58 patients were included in the study. The study cohort consisted of 29 men and 29 women, with a mean age of 65 years at the time of diagnosis (range: 21–92). Most common cause of esophageal perforation was iatrogenic (n = 30, 51.7%), followed by spontaneous (n = 16, 27.6%) and traumatic perforation (n = 5, 8.6%). Further demographics and clinical details of patients are shown in Table 1. Based on primary treatment choice, patients were divided into three groups: endoscopic, surgical and conservative.
Table 1
Demographic and clinical characteristics of 58 patients with esophageal perforation (non-follow-up and follow-up patients).
Variables | All (n = 58) | Non-Follow up (n = 38) | Follow up (n = 20) | P value |
| n (%) | n (%) | n (%) | |
Gender, female | 29 (50) | 18 (47.4) | 11 (55) | 0.783 |
Age (years) | 64.6 (SD13.9) | 64.89 (SD 15.1) | 64 (SD 11.6) | 0.600 |
BMI (kg/m²) | 24.4 (SD 4.4) | 24.6 (SD 4.1) | 24.1 (SD 5.1) | 0.404 |
Smoking | 9 (15.5) | 8 (21.1) | 1 (5) | 0.143 |
Alcohol | 11 (18.9) | 11 (28.9) | 0 (0) | 0.011 |
Comorbidity | 55 (94.8) | 36 (94.7) | 19 (95) | 1.000 |
Arterial Hypertension | 27 (46.6) | 18 (47.4) | 9 (45) | 1.000 |
Atrial Fibrillation | 17 (29.3) | 11 (29) | 6 (30) | 1.000 |
COPD | 10 (17.2) | 7 (18.4) | 3 (15) | 1.000 |
Coronary Heart Disease | 10 (17.2) | 9 (23.7) | 1 (5) | 0.141 |
Diabetes | 7 (12.1) | 6 (15.8) | 1 (5) | 0.403 |
Gastric and duodenal Ulcers | 6 (10.3) | 3 (7.9) | 3 (15) | 0.405 |
Achalasia | 4 (6.9) | 1 (2.6) | 3 (15) | 0.114 |
Cause of perforation | | | | |
Iatrogen | 30 (51.7) | 19 (50) | 11 (55) | 0.787 |
Spontaneous | 16 (27.6) | 12 (31.6) | 4 (20) | 0.538 |
Traumatic | 5 (8.6) | 2 (5.3) | 3 (15) | 0.328 |
Other | 4 (6.9) | 3 (7.9) | 1 (5) | 1.000 |
Unkown | 3 (5.2) | 2 (5.3) | 2 (10) | 1.000 |
Site of Perforation | | | | |
Proximal | 10 (17.2) | 2 (5.3) | 8 (60) | 0.002 |
Middle | 21 (36.2) | 14 (36.8) | 7 (35) | 1.000 |
Distal | 26 (44.8) | 21 (55.3) | 5 (25) | 0.051 |
Size of Perforation (cm) | 2 (0.4–11) | 2 (0.4–11) [2–4] | 2 (1–6) | 0.627 |
Delayed diagnosis > 24 h | 20 (34.5) | 11 (36.7) | 9 (52.9) | 0.362 |
Delayed diagnosis (days) | 4.5 (2–35) | 9 (2–35) [3–16] | 3 (2–7) | 0.142 |
Categorical variables are expressed as number (percentage), continuous variables are expressed as mean (standard deviation). |
With the upcoming endoscopic treatment options in the latest years, primary treatment selection shifted from surgical to mainly endoscopic therapy as shown in Fig. 1.
Twenty-seven patients (46.6%) were treated endoscopically. Esophageal stenting was performed in 18 patients with a median duration of stent placement of 33 days (range: 14–82). Stents were changed median once, maximum twice. Two patients were treated with endoscopic vacuum therapy (EVT) with a median sponge inlay of 10.5 days and at least two endoscopic changes. Seven patients received a combined treatment of stent and EVT with a median stent inlay of 9 days (range: 4–50) and a median EVT of 10 days (range: 4–27) and a median sponge changing of 2 (range: 1–7).
Surgery was performed in 20 patients (34.5%). Fifteen patients initially received a transthoracic esophagectomy. Cervical diversion was required in 13 of these patients (65%). In 7 patients, gastrointestinal reconstruction was performed later on. The remaining 5 patients were treated with primary suture of the perforated area. In three of these patients transthoracic esophagectomy was performed in the follow-up (2x cervical deviation, 1x intrathoracic esophagogastrostomy). Median time to reconstruction of cervical esophagostomy was 11.5 months (range: 6–42).
Conservative management was applied in 11 patients (19%). Therapy mainly consisted of antibiotics, proton pump inhibitors, parenteral nutrition, and in 5 cases chest tube drainage.
