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Background: Oesophageal rupture (OR) and perforation (OP) are serious injuries with high morbidity and mortality. While OR from barotrauma can lead to extensive soiling of the mediastinum with gastric content, OP is frequently an iatrogenic occurrence in a starved patient, which may facilitate early identification of the injury and less mediastinal soiling. The traditional management has been open surgical repair with wide drainage ± debridement. Self expanding metal stents (SEMS) can complement or replace usual surgical management of these injuries, but their best use is still being defined. The aim of this study was to compare the management and outcomes of OR and OP and to examine whether there have been changes in management of these injuries, such as in use of SEMS. Method: In this retrospective cohort study, patients with full-thickness OR or OP admitted to Auckland City Hospital between January 2004 and December 2013 were identified by searching electronic hospital databases. Mucosal or submucosal injuries to the oesophagus, and post-operative leaks, were excludedy. OR were compared to OP, and two time periods were compared (admissions from 2004-2008 versus 2009-2013) for differences in the management of the leak (source control with endoscopy or surgery) and drainage ± debridement (radiological or surgical) of mediastinum and pleural cavity(s). Outcome measures were length of hospital stay, length of ICU/HDU stay, and mortality during admission or within 30 days from discharge. Results: There were 22 OR and 11 OP over the time period. There were no differences in source control between these cohorts, but more drainage procedures were required for OR than OP (17/22 vs. 4/11, p=0.02), with the majority requiring surgical drainage. In the OR cohort, there was a longer length of hospital stay (median 23 days, range 1-659 vs. 8, 1-59, p=0.007) and ICU/HDU stay (4 days, 0-659 vs. 0, 0-10, p=0.01), but no difference in mortality (4/22 vs. 3/11, p=0.66). There were 19 patients admitted from 2004-2008 and 14 from 2009-2013. There was a trend towards using SEMS for source control over time (3/19 vs. 7/14, p=0.06), but no differences in drainage interventions, length of stay or mortality between the two time periods. Conclusions: OR and OP are different oesophageal injuries, with different management and outcomes. At Auckland Hospital OR required more drainage procedures than OP, and spent longer in intensive care and hospital. There is a trend towards using endoscopic stenting for source control. |
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