Endoscopic management of esophageal perforations: a multi-center study

Esophageal perforation (EP) is a rare but life-threatening condition with an incidence of approximately 3.1 per million annually. While iatrogenic injury during endoscopy is the leading cause, other etiologies include spontaneous rupture, trauma, and malignancy. EP can present with nonspecific symptoms, most commonly chest pain or dysphagia, and diagnostic delays are associated with worse outcomes. Multiple non-operative strategies exist, including primary closure, stenting (bypass), combination therapy, and conservative management. However, data guiding the optimal approach remain limited. The aim of this study was to evaluate outcomes of different non-operative management strategies for EP and identify predictors of successful repair.

We retrospectively analyzed adult patients with EP across three Mayo Clinic sites between 2007 and 2023. Patients were categorized into four groups based on treatment modality. Demographics, clinical features, imaging, endoscopic intervention, and outcomes were recorded. The primary outcome was clinical success, defined as avoidance of surgical intervention. Logistic regression was used to identify predictors of success.

A total of 72 patients were included (mean age 63.7 years, 65.3% male). The most common cause was iatrogenic injury (58.3%), and the distal esophagus was the most frequent site (67.6%). Non-operative success was 100% in the primary closure and combination groups, and 42.9% in the conservative group (p < 0.001). On multivariate analysis, non-conservative therapy significantly predicted success (aOR 22.4, 95% CI [1.2-407.4], p = 0.036).

Primary closure and combination endoscopic approaches offer superior outcomes in managing EP. Early intervention with appropriate modality selection is critical to avoid surgical escalation and improve prognosis.