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PRIMARY REPAIR AND ENDOSCOPIC STENT PLACEMENT AFTER ESOPHAGEAL PERFORATION: COMPARING READMISSION
Khuzema Mohsin*1, Oumar Thiero2, Christopher DuCoin1
1Surgery, Tulane University School of Medicine, New Orleans, LA; 2Biostatistics, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
Introduction
Esophageal perforation is an emergent condition that can be difficult to diagnose and treat and has high mortality. Furthermore, the medical literature is lacking because of the rarity of this disease. Both surgical and non-surgical treatment options exist, and it is not well understood which management strategy is best.
Methods
We queried the National Readmission Database (NRD) for adult patients having endoscopic stent placement or primary surgical repair for esophageal perforation. The NRD follows patients across time over one-year intervals to allow for analyses of national readmission rates for all payers and the uninsured. Primary outcome was set as 30-day non-elective readmission.
Results
A total of 5,196 weighted cases of esophageal perforation were included. 33.7% of patients had endoscopic stent placement. 11.8% of patients died during the surgical admission, 11% of primary repair cases and 13.4% of stent placement cases (p=0.2). 21.5% of patients were readmitted. Mean and median time for readmission was 11.4(SEM: 0.4) and 9.3(SEM: 0.6) days, respectively. 18.6% of patients were readmitted to a hospital other than where the surgery was performed. On multivariate analysis assessing for which cases received stent placement compares to surgical repair, patients were more likely to receive stent placement if they had higher Charlson Comorbidity Index (CCI) (OR: 1.3, p<0.01) or were Medicaid patients compared to private insurance patients (OR: 1.01, p=0.03); females were less likely to receive stent placement than males (OR: 0.8, p=0.04) and non-teaching and non-metropolitan hospital patients were less likely to receive stent placement compared to teaching hospital patients (OR: 0.48, p=0.02; OR: 0.06, p<0.01, respectively). On multivariate analysis modeling for readmission, patients who had stent placement had higher risk for readmission compared to patients who had primary repair (OR: 1.6, p<0.01). Other factors associated with readmission included Medicaid insurance compared to private insurance (OR: 1.3, p<0.01) and longer length of stay (OR: 2.2, p<0.01); patients from small bedsize hospitals were less likely to be readmitted compared to patients from large bedsize hospitals (OR: 0.58, p=0.02). The most common reasons for readmission were re-perforation of esophagus, mechanical complication due to internal device, empyema, wound and other postoperative infection, and stricture and stenosis of esophagus.
Conclusion
Endoscopic stent placement for treating esophageal perforation puts patients at higher risk for readmission compared to primary surgical repair. Differences in treatment options used and readmission risk exist for patients on Medicaid compared to private insurance patients; hospital teaching-status and hospital number of beds also impact choice of treatment and readmission risk.
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