College of Medical and Dental Sciences, University of Birmingham, Birmingham,UK.
Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Dis Esophagus. 2019 Feb 1;32(2). doi: 10.1093/dote/doy109.
Esophageal perforation is an uncommon and challenging surgical emergency associated with high rates of morbidity and mortality. At present, no consensus exists on optimal management of the condition. The Pittsburgh Severity Score (PSS) is a tool intended to stratify perforation severity and guide treatment. However, there is a paucity of literature examining the validity of the score or its application in a UK population. This study aims to validate the PSS and explore its use in stratifying patients with esophageal perforation into distinct subgroups with differential outcomes in an independent UK study population.All patients treated for esophageal perforation at Queen Elizabeth Hospital, Birmingham between September 2003 and October 2017 were included in this study. Cases were identified using a combination of ICD-10 and OPCS informatics search codes and prospective case collection. Data relating to the clinical presentation, diagnosis, management, and outcome of cases were recorded using a preformed data collection form. PSS predictive performance was assessed against five outcomes: rates of post-perforation and post-operative complications, in-hospital mortality, length of intensive care (ICU/HDU) stay, and total length of hospital stay.A total of 87 cases were identified, consisting of 48 (55%) iatrogenic perforations, 24 (28%) cases of spontaneous (Boerhaave's) perforation, and 15 perforations due to other etiologies (17%). Operative management was favored in this series, with 47% of all perforations being treated surgically. Overall in-hospital mortality was 13%, coupled with a median length of hospital stay of 24 days (interquartile range [IQR]: 12-49), of which a median of 2 days was spent in intensive care facilities (IQR: 0-14). A total of 46% of patients developed post-perforation complications, with 59% of the operatively managed cohort developing complications post-operatively.The PSS was not found to be significantly predictive of post-perforation complications (area under the ROC curve [AUROC]: 0.62, p = 0.053) or in-hospital mortality (AUROC: 0.69, p = 0.057) for the cohort as a whole. However, a subgroup analysis found the accuracy of the PSS to vary considerably by etiology, being significantly predictive of post-perforation complications within the subgroup of Boerhaave's perforations (AUROC: 0.86, p = 0.004).In conclusion, we found that the PSS has some utility in stratifying esophageal perforation severity and predicting specific patient outcomes. However, it appears to be of more value when applied to the subgroup of patients with Boerhaave's perforations.
食管穿孔是一种罕见且具有挑战性的外科急症，其发病率和死亡率都很高。目前，对于这种疾病的最佳治疗方法尚无共识。匹兹堡严重程度评分（PSS）是一种旨在对穿孔严重程度进行分层并指导治疗的工具。然而，目前很少有文献研究该评分的有效性或其在英国人群中的应用。本研究旨在验证 PSS，并在英国独立研究人群中，将其应用于将食管穿孔患者分为不同亚组，以预测不同的结果。
所有在伯明翰伊丽莎白女王医院接受食管穿孔治疗的患者均纳入本研究。通过 ICD-10 和 OPCS 信息学搜索代码的组合以及前瞻性病例收集来确定病例。使用预先制定的数据收集表记录与病例临床表现、诊断、治疗和结局相关的数据。使用五个结局评估 PSS 的预测性能：穿孔后和手术后并发症发生率、院内死亡率、重症监护（ICU/HDU）停留时间和总住院时间。
本研究共纳入 87 例患者，其中 48 例（55%）为医源性穿孔，24 例（28%）为自发性（Boerhaave's）穿孔，15 例为其他病因（17%）。本系列中更倾向于手术治疗，所有穿孔中有 47%采用手术治疗。总体院内死亡率为 13%，中位住院时间为 24 天（四分位距[IQR]：12-49），其中中位 2 天在重症监护病房（IQR：0-14）。共有 46%的患者出现穿孔后并发症，手术治疗组中有 59%的患者术后出现并发症。
PSS 并未显著预测整个队列的穿孔后并发症（ROC 曲线下面积[AUROC]：0.62，p=0.053）或院内死亡率（AUROC：0.69，p=0.057）。然而，亚组分析发现，PSS 的准确性因病因而异，在 Boerhaave's 穿孔亚组中，PSS 对穿孔后并发症的预测具有显著意义（AUROC：0.86，p=0.004）。
总之，我们发现 PSS 在对食管穿孔严重程度进行分层和预测特定患者结局方面具有一定的作用。然而，当应用于 Boerhaave's 穿孔患者亚组时，其似乎更有价值。
