Stents better than surgery for esophagus tears?

Key clinical point: Esophageal stent placement for the treatment of an acute esophageal tear seems to be as effective as surgery in propensity-matched patients.

Major finding: Morbidity scores were 43% for patients who had surgical repair vs. 17% for those who underwent stent placement for esophageal tear.

Data source: Retrospective analysis of 60 propensity-matched patients over a 4-year period at a single health system’s hospitals, as drawn from the Premiere national database.

Disclosures: The authors reported having no financial disclosures.

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Shorter stays, lower costs

“This paper addresses an important question for thoracic surgeons and the findings are promising,” Dr. Katie S. Nason of the University of Pittsburgh said in her invited commentary (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.02.028]). She also commended the study authors for using propensity matching to create comparable groups.

Dr. Katie S. Nason

However, the study did not address several patient factors that can influence a surgeon’s selection of an operation or stent placement, Dr. Nason said: injury size and location, other esophageal disorders patients might have, and the degree of contamination around the operative site. “It is premature to definitively interpret the higher rate of mortality, morbidity, cost, and length of stay with surgery as a direct result of treatment choice, when unmeasured differences in the patient’s perforation-associated condition are not accounted for in propensity-matching or outcomes analysis,” she said.

Nonetheless, she called the data “compelling” and that examination of other studies was warranted. Dr. Nason cited four other reports that arrived at similar conclusions (Ann. Surg. 2014;259:852-60; World J. Surg. 2013;37:1051-9; J. Am. Coll. Surg. 2014;218:768-74; World J. Surg. 2014;38:902-9). “Taken together with these prior studies, the data for management of iatrogenic perforation increasingly favor early intervention with esophageal stenting,” Dr. Nason said.

Dr. Nason is an assistant professor of cardiothoracic surgery at the University of Pittsburgh.




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.

Stent placement is safe and effective. Courtesy of AATS
Stent placement is safe and effective.

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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