Current referral patterns and pitfalls pertaining to the treatment of esophageal perforation

Introduction

Background

Esophageal perforation is considered one of the most feared and morbid pathologies in the spectrum of hollow viscus injuries. Esophageal anatomy places both the thoracic and abdominal cavities at risk when esophageal perforation occurs leading to its high-risk nature and challenging treatment. In the current era, the reported morbidity and mortality for patients presenting with this pathology ranges up to 70% and 40%, respectively (1,2). Timely diagnosis and treatment initiation within 24 hours of diagnosis are paramount in achieving source control and minimizing mortality (1). With medical advancements, the treatment paradigm has shifted to medical management and/or more frequently the use of minimally invasive procedures (3). However, this treatment paradigm shift has come at the expense of transitioning the care for esophageal perforations to specialized tertiary centers with specialized clinicians. With this shift, delay in treatment occurs which is detrimental for patients and may lead to worst outcomes.

Rationale and knowledge gap

Data regarding the rate and timing of hospital transfers to specialized centers for suspected esophageal perforation is limited. Prior data from our tertiary care center demonstrated that from 2001 to 2019, 79% of the 27 patients with radiographic evidence of primary spontaneous pneumomediastinum alone were transferred to our hospital due to concern for esophageal perforation (4). Treatment for this group ranged from hospital admission for observation, antibiotic administration, or discharge home. No patients required operative intervention.

Over the past few decades, we have observed a shift in the treatment options and referral patterns for all-comers suspected of esophageal perforation, not just those with primary spontaneous pneumomediastinum. Etiologies of the suspected esophageal perforations ranged from esophageal neoplasms, foreign bodies, iatrogenic, Boerhaave syndrome, and pneumomediastinum. There is a spectrum of treatment options for these various conditions at our tertiary care center. Non-operative management may include a combination of the following: admission for observation, provocative imaging, oral diet challenge, intravenous hydration, intravenous antibiotics, oral intake restriction, and/or enteric delivered tube feeds. Operative management encompasses these options as well as endoscopic treatments (e.g., stenting), video assisted thoracoscopic interventions, or thoracotomies. When patients present with suspected esophageal perforation, inter-hospital transfer requests may be placed for further evaluation or management. The details of these inter-hospital transfers and whether operative management is pursued for suspected esophageal perforations are understudied.

Objective

We sought to determine the referral patterns and if operative management was pursued for all forms of suspected esophageal perforation to a tertiary care center, including the length of time to treatment and geographic distance of the referral.

Methods

Using the University of Wisconsin Hospital and Clinics institutional administrative databases that capture diagnosis codes both for inter-hospital referral center requests and hospital encounters, records were queried from October 1, 2015 to December 31, 2023. The specific diagnosis codes included were ICD-10 (International Classification of Diseases 10^th Revision) codes for esophageal perforation (K22.3), pneumomediastinum (P25.2), unspecified injury of esophagus (thoracic part) (S27.819A). Current procedural terminology (CPT) codes for repair procedures of the esophagus (43300–43425) were queried as well. Encounters were limited to emergency, inpatient, observation, and outpatient short stay subtypes and only initial encounters were requested. The query yielded 472 individual records. Each record was adjudicated and duplicated records were deleted yielding 455 individual records for review. Data variables included details regarding the inter-hospital referral request type, the date, timing, and location of the inter-hospital request, and information regarding outcomes of each request (Table S1).

All data were stored within a Microsoft Office Excel file. All analyses and graphs were created using Microsoft Office Excel. The normality of the continuous variables (hospital length of stay) was assessed using a Shapiro-Wilk test and determined to be skewed therefore data were reported as medians. Mann-Whitney U test was performed to compare medians between groups. Randymajors.org Research Hub LLC (randymajors.org/zipcodegmap) an open source website was used to construct the geographic region corresponding to the inter-hospital referral center requests using postal zip codes. We then used publicly available data (https://www.dhs.wisconsin.gov/trauma/index.htm) to map the locations of verified Level I–III trauma centers in the state of Wisconsin to compare their geographic catchment area with the respective inter-hospital referral center requests. Verified Level I–III trauma centers were chosen as a surrogate for a center’s ability to possess healthcare providers and resources to triage and stabilize patients with acute pathology such as esophageal perforation.

