First impressions, second chances in esophageal perforations: treatment pathways and outcome prediction

Benign esophageal perforations present a significant clinical challenge due to their high morbidity and potential for fatal outcomes. The complex nature of these perforations demands prompt diagnosis and effective management to mitigate the associated risks. This study aims to evaluate the clinical outcomes of various management strategies for esophageal perforations, focusing on the effectiveness of organ-preserving approaches. We retrospectively analyzed patients diagnosed with benign esophageal perforation between January 2011 and December 2021. Patients were stratified into two groups: those who underwent resection and those who did not. Subgroup analysis was performed on patients managed initially without resection to assess the success of organ-preserving strategies (successful organ preservation, SOP) vs. either salvage resection or death (unsuccessful organ preservation, UOP). Forty-two patients were included: 22 underwent esophageal resection, while 20 were managed non-operatively. The overall 90-day mortality rate was 26%, with higher mortality observed in the resection group. In patients managed initially without resection, 62.1% had successful outcomes, while 37.9% required salvage esophagectomy or died within 90 days. The Pittsburgh Severity Score (PSS) did not significantly predict the need for resection. Distal perforations underwent resection more frequently (p <.001). Overall 90-day mortality was high both among patients who underwent initial resection (5/13, 38.5%) and salvage esophagectomy (3/8, 37.5%). Twenty-nine patients did not initially undergo resection, of which n = 18 (62.1%) were categorized as SOP and n = 11 (37.9%) as UOP. Among the latter, n = 3 (10.3%) died within 90 days and n = 8 (27.6%) underwent salvage esophagectomy. On subgroup analysis on initially unresected patients, delayed diagnosis ≥ 24 h was higher among UOP than SOP patients (n = 5, 45.5% vs. n = 2, 11.1%, p = 0.49). Our findings underscore the importance of early diagnosis and the feasibility of a step-up approach in a select group of patients presenting with favorable variables.