Esophagram Should Be Performed to Diagnose Esophageal Perforation Before Transfer to Higher-Level Care

INTRODUCTION: Early recognition of esophageal perforation may prevent morbidity and mortality. Accurate diagnostic imaging aids in triage, and stable patients with suspected perforation may be transferred to higher levels of care lacking appropriate work-up, delaying treatment. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow. METHODS: We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher’s exact tests for categorical variables. RESULTS: Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included 7 states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n = 24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n = 41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care. CONCLUSION: After transfer a large proportion of transferred patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that an esophagram at the presenting site is imperative to prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays.