Efficacy and safety of esophageal stenting for esophageal perforation: a systematic review and meta-analysis

Adnan Malika, Muhammad Imran Malikb, Sadia Javaidc, Shahbaz Qureshia, Aboud Kaliounjid, Abdul Nadira, Douglas G. Adlere

Mountain Vista Medical Center, Mesa, AZ, USA; Airedale General Hospital, West Yorkshire, England; Nishtar Hospital, Multan, Pakistan; Sunny Downstate, NY, USA; Porter Adventist Hospital Denver, CO, USA

aMountain Vista Medical Center, Mesa, AZ, USA (Adnan Malik, Shahbaz Qureshi, Abdul Nadir); bAiredale General Hospital, West Yorkshire, England (Muhammad Imran Malik); cNishtar Hospital, Multan, Pakistan (Sadia Javaid); dDepartment of Internal Medicine, Sunny Downstate, NY, USA (Aboud Kaliounji); eCenter for Advanced Therapeutic Endoscopy Centura Health, Porter Adventist Hospital Denver, CO, USA (Douglas G. Adler)

Correspondence to: Douglas G Adler, MD, Director, Center for Advanced Therapeutic Endoscopy Centura Health, Porter Adventist Hospital Denver, CO, USA, e-mail: dougraham2001@gmail.com
Received 3 June 2024; accepted 21 October 2024; published online 28 February 2025
DOI: https://doi.org/10.20524/aog.2025.0943
© 2025 Hellenic Society of Gastroenterology

Abstract

Background Esophageal perforations are managed with endoscopic stenting. However, surgical repair is still employed in many centers, if they lack endoscopic services, or for complex perforations.

Methods We searched PubMed, Scopus, and Web of Science for relevant clinical trials and observational studies. Quality assessment was evaluated according to GRADE. The studies included were assessed based on the National Heart, Lung, and Blood Institute criteria. We included the following outcomes: leak after primary repair, operative repair after endoscopic therapy, stent migration, length of hospital stay (days), and mortality. We analyzed continuous data using mean differences and 95% confidence intervals (CI), while dichotomous data were analyzed using odds ratios and 95%CI. Statistical heterogeneity was assessed using the I2 statistic.

Results Eight studies were analyzed and found to include 95 patients with esophageal perforation. Mortality rates decreased over time from 16.3% (Abbas, 2009) to 6.7% (Heel, 2020). Re-operative procedures were highest at 51.4%(D’Cunha, 2011) and lower in later studies. Stent migration rates varied from 16.2-22.3%. Leakage rates ranged from 8.8-16.2%. Hospital stays ranged from 5.0 days (D’Cunha, 2011) to 15.3 days (Law, 2017), with significant variability across studies.

Conclusion Esophageal stenting is considered an efficient and well-tolerated method for managing esophageal perforation.

Keywords Keywords Esophageal rupture, perforation, esophageal stenting

Ann Gastroenterol 2025; 38 (2): 156-162

Introduction

Esophageal perforation is a severe, life-threatening condition that is most commonly associated with iatrogenic causes, such as surgery or endoscopic procedures, while spontaneous perforations also occasionally occur [1,2]. Boerhaave syndrome is a spontaneous longitudinal esophageal wall tear due to high intra-abdominal pressure combined with low intra-thoracic pressure, as in retching, trauma, seizures and defecation [3]. This tear usually occurs above the diaphragmatic esophageal hiatus, most commonly on the left side [4-6]. Rarely, malignancy can lead to esophageal perforation, often secondary to chemotherapy and/or radiation therapy. Law et al reported spontaneous rupture as the main cause of perforation, with one-third of cases related to malignant etiologies receiving chemotherapy.

Esophageal stenting has been used to treat patients with esophageal perforation to good effect, especially patients who are poor candidates for surgery [7-10]. However, esophagectomy or primary surgical repair for esophageal perforation are still performed in many institutions, despite their high mortality and morbidity [11,12]. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of esophageal stent placement to manage esophageal perforation.

Materials and methods

Our study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13].

Search strategy

We searched various electronic databases using the following strategy: (“esophageal rupture” OR “esophageal perforation” OR “Boerhaave’s Syndrome”) AND (stent).

Study selection

We screened in the subsequent steps. First, we imported the data from research databases to a Microsoft Excel sheet using EndNote software. Then, we screened the articles’ titles and abstracts in our Excel sheet. Finally, we screened the included studies from the second step in full text.

Eligibility criteria

The inclusion criteria for study selection were:

  • Study design: we included observational studies and randomized clinical trials, and we excluded other study designs, conference abstracts, meta-analyses, all animal studies, and reviews.

  • Participants: patients with esophageal perforation.

  • Intervention: esophageal stent placement.

  • Outcomes: leak after primary surgical repair, need for surgery, stent migration, length of hospital stay (days), and mortality.

