Endoscopic vs. Operative Management of Acute Esophageal Perforation: A 21-Year Experience at a High-Volume Referral Center.

BACKGROUND Management of acute esophageal perforation varies significantly. Data are particularly limited regarding optimal management of patients with Boerhaave's syndrome (BS). We aimed to compare operative to endoscopic management for patients with acute esophageal injury at a high-volume tertiary referral center.

METHODS This retrospective cohort study included adult patients presenting to a tertiary referral center with acute esophageal perforation from January 2002 to January 2023. Patients with esophageal cancer or prior esophagectomy were excluded. Our primary variable of interest was endoscopic (EM) versus operative management (OM) and our outcomes of interest included incidence of major postoperative morbidity and 30-day mortality. Additional covariates included demographic characteristics and preoperative clinical factors.

RESULTS Among 117 patients, 65 (55%) met criteria for BS, and 52 (44%) had other etiologies. Mean age was 57±18 years and 36 patients (31%) were female. Overall, 95 patients (81%) received OM. Twenty-two patients (19%) had EM with stenting; of these, 5 patients (23%) also had endoluminal vac therapy. Median ICU length of stay was 6 days (IQR 8), 30 patients (26%) required readmission and 30-day mortality was 2.6% (3 patients, 1 with EM). Among patients with BS, 13 (20%) had EM and 52 (80%) had OM. Between BS patients managed endoscopically versus operatively, there were no significant differences in use of enteral feeding access, leaks, strictures, length of stay, readmission or 30-day mortality (P>0.05).

CONCLUSIONS At a high-volume center, endoscopic management with stenting and/or endoluminal therapy can be safely employed for well-selected patients, including those with Boerhaave's syndrome.