Spontaneous compared with iatrogenic esophageal perforation: A comparison between etiologies

Esophageal perforation is a rare condition with high mortality. Spontaneous perforations may be associated with worse outcomes because of the degree of mediastinal contamination when compared with "clean" iatrogenic perforations, with different timings for intervention. This study aims to assess the differences in treatment and outcomes between these 2 groups.

Data were collected retrospectively from a tertiary center from 2009 to 2021 using the electronic patient record (n = 73, 42 spontaneous, 31 iatrogenic). Complications were quantified using the Comprehensive Complication Index. Univariate analysis was used to determine statistical significance.

Spontaneous perforations had a significantly greater 30-day mortality compared with iatrogenic perforations (21.4% vs 3.2% P = .025), although not at 90 days and 1 year (21.4% vs 16.1% P = .570 and 21.4% vs 19.4% P = .828). Iatrogenic perforations were more commonly managed nonoperatively (73.8% iatrogenic vs 22.6% spontaneous perforations P < .001). All of the iatrogenic deaths that occurred between 30 days to 1 year had been managed nonoperatively. Median length of intensive care stay was greater in spontaneous perforations (15 days vs 6 days P = .047), with no significant difference in median overall length of stay (48 days spontaneous perforations vs 38 days iatrogenic P = .885). Median Comprehensive Complication Index score was greater in those with spontaneous perforations (53.9 vs 29.6 P = .002) CONCLUSION: Although Comprehensive Complication Index and 30-day mortality were greater in spontaneous perforations, there was no difference in 90-day and 1-year mortality, suggesting that long-term survival is not dictated by etiology of the perforation. Most iatrogenic perforations were managed nonoperatively, which raises the question whether iatrogenic perforation should be managed more aggressively.