Results

There were 455 records for 419 unique patients. Of the 455 records, 381 records resulted in completed hospital transfers/admissions with 17 records being limited to inter-hospital case discussions and 57 records were canceled inter-hospital transfers. Reasons for cancellation included limited hospital bed availability at University of Wisconsin Hospital and Clinics, medical necessity criteria not met, and/or referring healthcare provider opted to treat the patient at their own facility. The 381 records that were completed hospital transfers/admissions included 357 individual patients. Non-operative treatment was performed for 237 records in 223 patients (62%) with operative interventions occurring for 144 records in 134 patients.

For the patients who were admitted to the University of Wisconsin Hospital and Clinics, most patients were admitted the same day as the inter-hospital request (Table 1). For the group treated with operative management (n=134), 32% of patients underwent their operation on the same day as the inter-hospital request, 26% underwent their operation the day after inter-hospital request, and 42% underwent their operation 2 or more days after the inter-hospital request. The median length of hospital admission was lower for the non-operative versus operative treatment group at 5 versus 11 days (P<0.01). Within the non-operative group, 45 patients (20%) were discharged from the hospital within 24 hours of admission.

The geographic catchment area of the various facilities requesting referrals spanned approximately 77,500 square miles and included Wisconsin, Illinois, and Michigan (Figure 1). Figure 1 also demonstrates that there is a fair amount of overlap between the esophageal perforation referral catchment area and the catchment area for both Level I–III trauma centers and Level I–II trauma centers. Within the Wisconsin Trauma Care System, 13 (10%) of the 127 participating hospitals are Level I or II trauma centers (i.e., they include 24-hour immediate coverage by general surgeons) and 26 additional hospitals are Level III trauma centers (i.e., they have prompt availability of general surgeons and are capable of resuscitating and stabilizing critically ill patients).

Figure 1 Geographic display of the referral and trauma center catchment areas. The left figure displays the geographic area corresponding to all hospitals (smaller blue insets refer to the postal zip codes) who referred patients with suspected esophageal perforation; the blue pin represents the location of our tertiary care center. The right top and bottom figures represent the overlapping areas that encompass trauma centers which may have similar expertise and resources to treat esophageal perforations. These images were created using Randymajors.org Research Hub LLC (randymajors.org/zipcodegmap).

The temporal pattern of inter-hospital transfers from 2016 to 2023 (records from the year 2015 were not included since data for the complete year was unknown) demonstrates consistency in the number and percentage of completed transfers (Figure 2). Similarly, the individual temporal patterns for both non-operative and operative treatment groups remain fairly constant over this time span. Notably, the number and percentage of canceled transfers steadily increases from 2020 to present.

Figure 2 The temporal patterns of transfers for esophageal perforation.

Discussion

Non-operative management

The majority of patients who present with a concern for esophageal perforation and are transferred to a tertiary care center were treated with non-operative management, which mirrors previously published series (1,3). These data challenge us to critically consider the clinical context for transfer and the future possibility of continuing non-operative treatment locally. Approximately 20% of our non-operative group were discharged home within 24 hours of admission suggesting that non-operative management (e.g., admission for oral diet challenge with or without repeat imaging) may be accomplished at local hospitals. This is especially important when considering the increasing number of canceled transfers to academic centers due to limited bed availability. The opportunity of local non-operative treatment versus referral for non-operative treatment for a patient presenting with concern of esophageal perforation may save tertiary center resources and bed availability for more critically-ill patients. Specific scenarios that may be conducive to this paradigm include spontaneous pneumomediastinum in patients without hemodynamic instability and no history of forceful emesis, fever, or pleural effusion (4). Furthermore, the increasing utilization of computed tomography “esophagrams” (e.g., computed tomography performed by radiology technologists with oral contrast swallowed immediately prior to performance to capture proximal esophageal images) at critical access hospitals no longer requires ‘in house’ clinical radiologists for performance and interpretation like the traditional radiographic esophagrams and can serve to exclude esophageal perforations in low-risk patients (4).

