Management and Outcomes of Esophageal Perforation: A National Study of 2,564 Patients in England

OBJECTIVES: Traditionally esophageal perforation is a rare clinical emergency that confers a high rate of mortality and major morbidity. The objective of this study was to establish the annual rate and mortality from esophageal perforation and determine the effect of hospital volume on clinical outcomes. METHODS: Hospital Episode Statistics database was used for the identification of patients admitted to hospitals within England with esophageal perforation between 2001 and 2012. The influence of hospital volume and treatment approach upon clinical outcomes was analyzed using multivariable analysis to control for patient age and medical comorbidities that may influence outcome. RESULTS: Over the 12-year study period 2,564 patients with esophageal perforation were treated at 158 hospitals. The 30- and 90-day mortality rates were 30.0 and 38.8%, respectively. Esophageal perforation etiology was spontaneous in 81.9% and iatrogenic in 5.9% of cases. There was a significant increase in the percentage of patients managed supportively and a reduction in surgical management over time. Furthermore there were significant reductions in 30-day (36.6% to 24.9%; P < 0.001) and 90-day mortality (44.1% to 35.4%; P = 0.006) over the 12-year study period. Important patient demographics associated with 30-and 90-day mortality included age = 70 years, preoperative congestive cardiac failure, ischemic heart, liver, and renal disease. High hospital volume was associated with significant reductions in 30-(odds ratio (OR)= 0.68; P = 0.001) and 90-day mortality (OR= 0.69; P = 0.001). In a subset analysis of patients undergoing endoscopic intervention, hospital volume was identified as an important factor associated with mortality. CONCLUSIONS: This study provides evidence for the centralization of management of esophageal perforation to high volume centers with appropriate multi-disciplinary infrastructure to treat these complex patients.