H. Theeuwen2, M. Ashbrook2, V. Cheng3, T. Harano1,2, S. Wightman1,2, S. Atay1,2, G. Rosenberg1,2, B. Udelsman1,2, A. W. Kim1,2 1University Of Southern California, Thoracic Surgery, Los Angeles, CA, USA 2University Of Southern California, General Surgery, Los Angeles, CA, USA 3Kaiser Permanente – Ontario Medical Center, Bariatric Surgery, Ontario, CA, USA
Introduction:
Esophageal perforation is a rare condition associated with significant morbidity and mortality if not expeditiously diagnosed and treated. Management includes open surgery, minimally invasive surgery, and endoscopic stent placement. The objective of this study was to analyze initial procedural management of esophageal perforation and associated outcomes.
Methods:
A retrospective study using the HealthCare Utilization Project – National Inpatient Sample (HCUP-NIS) between October 2015 and December 2019 was conducted. Adults ≥ 18 years with a diagnosis of esophageal perforation undergoing an initial non-elective esophageal procedure were identified, and categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement using the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System (ICD-10-CM, PCS). Patients with esophageal cancer were excluded. The Elixhauser comorbidities with van Walraven (VW) scores were identified for each patient. Clinical outcome variables included mortality and postoperative complications including pulmonary, cardiovascular, gastrointestinal, infectious, wound related, genitourinary, neurocognitive, and systemic complications. Univariate and multivariate Cox regression analysis was used to compare in-hospital survival.
Results:
A total of 3,345 patients met inclusion criteria. The median age was 62 years with 1,310 (39%) being female. An open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%). There were no significant differences in VW score nor mortality between groups. Patients undergoing minimally invasive surgery had a higher proportion of gastrointestinal complications (p=.006), otherwise there were no significant differences in post-intervention complications. A total of 380 (11%) patients died. Patients who died were significantly older, had higher VW scores, and had more complications including genitourinary, cerebrovascular, cardiovascular, myocardial infarction, and electrolyte derangements. Univariable Cox regression analysis showed that age (Hazard Ratio (HR) 1.95, p<.001), VW score (HR 1.06, p<.001), stent placement (HR 1.93, p=.045) and transfer from a health facility (HR 2.40, p=.049) were associated with poorer in-hospital survival.
Conclusion:
Patients presenting with esophageal perforation had an approximately 11% mortality rate and significant associated complications regardless of initial procedural intervention chosen. Increasing age, comorbidities, initial management with endoscopic stent placement, and transfer from a health facility are associated with poorer in-hospital survival.