Distance and delay of transfer

Despite recognizing that outcomes after esophageal perforation are improved when treatment is initiated within the first 24 hours of diagnosis, delay of treatment related to patient transport and/or hospital bed availability remains prevalent. For our single academic institution, transport alone may take several hours due to the geographic area included. Furthermore, the delay from the referral request to arrival at our institution [especially in the setting of the post-coronavirus disease (post-COVID) inter-hospital transfer wait list] may be considerable. We must also factor in the additional time that the referral request process consumes. In our experience, initial treatment may be postponed when the inter-hospital request is pending but ultimately canceled (i.e., hospital capacity does not permit) that may delay the patient from receiving timely care at the local hospital. Even when inter-hospital referrals and transportation are successful, our data demonstrated that only 32% of patients proceeded to surgery the same day as the inter-hospital request was placed. For patients presenting with concern of esophageal perforation who warrant intervention (e.g., hemodynamic instability, pleural effusion), the primary treating physician must consider initial salvage interventions as to not delay care.

The catchment area overlap with Level I–III trauma centers suggests that there are facilities in closer proximity that have adequate expertise and resources for more timely triage of esophageal perforations including stabilization and source control intervention (Level I–III trauma centers) or more definitive management (Level I–II trauma centers that have 24-hour general surgeon coverage). This treatment shift may become more prevalent as tertiary care facilities continue to struggle with bed availability.

Surgery training and education

According to the Accreditation Council for Graduate Medical Education, surgical residents must complete at least five esophageal cases and the American Board of Surgery requires a basic understanding of esophageal pathology on both written and oral boards (https://www.absurgery.org/get-certified/general-surgery/training-requirements/essentials-of-general-surgery/). Thus, general surgeons are expected to be capable of caring for suspected esophageal perforations. This includes initial assessment, diagnostic evaluation, and interventions (e.g., chest tube insertion, esophagogastroduodenoscopy, video assisted thoracoscopy, and/or thoracotomy) if deemed appropriate. The American Board of Thoracic Surgery has even more robust procedural requirements for training and trainees will be tested on esophageal perforation in both written and oral boards (https://www.abts.org/ABTS/CertificationWebPages/Residency_Requirements.aspx). Despite these requirements, current practices for esophageal pathologies, even acute perforation, rely heavily on referring to tertiary or academic centers, even at centers where there is 24-hour general surgery coverage (e.g., Level I–II trauma centers). This inevitably causes detrimental delays in care and high resource utilization. When hospital resources and circumstances permit, it is paramount for practicing general or cardiothoracic surgeons to triage patient’s presenting with esophageal perforation prior to transfer to a referral center.

Limitations

This manuscript relied upon the use of a retrospective analysis of an administrative database over a finite period which limited our ability to compare time to treatment with clinical data or clinical outcomes. Important details such as etiology of perforation, patient clinical status, and the specific treatment received were not included. These details and their association with outcomes (e.g., survival, morbidity) for referral patients suspected of esophageal perforation warrant further research and are a focus of future work. Furthermore, we relied on surrogate data such as verified trauma centers as a means to estimate hospitals’ resources and capabilities, though this may not adequately qualify individual facility’s ability to care for esophageal perforation specifically.

Conclusions

Esophageal perforation is a challenging pathology that frequently prompts referral to a tertiary care center for evaluation and definitive treatment. Data from our single academic institution’s experience demonstrate that the majority of patients referred to our tertiary care center for suspected esophageal perforation received non-operative treatment. Furthermore, for the referral patients who receive operative treatment, only one-third undergo surgical treatment within 24 hours of referral request. The association these patterns have on clinical outcomes in unknown. Nonetheless, we must be judicious when considering inter-hospital transfers for a time sensitive pathology of esophageal perforation. The fear of this complex illness must not delay the appropriate treatment. Instead, we encourage primary non-operative treatment to be pursued at local hospitals and, for higher acuity patients, we recommend triage and prompt temporizing interventions until referral to higher-level care facilities is availability.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-13/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-13/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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