The first case of spontaneous esophageal rupture (Boerhaave syndrome) was reported 300 years ago. Until 1947, no successful treatment was available. In 1947, Olson and Clagett attempted surgical treatment of EPR; several years later, a successful treatment approach was achieved [10]. The goals of treatment for EPR are to control systemic infection and early oral intake. The development of systemic infection has a strong negative impact on EPR prognosis.
The management of EPR has always been challenging because when not properly treated, EPR can lead to patient death [11]. In addition, the relatively low incidence of EPR makes it difficult for medical providers, including physicians, to gain sufficient experience in providing appropriate treatment for the condition [12, 13].
In recent decades, endoscopic examination of digestive organs and transesophageal echography for cardiovascular disease evaluation have had great impacts on the early detection and improved the outcomes of digestive system and heart diseases [14]. However, the incidence of iatrogenic esophageal perforation as assessed using endoscopic examinations has also increased in proportion to the incidence of EPR [2, 15]. Recent studies have suggested that iatrogenic causes are the most common etiology of EPR [16, 17]. However, the most common cause of EPR in the present study was ingestion of fish bone. This is considered to occur because of a combination of ingestion of relatively small and sharp seaweed fish bones and the carelessness of the patient while eating fish. EPR due to fish bone has several characteristics. First, it can usually be diagnosed rapidly. The main reason for EPR treatment failure is delayed diagnosis and intervention [15, 18]. This is because the symptoms of EPR are usually nonspecific, such as chest discomfort, orthopnea, fever, and dysphagia [8, 19, 20, 21]. Therefore, time is required to differentiate EPR from coronary artery disease, aortic dissection, pericardial effusion, and pneumonia. In the absence of rapid treatment following the occurrence of EPR, gastric and oral content leakages leading to mediastinitis and other infections are more likely to occur, which can increase mortality and morbidity.
According to previous reports, the most important prognostic factor in EPR is the time from onset to treatment. In most previous studies, patients treated within 24 hours of presentation showed better outcomes than those with more delayed treatment [3, 9, 19, 22, 23].
Esophageal perforation due to fish bone can present with a clear picture of the time of development and the location of the EPR as compared with other causes because acute pain with dysphagia is prominent in most patients.
The second characteristic of EPR due to fish bone ingestion is that the size of the EPR is smaller than that associated with Boerhaave syndrome or iatrogenic causes. The size of the EPR is an important feature that affects prognosis. Therefore, esophageal perforation due to fish bone, in comparison with other causes, seems to have a good clinical prognosis (Table 3).
In previous studies, the mortality of EPR was reported to range from 20 to 30%, but in our study, the mortality rate was 10% (8/79), which is relatively low [8, 24]. This is due to the high proportion of cases involving small EPRs due to fish bone. With the development of radiological diagnostic techniques, the size and location of the esophageal perforation and the presence of complications such as mediastinitis or abscess can be diagnosed more accurately than ever before. The clinical outcome of EPR is improving owing to the advancements in TPN, antibiotic therapy, and accumulation of treatment experience with EPR. However, some patients still require surgical intervention, and death can still occur without adequate treatment. EPR warrants further study as a serious, potentially life-threatening condition.
The present author aimed to identify the factors that affect the outcome of EPR in addition to the timing of treatment initiation. Therefore, this study was conducted under the assumption that the EPR size and initial inflammatory values (white blood cell [WBC] count, segmented neutrophil count percentage, C-reactive protein [CRP] level) would affect the outcome of EPR. Among these factors, segmented neutrophil count percentage and EPR size were found to be statistically significantly associated with the outcome of EPR. Although the WBC and CRP values of the patients who died were higher than those of the patients who survived, no statistically significant differences were found.
This study had limitations such as its retrospective design and relatively small number of patients. Further study will require additional consideration to overcome these limitations.
Table 3
Characteristics of esophageal perforation and rupture (EPR) according to etiology
Cause of EPR | No. of cases | Size (mm), mean | Time to treatment (days) | Hospital stay duration | Mortality, n (%) |
Fish bone | 41 | 10.80 | 2.06 | 15.07 | 2 (4.87%) |
Boerhaave syndrome | 22 | 33.64 | 2.32 | 29.82 | 3 (13.6%) |
Iatrogenic | 5 | 16.80 | 3.7 | 19.4 | 1 (20%) |
Other | 11 | 25.7 | 2.61 | 28 | 1 (9.1%) |
Total | 79 | | | | 7 |