Outcome parameters were compared between treatment groups to identify possible differences. Overall, median hospital stay was 31.5 days (range 6-243) and median ICU stay was 9 days (range 1-200). Both were significantly longer in patients treated with surgery (p = 0.017; 0.003). Patients suffered from various complications including pleural effusion and empyema or pneumonia. Complication rate was highest in the surgical group with 85%, compared to 72.7% (n = 8) in the conservative and 81.5% (n = 22) in the endoscopic group. Thirteen patients had to return to hospital for further therapy of late complications like esophageal stenosis, most of whom had been treated endoscopically (n = 8, 29.6%). Overall, 90-day mortality-rate was 13.8% (n = 8, 4 endoscopic, 2 conservative, 2 surgical). Further details are displayed in Table 2.
Table 2
Short-term outcome stratified by treatment groups.
Variables | All (n = 58) | Conservative (n = 11) | Endoscopic (n = 27) | Surgical (n = 20) | P value |
| n (%) | n (%) | n (%) | n (%) | |
Complications | 42 (72.4) | 7 (63.6) | 18 (66.7) | 17 (85) | 0.279 |
Pleural Effusion | 33 (56.9) | 7 (63.6) | 16 (59.3) | 10 (50) | 0.781 |
Pneumonia | 14 (24.1) | 1 (9.1) | 3 (11.1) | 10 (50) | 0.005 |
Pneumothorax | 12 (20.7) | 2 (18.2) | 6 (22.2) | 4 (20) | 1.000 |
Pleural Empyema | 9 (15.5) | 0 (0) | 3 (11.1) | 6 (30) | 0.060 |
Sepsis | 9 (15.5) | 2 (18.2) | 2 (7.4) | 5 (25) | 0.254 |
Hospital Stay (days) | 31.5 (6-243) | 18 (8–54) | 36 (6–89) | 42.5 (18–243) | 0.017 |
ICU Stay (days) | 9 (1-200) | 4.5 (1–12) | 9 (1–59) | 21 (4-200) | 0.003 |
Return to Hospital | 13 (22.4) | 1 (9.1) | 8 (29.6) | 4 (20) | 0.424 |
In-Hospital-Mortality | 7 (12.1) | 1 (9.1) | 4 (14.8) | 2 (10) | 1.000 |
90 Day-Mortality | 8 (13.8) | 2 (18.2) | 4 (16) | 2 (10.5) | 0.789 |
Categorical variables are expressed as number (percentage), continuous variables are expressed as median (range). |
At the onset of the study, already 25 of 58 (43.1%) patients were deceased. Of the remaining 33 patients, 20 were available for the survey. HRQoL was measured after a median follow-up of 49 months. Eight patients had been treated endoscopically, 6 had underwent surgery and another 6 had been treated conservatively. Due to the small number of cases, we were not able to find statistically significant results, except for a single symptom scale in the EORTC QLQ-C30.
The study found a general trend of lower HRQoL in patients with benign esophageal perforation compared to published reference data (10). The endoscopic treatment group showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group, although the order varied between subscales. Surgical patients generally showed the lowest HRQoL scores.
Mean overall score for HRQoL Index for GERD was 4.60 (SD 4.3). The surgical treatment group had the highest overall score 6.2, (SD 4) indicating severe symptoms, followed by the endoscopic (4.4, SD 4.5) and the conservative group (3.3, SD 4.6). Sixty percent (n = 12) of follow-up patients were generally satisfied with their current health status. Only three patients showed no symptoms. The other patients reported mainly a feeling of fullness (60%, n = 12) and heartburn (50%, n = 10) (Fig. 2).
Results of GIQLI showed a mean overall score of 111 (SD 18.9) compared to a reference score for healthy individuals of 125.8 (7). Most problems occurred in the physical function domain: 75% (n = 15) of patients reported tiredness and 65% (n = 13) woke up 3–4 nights of the week. All subdomains showed highest scores for the endoscopic treatment group and lowest scores for the surgical group (Fig. 3).
Global health status (GHS) in the EORTC QLQ-C30 was lower for patients with benign esophageal perforation than healthy individuals. Follow-up patients reached a mean score of 58.8 (SD 25.4) compared to 71.2 (SD 22.4) in the reference population (10). Only two scores showed a statistical difference between treatment groups: Insomnia was reported by all conservatively treated patients (100%, n = 6) vs. 25% of endoscopic patients (n = 2) and constipation was reported exclusively by conservatively treated patients. Common symptoms were fatigue (84.2%, n = 16) and insomnia (60%, n = 12) matching the results of the GIQLI. The QLQ-C30 and QLQ-OES18 found lower function scores and higher symptom scores for the surgical group compared to conservatively or endoscopically treated patients. The GHS and functional scores are shown in Fig. 4.