C0446 - Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Khushboo S. Gala, MD

Mayo Clinic
Rochester, MN

Farah Abdul Razzak, MD, Khushboo S. Gala, MD, Reem Matar, BSc, Babusai Rapaka, MD, Donna Maria Abboud, MD, Rebecca Yao, MD, MPH, Daniel Maselli, MD, Veeravich Jaruvongvanich, MD, Eric J. Vargas, MD, MS, Andrew C. Storm, MD, Barham Abu Dayyeh, MD, MPH
Mayo Clinic, Rochester, MN

Introduction: Endoscopic advancements in stenting and tissue plication have proven to be viable alternatives to surgical management of esophageal perforations and are increasingly being used in clinical practice. We aim to assess the efficacy and outcome of different endoscopic treatment modalities in patients with esophageal perforations.

Methods: We performed a retrospective analysis of patients with esophageal perforations from an endoscopic database since 2007. Patients with esophageal fistula, stricture, or stenosis were excluded. Patients were categorized into four treatment groups: primary closure (endoscopic suturing), primary bypass (stenting), combination (suturing defect and stenting), and conservative therapy (NPO, trans-nasal feeding tubes). Baseline demographics, patient characteristics, and treatment modality outcomes were collected. Predictors of success were identified using logistic regression.

Results: 95 patients (mean age 64 ±15, 67% male) with esophageal perforations were included. The most common etiology was iatrogenic after dilatations or endoscopic myotomy (40%). 64% of perforations were in the distal esophagus. Regardless of strategy employed, 49% of patients had successful endoscopic repair of perforation. Only 7 patients required subsequent operative intervention. The combination approach achieved the greatest clinical success (66%), defined as no need for surgical intervention, when compared to the other modalities (primary bypass 35%, closure 57%, and conservative 25%, p=0.05). Patients with concomitant systemic inflammatory response syndrome had greater clinical success if they were treated with combination approach compared to primary bypass approach (18% vs. 64%, p=0.01). If the perforation was greater than or equal to 20mm, combination therapy had greater clinical success compared to primary bypass approach (0% vs. 50%, p=0.04). Early stent migration was associated with greater need for rescue surgery (p=0.02).

Discussion: Esophageal perforations can be managed effectively with endoscopic therapy. Larger, prospective trials are needed to clarify ideal individualized endoscopic strategies. Patients with systemic inflammatory response and/or perforation ≥20 mm are managed most effectively with combination therapy.

Variables (%)	All (n=95)	Primary bypass (n=43)	Primary closure (n=12)	Combination (n=29)	Conservative (n=11)
Demographics
	All	Primary bypass (n=43)	Primary closure (n=12)	Combination (n=29)	Conservative (n=11)	p-value
Age (± SD)	63 ±14	66 ±13	61 ±13	61 ±15	64 ±15	0.23
Sex (Male)	64(67)	16(70)	10 (83)	19(65)	7(63)	0.61
History of EC	14 (16)	6(26)	1(8.3)	3(10)	2(18)	0.31
History of Radiotherapy	15 (19)	6(26)	0(0)	4(14)	2(18)	0.245
Diabetes	14(15)	2(9)	7 (43)	3(10)	2(18)	0.686
Hypertension	48(51)	12(52)	7(58)	13(45)	5(46)	0.927
Sleep apnea	16(17)	5(22)	2(17)	5(17)	0(0)	0.45
Site of Perforation
Proximal		4(9.3)	0	2(6.9)	6(54.5)
Middle		7(6.3)	3(25.0)	7(24.1)	0
Distal		29 (67.4)	8(66.7)	20(69.0)	5(45.5)
Etiology of perforation
Spontaneous Iatrogenic Food impaction Anastomotic leak Esophageal cancer Boerhaave syndrome		7(16.3) 22(51.2) 2(4.7) 4(9.3) 2(4.7) 6(14.0)	1(8.3) 9(75.0) 1(8.3) 0 0 1(8.3)	0 21(72.4) 2(6.9) 3(10.3) 0 1(3.4)	2 (18.2) 7(63.6) 1(9.1) 0 0 1(9.1)
Symptoms at time of diagnosis
Dysphagia Chest pain Abdominal pain Fever Other		10(23.3) 11(25.6) 1(2.3) 4(9.3) 10(23.3)	1(8.3) 4(33.3) 0 1(8.3) 2(16.7)	4(13.8) 4(13.8) 1(3.4) 5(17.2) 8(27.6)	4(36.4) 1(9.1) 1(9.1) 0 2(18.2)
Outcomes by Treatment Group
Pittsburgh Perforation Severity Score (n=47)	3.17 ±2.1	3.59 ±2.2	2.5±2.0	2.72±1.8	3.45±2.25	0.225
Operative intervention required	7(5.7)	2(4.7)	1(8.3)	3(10.3)	1(9.1)	0.95
Mortality	9(7.4)	4(9.3)	0	3(10.3)	2(18.2)	0.652
SIRS	44(36.1)	19(44.2)	4(33.3)	16 (55.2)	5(45.5)	0.635
Stent migration	11	10(23.3)	0	2(6.9)	0	0.182
LOS* (days)	16±15	19 ±15	11±10	18±19	7.9±7.0	0.123
LOF* (months)	4.6±4.1	4.25±1.5	6±8.8	3.5±2.1	9.3±6.4	0.07

Table: Demographics, Presentation and Outcomes by Treatment Group (*LOS – Length Of Stay In The Hospital; LOF - Time From Diagnosis To Last-Follow Up; SIRS - Systemic Inflammatory Response Syndrome)

Disclosures:

Farah Abdul Razzak indicated no relevant financial relationships.

Khushboo Gala indicated no relevant financial relationships.

Reem Matar indicated no relevant financial relationships.

Babusai Rapaka indicated no relevant financial relationships.

Donna Maria Abboud indicated no relevant financial relationships.

Rebecca Yao indicated no relevant financial relationships.

Daniel Maselli indicated no relevant financial relationships.

Veeravich Jaruvongvanich indicated no relevant financial relationships.

Eric Vargas indicated no relevant financial relationships.

Andrew Storm: Apollo Endosurgery – Consultant. Apollo Endosurgery – Grant/Research Support. Boston Scientific – Grant/Research Support. Endo-TAGSS – Grant/Research Support. Enterasense – Consultant. ERBE – Consultant. GI Dynamics – Consultant. Olympus – Consultant.

Barham Abu Dayyeh: Apollo Endosurgery – Grant/Research Support. Aspire Bariatrics – Grant/Research Support. BFKW – Consultant. Boston Scientific – Consultant, Grant/Research Support. Cairn Diagnostics – Grant/Research Support. DyaMx – Consultant. Endogastric Solutions, – Speakers Bureau. Endo-TAGSS – Consultant. GI Dynamics – Grant/Research Support. Johnson and Johnson – Speakers Bureau. Medtronic; – Grant/Research Support. Metamodix – Consultant. Olympus – Speakers Bureau. Spatz Medical – Grant/Research Support. USGI Medical – Consultant, Grant/Research Support.

Farah Abdul Razzak, MD, Khushboo S. Gala, MD, Reem Matar, BSc, Babusai Rapaka, MD, Donna Maria Abboud, MD, Rebecca Yao, MD, MPH, Daniel Maselli, MD, Veeravich Jaruvongvanich, MD, Eric J. Vargas, MD, MS, Andrew C. Storm, MD, Barham Abu Dayyeh, MD, MPH. C0446 - Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.