,000,000. Perforations were spontaneous in 14 patients (30%), iatrogenic in 25 (53%), and caused by trauma and foreign body impaction in 8 patients (17%). ASA score (p = 0.004), perforation localization (p = 0.001), diagnostic delay (p = 0.002), and perforation score (p < 0.001) differed significantly between patient groups with different etiology, but not between groups with different outcomes. Early diagnosis (≤24 h) was significantly associated with a low perforation score (p = 0.033). A non-operative approach was employed in 26 patients (55%) – more commonly for proximally localized perforations (p = 0.045). The non-operative group showed lower severe complication rates (p = 0.033), shorter ICU stays (p < 0.001) and durations of mechanical ventilation (p = 0.022). The overall 30-day mortality was 23.4%. Conclusion: Careful clinical evaluation and appropriate, individualized treatment are important. The high mortality may be partly explained by the underlying disease and the complexity of the clinical condition in many patients.

Outcomes after oesophageal perforation: a retrospective cohort study of patients with different aetiologies

“…cause of perforation reported in many studies. 1,2,4,5 Diagnosis and treatment within 24 hours of perforation are critical if favourable outcomes are to be achieved. 1,6 After diagnosis and the initial phase of resuscitation, there is a wide range of treatment options, which are informed by the presentation, aetiology, location of perforation, and the extent of mediastinal or intrathoracic contamination.…”

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system

“…In modern times it is still associated with substantial morbidity and mortality. 1 In Denmark, contemporary population-based data reveal an overall national mortality rate of 21% for patients with esophageal perforation, including spontaneous rupture and iatrogenic perforation. 2 Specialist centers of foregut surgery report comparable results.…”

Oesophageal Perforations Commentary

“…Diagnostic delay leads to delayed surgical treatment or may prevent consideration of surgery entirely. The diagnosis may be difficult, and half of the patients included in the study by Søreide and co-workers [1] were not diagnosed within 24 h. This study also highlights a high rate (35%) of false-negative studies using contrast oesophagograms, and 4% of patients had a negative CT scan. Accordingly, a high index of clinical suspicion remains important in making an early diagnosis.…”

“…Prognostication with respect to these patients would be of benefit in order to elucidate which patients might safely be managed conservatively. As demonstrated in the study by Søreide and co-workers [1], the attempt to create a scoring system by Abbas et al [11] was not methodologically sound and does not translate validly into the clinical setting.…”

“…The paper by Søreide's group [1] illustrates both the heterogeneous presentation and management of oesophageal perforations, and also highlights the significant associated mortality rate in a modern series notwithstanding major advances in the management of sepsis. The development of multi-centre or national clinical registries and collaborative groups may enable standardisation of approaches and clinical trials in this complex patient group.…”