Data collection

We searched Scopus, PubMed and Web of Science databases up to April 2024 for articles that matched our inclusion criteria. We collected baseline and demographic characteristics of the included participants, including author, year, age, sex, diagnosis of sepsis, and time from perforation to treatment (measured in h). The main outcomes for analysis included leak after primary repair, operative repair after endoscopic therapy, stent migration, length of hospital stay (days), morbidity and mortality. The data collection process was done using Microsoft Excel.

Risk of bias assessment

We used the quality assessment tools from the National Heart, Lung, and Blood Institute (NHLBI) to assess the risk of bias in observational studies [14]. We followed The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Guidelines for assessing the quality of this study.

Statistical analysis

We used Open Meta analyst [15]. Our study included dichotomous and continuous outcomes. We analyzed data using pooled proportion and a 95% confidence interval (CI) for all data. The homogeneous data were analyzed using a fixed-effects model, while heterogeneous data were analyzed using a random-effects model. To measure heterogeneity among the studies, we used the I2 and the P-value of the chi-square tests [16]. Values of P<0.1 or I2>50% were significant indicators of heterogeneity. We solved the inconsistency of heterogeneous outcomes using subgroup analysis, according to the duration of treatment or Cochrane’s leave-one-out method [17].

Results

Summary of included studies

Our electronic search strategy is illustrated in Fig. 1. Ninety-five patients with esophageal perforation were evaluated from the 8 studies included in our analysis (Supplementary Tables 1,2) [18-25]. All patients underwent esophageal stent placement to manage perforation. Their mean age was 57.65 years. Data from the included studies, patients’ demographic data, number of patients with sepsis at diagnosis, and perforation-to-treatment time are presented in Table 1.

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Figure 1 PRISMA flow diagram of the literature search

Table 1 Summary of the included studies and patients' demographic data

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Results of risk of bias

The quality assessment yielded an overall score of 9.5 of 14 according to the NHLBI tool for quality assessment. Supplementary Table 1 shows the quality assessment of the included studies in detail.

Analysis of outcomes

Leakage after primary repair

The meta-analysis for leakage after primary repair used a binary fixed-effect model with the inverse variance method. The proportions varied across studies: Law [21] reported a leakage rate of 9.3% (95%CI 0.6-18.0%), while D’Cunha [22] found a higher rate of 20.9% (95%CI 13.3-28.5%). Van Heel [18] reported 14.0% (95%CI 8.4-19.5%), Freeman [37] 12.1% (95%CI 7.3-16.9%), Freeman [20] 11.9% (95%CI 7.4-16.4%), and Glatz [24] 13.2% (95%CI 8.7-17.6%). All estimates were statistically significant with P-values <0.001 (Fig. 2).

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Figure 2 Forest plot for leakage after primary repair

C.I., confidence interval; Ev, event; Trt, total rate

Mortality

Regarding mortality rates, the binary fixed-effect model analysis revealed diverse outcomes: Law [19] reported a mortality rate of 23.3% (95%CI 10.6-35.9%), whereas D’Cunha [22] showed a rate of 17.7% (95%CI 9.4-26.0%). Van Heel [18] had a rate of 18.6% (95%CI 11.5-25.8%), Freeman [37] 6.6% (95%CI 2.8-10.5%), Freeman [17] 5.6% (95%CI 2.3-9.0%), Abbas [21] 7.6% (95%CI 4.6-10.5%), Glatz [24] 7.7% (95%CI 4.8-10.6%), and Gray [23] 13.4% (95%CI 11.7-15.0%). All estimates were statistically significant with P-values <0.001 (Fig. 3).

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Figure 3 Forest plot for mortality

C.I., confidence interval; Ev, event; Trt, total rate

Re-operative procedures

The analysis of re-operative procedures, using a binary fixed-effect model, showed proportions ranging from Law [19] at 14.0% (95%CI 3.6-24.3%) to D’Cunha [22] at 24.9% (95%CI 16.2-33.6%). Van Heel [18] reported 17.9% (95%CI 11.4-24.4%), Freeman [37] 14.3% (95%CI 8.9-19.6%), Freeman [20] 13.8% (95%CI 8.8-18.7%), Abbas [21] 10.5% (95%CI 7.1-14.0%), and Glatz [23] 10.9% (95%CI 7.5-14.3%). All proportions were statistically significant with P-values <0.001 (Fig. 4).

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Figure 4 Forest plot for re-operative repair

C.I., confidence interval; Ev, event; Trt, total rate

Stent migration

For stent migration, the binary fixed-effect model revealed proportions as follows: D’Cunha [22] at 16.2% (95%CI 4.3-28.1%), Van Heel [18] at 22.3% (95%CI 12.7-31.8%), Freeman [37] at 20.6% (95%CI 12.8-28.5%), and Freeman [20] at 20.7% (95%CI 13.5-27.9%). All estimates were statistically significant with P-values <0.001 (Fig. 5).

