title: Predictors for failure of stent treatment for benign esophageal perforations - a single center 10-year experience.
abstract: OBJECTIVE
  To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).
  
  
  METHODS
  All patients between 2003-2013 treated for EPR at the Karolinska University Hospital, a tertiary referral center, were studied with regard to initial management with SEMS. Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded. Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible. Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis, which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis. Patient and lesion characteristics were analyzed and are presented as median and interquartile range. Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression, while variables with P < 0.2 were further analyzed with multi-variate logistic regression.
  
  
  RESULTS
  Of the total number of 48 patients presenting with EPR, 40 patients (83.3%) were treated with SEMS at the time of admission, with an intention to heal the perforation. Twenty-three patients had Boerhaave's syndrome (58%), 16 had an iatrogenic perforation (40%) and 1 had external trauma to the esophagus (3%). The total in-hospital mortality, including the cases that had other initial treatments (n = 8), was 10.4% and 7.5% among those who were subjected to the SEMS-based strategy. In 33 of the 40 patients (82.5%) who were treated with stent, the EPR healed without further change in treatment strategy. Patients classified as treatment success received a SEMS at a median time of 1 (1-1) d after the actual EPR, compared to 3 (1-10) d among those where the initial treatment failed, P = 0.039 in uni-variate analysis and P = 0.052 in multi-variate analysis. No other significant factors emerged, indicating an increased risk for failure. Six of 7 patients, where stent treatment of the defect failed, underwent an emergency esophagectomy with end esophagostomy and one patient died.
  
  
  CONCLUSIONS
  SEMS as an upfront therapeutic strategy seems to be a successful concept, when applied to an unselected group of patients with EPR.
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Saga
authors.initials: S
authors.lastname: Persson
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Elbe
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Rouvelas
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Mats
authors.initials: M
authors.lastname: Lindblad
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Koshi
authors.initials: K
authors.lastname: Kumagai
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: Nilsson
authors.affiliation: Saga Persson, Peter Elbe, Ioannis Rouvelas, Mats Lindblad, Koshi Kumagai, Lars Lundell, Magnus Nilsson, Jon A Tsai, Division of Surgery, Karolinska Institutet and GastroCentrum, Department of Clinical Sciences, Intervention and Technology, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
authors.forename: Jon A
authors.initials: JA
authors.lastname: Tsai
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D016629:Esophagectomy; D004946:Esophagostomy; D005260:Female; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D016015:Logistic Models; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D008670:Metals; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012307:Risk Factors; D015607:Stents; D013548:Sweden; D062606:Tertiary Care Centers; D013997:Time Factors; D017211:Treatment Failure; D055815:Young Adult
chemical_list: D008670:Metals
keywords: Esophageal perforation; Esophagectomy; Mediastinitis; Morbidity; Mortality; Stents