title: Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system.
abstract: OBJECTIVE
  The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population.
  
  
  METHODS
  In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups.
  
  
  RESULTS
  Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS.
  
  
  CONCLUSIONS
  The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.
authors.affiliation: Department of General and Thoracic Surgery, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Germany. Electronic address: Schweigert-Mi@khdf.de.
authors.forename: Michael
authors.initials: M
authors.lastname: Schweigert
authors.affiliation: Hospital São João, Porto, Portugal.
authors.forename: Hugo Santos
authors.initials: HS
authors.lastname: Sousa
authors.affiliation: Szent István University, Budapest, Hungary.
authors.forename: Norbert
authors.initials: N
authors.lastname: Solymosi
authors.affiliation: University Hospital St George, Medical University of Plovdiv, Plovdiv, Bulgaria.
authors.forename: Aleksandar
authors.initials: A
authors.lastname: Yankulov
authors.affiliation: Hospital Universitario de la Princesa, Madrid, Spain.
authors.forename: Marta Jiménez
authors.initials: MJ
authors.lastname: Fernández
authors.affiliation: Royal Victoria Hospital, Belfast, United Kingdom.
authors.forename: Rory
authors.initials: R
authors.lastname: Beattie
authors.affiliation: Klinikum Nuremberg, Nuremberg, Germany.
authors.forename: Attila
authors.initials: A
authors.lastname: Dubecz
authors.affiliation: Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Rabl
authors.affiliation: The University of Hong Kong, Hong Kong, Hong Kong.
authors.forename: Simon
authors.initials: S
authors.lastname: Law
authors.affiliation: St Sophia University Hospital for Pulmonary Diseases, Medical University, Sofia, Bulgaria.
authors.forename: Daniel
authors.initials: D
authors.lastname: Tong
authors.affiliation: Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany.
authors.forename: Danail
authors.initials: D
authors.lastname: Petrov
authors.affiliation: Department of General and Thoracic Surgery, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Germany.
authors.forename: Annemaria
authors.initials: A
authors.lastname: Schäbitz
authors.affiliation: Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria.
authors.forename: Rudolf J
authors.initials: RJ
authors.lastname: Stadlhuber
authors.affiliation: Klinikum Neumarkt, Neumarkt in der Oberpfalz, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Gumpp
authors.affiliation: Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Ofner
authors.affiliation: Royal Victoria Hospital, Belfast, United Kingdom.
authors.forename: Jim
authors.initials: J
authors.lastname: McGuigan
authors.affiliation: Hospital São João, Porto, Portugal.
authors.forename: José
authors.initials: J
authors.lastname: Costa-Maia
authors.affiliation: Department of General and Thoracic Surgery, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Witzigmann
authors.affiliation: Klinikum Nuremberg, Nuremberg, Germany.
authors.forename: Hubert J
authors.initials: HJ
authors.lastname: Stein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D003661:Decision Support Techniques; D003663:Decision Trees; D004939:Esophageal Perforation / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D005060:Europe; D005260:Female; D006723:Hong Kong; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: esophageal perforation; esophagus; foregut surgery; sepsis