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Figure 5 Forest plot for stent migration

C.I., confidence interval; Ev, event; Trt, total rate

Hospital stay duration

The meta-analysis of mean hospital stay duration used a continuous fixed-effect model with the inverse variance method. D’Cunha (2011) reported a mean stay of 5.0 days (95%CI 2.7-7.3). Freeman [20] reported a mean stay of 7.0 days (95%CI 3.2-10.8), Freeman et al [37] reported 7.5 days (95%CI 4.7-10.2), Glatz [24] reported 8.8 days (95%CI 6.1-11.5), Gray [23] reported 8.7 days (95%CI 6.5-11.0), Heel [18] reported 14.3 days (95%CI 12.2-16.3), and Law [19] reported 15.3 days (95%CI 13.3-17.4). All studies except D’Cunha had P-values <0.001 (Fig. 6).

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Figure 6 Forest plot for duration of hospital stay

C.I., confidence interval

Discussion

Esophageal perforation, whether spontaneous or iatrogenic, is a severe condition traditionally managed by primary surgical repair. With advances in endoscopic techniques, esophageal stenting has emerged as a less invasive alternative, particularly beneficial for patients unsuitable for surgery. This meta-analysis evaluated the efficacy and safety of esophageal stenting for managing esophageal perforation, evaluating 8 studies that met our inclusion criteria.

Our analysis revealed a mortality rate associated with stenting of approximately 6.7% (95%CI 3.6-9.8%), which is lower compared to earlier studies. Stent migration was observed in 16.2-22.3% of patients, showing a consistent issue but with variability in reported rates. Leakage after primary repair ranged from 8.8% (95%CI 3.0-14.6%) to 16.2% (95%CI 12.1-20.3%), indicating a persistent challenge across studies. The mean hospital stay varied from 5.0 days (D’Cunha [22]) to 15.3 days (Law [19]), a notable variability, but generally reflecting a trend towards longer stays compared to earlier studies.

Primary repair in delayed diagnosis can be very challenging, because of severe tissue necrosis, and has a higher risk of leakage with mediastinal contamination [25]. Keeling et al reported a postoperative leak rate of approximately 30% [5]. Heel et al described a single-center prospective trial that reported the short-term effect of esophageal stenting in treating benign perforations [18]. The investigators suggested that the use of a temporary stent in benign esophageal perforation was effective and well-tolerated, and could provide an alternative option to operation. Freeman et al found that esophageal stenting in patients with acute esophageal perforation is as effective as surgical repair, compared to propensity-matched patients, with no difference in persistent leaks after initial repair [17].

Fischer et al reported that 15 patients with benign esophageal perforations treated using a self-expandable metal stent had a 7% mortality rate [26]. Another retrospective study of 27 patients reported that early diagnosis and management (within 24 h) led to a significant decrease in mortality rate (6.2% vs. 40%, P=0.047) [25]. Deng et al reported higher perioperative mortality in abdominal esophageal perforation (11%) and malignant thoracic esophageal perforation (63%), cervical esophageal perforation (8%), and benign esophageal perforation (13%) [27]. Co-existing hepatic and pulmonary diseases increase hospital-related morbidity and mortality significantly [19]. Some studies report a better response with palliative metallic stenting for spontaneous esophageal perforation in elderly patients with advanced cancer [28,29]. However, our analysis was limited to reporting the mechanism, site and etiology of perforation in included patients.

Dumonceau et al reported stent migration as the most common etiology for treatment failure in 33% of patients [30-35]. Benign lesions, distal esophageal perforations and partially covered self-expanding metal stents are reported risk factors for stent migration [36].

Freeman et al reported leak occlusion in 93% of cases with esophageal stent placement, as opposed to 6.8% of cases requiring postoperative repair for persistent leak, mostly due to delayed (>24 h) primary intervention [27]. Post-primary repair stent placement provided an opportunity for early oral nutrition, while decreasing the length of hospital stay and the risk for repeat surgical repair [20,37]. The main limitation of this paper is the heterogeneity in one outcome, which weakens the certainty of evidence, according to GRADE [38]. Another limitation is the lack of a placebo or comparator and the observational nature of some studies.

In conclusion, we suggest that esophageal stenting is an effective and well-tolerated method for treating esophageal perforation. It can reduce both morbidity and mortality, the need for postoperative surgical leak repair, and the duration of hospitalization.

Summary Box

What is already known:

  • Esophageal perforation is commonly managed with either endoscopic stenting or surgical repair

  • Surgical repair is often preferred in centers without advanced endoscopic services or for complex perforations

  • Previous studies have reported variable outcomes regarding the efficacy and safety of esophageal stenting

  • Mortality rates, stent migration and hospital stay durations have been reported with differing results across studies

What the new findings are:

  • This systematic review and meta-analysis consolidates data from 8 studies, demonstrating a decreasing trend in mortality rates associated with esophageal stenting over time

  • Re-operative procedures were notably high in earlier studies, with lower rates observed in more recent research

  • Stent migration occurred in 21.7% of patients, with leakage rates ranging from 8.8-16.2%, providing a clearer picture of stenting complications

  • The review highlights significant variations in hospital stay durations across studies, with a range from 5.0-15.3 days, indicating variability in patient outcomes and management practices

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Notes

Conflict of Interest: None