Sdralis E Ilias K, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A
Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK.
Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece.
Dis Esophagus. 2017 Aug 1;30(8):1-6. doi: 10.1093/dote/dox013.
We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.
我们对食管穿孔的流行病学、诊断及治疗结果进行了一项系统评价。在PubMed数据库中使用关键词“食管穿孔”进行了系统评价。对所有关于急性食管穿孔的研究进行了综述，并纳入了2005年至2015年发表在文献中的流行病学、诊断及管理参数。排除术后食管漏的研究。两名研究人员分别进行研究，同时根据GRADE分类进行质量评估。主要结局和暴露因素包括总死亡率、穿孔至入院间隔、解剖位置、病因、入院时的常见症状、使用的诊断检查、初始治疗类型（保守或手术）、愈合率及瘘管并发症。共检索到1319篇文章，其中52项研究（包括2830例病例）最终符合纳入标准。研究期的平均时长为15.2年。患者的平均年龄为58.4岁。在纳入的52项研究中，有43项研究质量极低或较低。根据提取的数据，总死亡率为13.3%（n = 214，1644例患者，39项研究）。58.1%的患者（n = 514）报告在24小时内入院。72.6%的患者穿孔位置在胸部（n = 813，1120例患者，20项研究）。穿孔的平均病因在46.5%的患者中为医源性（n = 899，1933例患者，40项研究）。51.3%的病例初始治疗为保守治疗（n = 904，1762例患者，41项研究）。在将CT用作影像诊断程序的总体病例中，38.7%的病例经CT确诊（n = 266），36.6%经X线确诊（n = 231），37.4%经内镜确诊（n = 343）。23.3%的病例入院时出现脓毒症（898例患者中的209例，16项研究）。本系统评价强调了很大一部分病例诊断延迟超过24小时，死亡率超过10%，且在最佳治疗方法和最佳诊断管理方面没有共识。由于食管穿孔是一种高危临床情况，在最佳管理方面没有共识，因此应该开展大型多中心前瞻性研究或随机对照试验（RCT），以推进对这种具有挑战性病理情况的诊断和治疗方法。
