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atrogenic esophageal perforation accounts for 60% of esophageal perforations and associated with 19% of mortality, while spontaneous perforations are less common.
Endoscopic procedures are the most common cause of iatrogenic esophageal perforation. The esophageal perforation rate is 1 to 5% in dilatation for achalasia, 1 to 6% for variceal sclerotherapy, 5% of endoscopic laser therapy, and 5 to 25% in esophageal stent placement.
Early aggressive management within the first 24 hours after diagnosis of esophageal perforation is crucial for excellent outcomes. Mortality in patients with delayed diagnosis and management (>24 hours) is 40%, which is higher compared to 6.2% in patients who received optimal management within 24 hours.
Surgical management such as primary repair, esophageal exclusion, diversion, and esophagectomy is warranted in the patients who not meet the criteria for non-operative management. The successful rate of reinforced primary repair is 89% with low mortality rate (14%).
Endoscopic management (esophageal stent) is an alternative treatment option with 80 to 90% of esophageal healing rate. The successful leak occlusion reported rates by stent placement are between 83 and 94% and the migration rates are 10 to 18%.
The present study was planned to compare efficacy of different management modalities and their indications in patients with iatrogenic esophageal perforations.
Selected papers for the present meta-analysis included those that provided data from 2007 to 2021 on factors related to patients of any age with iatrogenic esophageal perforation to discuss comparison between different management modalities of iatrogenic esophageal perforations.
We made pairwise meta-analyses of our outcomes using Comprehensive Meta-Analysis software (CMA version 3.9). Event rate with the corresponding 95% confidence intervals (95%CI) was also being calculated for categorical data.
The different management modalities addressed in relevant meta-analysis were conservative, endoscopic (stent or clipping) and surgical management.
We compared the outcome of the three management modalities according to the mortality rate, leak after initial repair, failure rate, dysphagia, oral intake (mean days) and total length of stay (mean days of stay).
In our review we concluded that the best management modality of iatrogenic esophageal perforation is determined by the patient’s criteria, location and time interval between perforation and diagnosis.
Our study showed that patients treated with conservative measure had the least significant mortality rate in iatrogenic esophageal perforation treatment than others with 6% mortality rate.
Related studies concluded that patient treated conservatively with broad-spectrum antibiotics and nothing by mouth the clinical course was further complicated by a pleural effusion, which required a drain in 38% and 6% died. In another review, the mortality rate after conservative therapy was reported to range between 0% and 33%.
Surgical management is warranted in the patients who not meet the criteria for non-operative management and present within 24 hours after perforation with successful rate of more than 80% but high dysphagia rate (68%) and prolonged hospital stay (42.5 days) become unavoidable.
Endoscopic management (esophageal stent) is an alternative treatment option, with 50 to 83% of esophageal healing and rates of mortality (16.8%), leak (32.8%) and failure (50%) but with lowest dysphagia rate (22%), shortest mean oral intake (3days) and hospital length of stay (9.989 days). Related one study of this issue reported leak rate of 50% and 80% associated with Initial surgical treatment and stenting respectively.
atrogenic perforation, the most common cause of esophageal perforation continues to be a serious disorder with significant morbidity and mortality. Our data show that both non-operative treatment, performed predominantly with stent implantation, and surgical treatment have a satisfactory outcome. The treatment method still has to be chosen on an individual basis. We recommend conservative treatment when the perforation is localized and does not cause severe general subsequent disorders. Extended perforations with spread of air and fluids to the mediastinum and subsequent development of systemic life-threatening disorders should be treated with a surgical approach. The best results can be obtained when the esophagus perforation was diagnosed and treated early.
We recommend the followings:
• To avoid a treatment delay, a high index of suspicion is necessary, especially when clinical signs appear after endoscopic instrumentation.
• To select treatment method on an individual basis.
• To use conservative treatment when the perforation is localized and does not cause severe general subsequent disorders.
• To implement surgical approach in extended perforations with systemic life-threatening conditions.
• Endoscopic management is an alternative treatment option in early perforations with small size of the defect and absence of clinical instability.