Outcomes of Esophageal Perforations Using the Pittsburgh Perforation Severity Score and Different Treatment Modalities. A Single Center Retrospective Analysis

Background Esophageal perforations are medical emergencies associated with high mortality and morbidity rates. The Pittsburgh perforation severity score (PPSS) was created to guide risk stratification and possibly treatment allocation. This study aims first to validate the PPSS as a risk stratification tool. The second aim is to analyze outcomes across different treatment modalities for esophageal perforation over the past 2 decades. Methods All patients treated for esophageal perforation at our institution from January 2003 until December 2022 were included. Data to calculate the PPSS (age, heart rate, leukocytosis, pleural effusion, body temperature, (non-)contained leak, respiratory impact, time to diagnosis, cancer, systolic blood pressure), the treatment strategy (conservative, endoscopic or surgical), as well as outcome parameters such as mortality, complications and length of stay (LOS), were retrospectively gathered from the electronic patient records. Comparison between era 2003–2012 and 2013–2022 was also performed. Results In 186 patients, overall mortality was 10.75%, morbidity 54.3% and median LOS 19 days. Stratification based on PPSS showed differences in mortality (p < 0.0001) morbidity (p < 0.0001) and LOS (p = 0.0069). PPSS as a continuous variable was closely related to mortality (AUC 0.75 [0.62–0.87]) and morbidity (AUC 0.69 [0.62–0.77]) but not to treatment strategies. Endoscopic treatment was more frequent (OR, 6.13 [1.71–33.61]) and conservative treatment less frequent (OR, 0.48 [0.24–0.92]) in the last decade. Surgically treated patients had higher morbidity (OR, 2.72 [1.33–5.83]) than conservatively managed patients, but mortality and LOS did not differ across treatment strategies. Conclusion The PPSS is valid to predict risk assessment and outcomes such as complications, mortality and LOS in patients treated for esophageal perforations. Over time, more patients are treated endoscopically and less conservatively. Surgically treated patients had a threefold increase in morbidity, but no differences were observed in mortality and LOS across treatment strategies.