Contemporary management of esophageal perforations: A resource-intensive problem

The study objective was to describe the outcomes of the modern management of esophageal perforations in a tertiary-quaternary referral center.

Retrospective single institution analysis of patients with esophageal perforation from 2017 to 2023. Patient characteristics, mechanism, time to presentation, pretransfer and in-hospital interventions, mortality, and hospital course were analyzed. Perforations were classified by location from incisors. One-year survival and 30- and 90-day mortality rates were calculated.

Seventy-three patients were identified. Sixty-six patients (90%) had delayed (>24 hours) presentation; 62 patients (85%) were transferred from an outside hospital. The median time from injury to transfer or surgical consult was 4 days (interquartile range, 1-11). Pretransfer temporizing measures included antibiotics only (60%, 37/62), thoracostomy tube (15%, 9/62), endoscopic stenting (11%, 7/62), attempted primary repair (3%, 2/62), and thoracoscopic chest washout (11%, 5/62). Definitive treatment was as follows: 49% (36/73) esophageal stenting, 23% (17/73) primary repair, 16% (12/73) washout with feeding tube placement, and 11% (8/73) esophagectomy with diversion. The 30- and 90-day mortality rates were 4% (3/73) and 10% (7/73), respectively. There was no difference in 30-day mortality or length of stay between patients undergoing invasive interventions before transfer versus treatment with antibiotics alone (P = .547 and P = .739, respectively). Compared with early presentation, patients with delayed presentation underwent more treatment interventions (median: 4 [interquartile range, 4-6] vs 1 [interquartile range, 1-3] interventions respectively, P = .005) and had longer intensive care unit stays (mean: 3.7 vs 10.5 days, P = .005).

Delayed esophageal perforation is a morbid condition, but high vigilance and multi-modal (surgical, endoscopic, radiologic) interventions improve survival. A conceptual modernization of the management of esophageal perforation includes more interventions and longer hospital stays.