Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study.

Abstract

To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.