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Ali JT, Rice RD, David EA, Spicer JD, Dubose JJ, Bonavina L, Siboni S, O'Callaghan TA, Luo-Owen X, Harrison S, Ball CG, Bini J, Vercruysse GA, Skarupa D, Miller CC, Estrera AL, Khalil KG. Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment. Dis Esophagus 2017; 30:1-8. [PMID: 28881905 DOI: 10.1093/dote/dox093] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/29/2017] [Indexed: 12/11/2022]
Abstract
The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.
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Affiliation(s)
- J T Ali
- The University of Texas at Austin, Austin, Texas
| | - R D Rice
- San Antonio Military Medical Center, San Antonio
| | - E A David
- Department of Surgery, University of California at Davis, Sacramento
| | | | | | - L Bonavina
- Department of Surgery, University of Milan, Milan, Italy
| | - S Siboni
- Department of Surgery, University of Southern California, Los Angeles County, Los Angeles
| | - T A O'Callaghan
- Division of Trauma Services, Loma Linda University, Loma Linda, California
| | - X Luo-Owen
- Division of Trauma Services, Loma Linda University, Loma Linda, California
| | - S Harrison
- Department of Cardiothoracic Surgery, University of Mississippi, Jackson, Mississippi
| | - C G Ball
- Department of Surgery, University of Calgary Foothills Medical Center, Calgary, Alberta, Canada
| | - J Bini
- Miami Valley Hospital, Department of Surgery, Dayton, Ohio
| | - G A Vercruysse
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - D Skarupa
- Department of Surgery, University of Florida-Jacksonville, Jacksonville, Florida, USA
| | - C C Miller
- Houston Medical Center, University of Texas, Houston, Texas
| | - A L Estrera
- Houston Medical Center, University of Texas, Houston, Texas
| | - K G Khalil
- Houston Medical Center, University of Texas, Houston, Texas
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