Severity-guided management of esophageal perforation: a retrospective cohort study supporting a pragmatic treatment algorithm.

backgroundEsophageal perforation is a rare but life-threatening condition associated with high morbidity and mortality. Optimal management remains controversial, particularly regarding the indications for conservative, endoscopic, and surgical strategies.

methodsWe conducted a retrospective single-center cohort study including adult patients treated for esophageal perforation between January 2018 and November 2023. Patients were categorized into conservative management (CM) or surgical management (SM). Clinical presentation, etiology, treatment modalities, complications, and mortality were analyzed. A subgroup analysis compared esophageal preservation with esophagectomy within the surgical group.

resultsFifty-eight patients were included (CM: n = 30; SM: n = 28). Patients in the SM group presented with significantly greater severity, including higher rates of mediastinitis (96.4% vs. 40%, p < 0.001), tachycardia (82.1% vs. 33.3%, p < 0.001), and vasopressor requirement (71.4% vs. 13.3%, p < 0.001). Severe complications were more frequent in the SM group (100% vs. 46.6%, p < 0.001), as was prolonged hospitalization (82.1% vs. 36.7%, p < 0.001). In-hospital mortality was similar between groups (21.4% vs. 20%, p = 0.89). Among surgically treated patients, esophagectomy was associated with higher mortality than esophageal preservation (50% vs. 10%, p = 0.02), likely reflecting greater baseline severity.

conclusionsManagement of esophageal perforation is primarily driven by initial clinical severity and the extent of contamination. Stable patients may be successfully managed with conservative or endoscopic approaches, whereas surgery is required in unstable patients or in the presence of extensive contamination. When surgery is indicated, esophageal preservation should be preferred whenever feasible.