FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

While stent placement has proved to be safe and effective for acute esophageal perforation, a head-to-head comparison with surgical repair has never been reported, so a team of investigators performed a small, single-system analysis that compared stenting and surgery and found that while both are equally effective, esophageal stent placement resulted in lower costs and lower morbidity rates.

Investigators led by Dr. Richard Freeman of St. Vincent Hospital in Indianapolis published their results in the June issue of the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [ doi:10.1016/j.jtcvs.2015.01.066 ]). Their study evaluated only 60 patients who had either stent placement or an operation for acute intrathoracic esophageal perforation between 2009 and 2012 within Ascension Health, a national Catholic-based network of 36 regional health systems; but the authors noted that they had extracted their data from the national Premier Inc. database, which covers 20% of U.S. hospital discharges, and used propensity matching to generate similar stent and surgical groups. Dr. Freeman presented the results at the annual meeting of the American Association of Thoracic Surgery in Toronto, April 28-30.

Patients who received stents had intensive care unit stays about half that of the surgery group – an average of 2 vs. 4 days. Likewise, their total hospital stays were about half: 6 days vs. 11 days for the surgery group. Complication rates were comparable: postrepair leaks were reported in 17% of the stent group and 20% who had surgery. While reoperation rates were significantly lower in the stent group (3% vs. 13%), four patients (13%) of the stent group did have stent migration. Morbidity was significantly higher in the surgery group (43% vs. 17%). While postprocedure leak rates were similar, those who had surgery were more likely to have reoperation for persistent leaks, the authors said.

Further, stent recipients were able to take nutrition by mouth earlier after surgery and had lower rates of needing enteral feeding at discharge – 17% vs. 60% for the surgery group. Dr. Freeman and his team also analyzed costs between the two procedures and found that total costs, including inpatient and outpatient costs, averaged $142,000 for surgery vs. $91,000 for stenting.

Because the incidence of esophageal perforation is so low, Dr. Freeman and his coauthors reported that performing a randomized trial comparing esophageal stenting and surgery has been difficult. The off-label nature of stenting for esophageal perforation has also complicated funding of a prospective trial. The study authors said a prospective, randomized design would have been preferable to the propensity-matched approach.

Surgery for esophageal tear has been around for almost 70 years with many improvements in technique, anesthesia, and antimicrobial therapy, but with a need for prolonged inpatient and outpatient care along with a postoperative leak rate as high as 39% ( Ann. Thorac. Surg. 2010;90:1669-73 ). “A persistent leak following operative repair may also result in the need for esophageal diversion and subsequent reconstruction with its associated significant morbidity and patient dissatisfaction,” Dr. Freeman and his coauthors said.

The authors acknowledged shortcomings of their study included not accounting for how different stents used in the stenting group and individual surgeons and facilities may have influenced outcomes. Other shortcomings were that cost calculations may not have accounted for inflation or costs outside the Ascension Health system and the uniqueness of the procedure itself. “Lastly, the fact that both treatment strategies employed for iatrogenic esophageal perforation are likely uncommon procedures at most treatment facilities implies that standardization, even at the local level, may be lacking,” the authors stated.

The authors reported having no financial disclosures.

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