Published online Aug 14, 2014. doi: 10.3748/wjg.v20.i30.10613
Revised: December 5, 2013
Accepted: January 8, 2014
Published online: August 14, 2014
AIM: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).
METHODS: All patients between 2003-2013 treated for EPR at the Karolinska University Hospital, a tertiary referral center, were studied with regard to initial management with SEMS. Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded. Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible. Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis, which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis. Patient and lesion characteristics were analyzed and are presented as median and interquartile range. Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression, while variables with P < 0.2 were further analyzed with multi-variate logistic regression.
RESULTS: Of the total number of 48 patients presenting with EPR, 40 patients (83.3%) were treated with SEMS at the time of admission, with an intention to heal the perforation. Twenty-three patients had Boerhaave’s syndrome (58%), 16 had an iatrogenic perforation (40%) and 1 had external trauma to the esophagus (3%). The total in-hospital mortality, including the cases that had other initial treatments (n = 8), was 10.4% and 7.5% among those who were subjected to the SEMS-based strategy. In 33 of the 40 patients (82.5%) who were treated with stent, the EPR healed without further change in treatment strategy. Patients classified as treatment success received a SEMS at a median time of 1 (1-1) d after the actual EPR, compared to 3 (1-10) d among those where the initial treatment failed, P = 0.039 in uni-variate analysis and P = 0.052 in multi-variate analysis. No other significant factors emerged, indicating an increased risk for failure. Six of 7 patients, where stent treatment of the defect failed, underwent an emergency esophagectomy with end esophagostomy and one patient died.
CONCLUSION: SEMS as an upfront therapeutic strategy seems to be a successful concept, when applied to an unselected group of patients with EPR.
Core tip: It is unclear to which extent esophageal stenting can heal esophageal perforation-rupture in unselected patients. In this single institution study 83.3% of all benign esophageal perforations/ruptures of mixed etiology, excluding anastomotic leakages, were treated with stent with an intention to heal the perforation, as first-line treatment during a 10-year period. Eighty-two point five percent recovered after stenting and no further intervention was required. Time between perforation and placement of stent emerged as potential risk factor for failure of stenting. The high rate of stenting as primary treatment may have contributed to the relatively low overall in-hospital mortality of 10.4%.