Tratamento cirúrgico versus tratamento conservador na perfuração esofágica benigna: revisão sistemática
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Data
2022-08-16
Autores
Braga, Rodrigo Paschoal
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
RESUMO Introdução: A perfuração de esôfago é um evento bastante grave e necessita de imediata intervenção para que não seja fatal. O tratamento dessa moléstia pode ser tanto conservador como reparador da lesão. Objetivo: Avaliar qual das intervenções leva a menor mortalidade. Método: Foi realizada uma revisão sistemática de estudos que contemplassem os dois tipos de tratamento em pacientes com perfuração esofágica não neoplásica e estudassem o desfecho mortalidade. Foram pesquisadas as principais bases de dados sem restrição de idiomas usando os termos “perfuração esofágica” AND “tratamento cirúrgico” AND “tratamento conservador”. Foi realizada metanálise com o programa Review Manager 5.4.1 utilizando-se efeito randômico. Foi planejada também a análise de subgrupos: perfuração cervical versus torácica, tempo de perfuração maior e menor que 24h, perfuração iatrogênica versus não iatrogênica e sutura versus esofagectomia na intervenção reparadora. A qualidade da evidência e força da recomendação foram avaliadas pelo sistema GRADE. Resultados: foram selecionados 40 estudos com 1673 participantes. Todos os estudos são série de casos que por sua natureza apresentam risco crítico de viés pelos potenciais confundidores associados à perfuração e também ao paciente. O desfecho mortalidade foi avaliado pelos 40 estudos. Não houve diferença no risco de morte entre os dois tipos de tratamento (RR= 1,15; IC 95% 0,88 a 1,52; I2= 0%). Em 11 estudos foi possível separar a mortalidade segundo a etiologia. Na etiologia iatrogênica, 201 participantes, não houve diferença na mortalidade entre as intervenções (RR 1,36, IC 95% 0,64 a 2,91, I2= 4%). Na etiologia não iatrogênica, 165 pacientes, não houve diferença na mortalidade entre as intervenções (RR 0,92, IC 95% 0,43 a 1,95, I2= 0%). Não houve diferença na mortalidade quando comparada a etiologia iatrogênica com a não iatrogênica (RR 0,68, IC 95% 0,42 a 1,10, I2= 8%). A comparação da mortalidade da perfuração cervical com a torácica, só foi possível em oito estudos, 306 participantes, e não houve diferença na mortalidade entre os grupos (RR 0,69, IC 95% 0,27 a 1,76, I2= 24%). A mortalidade segundo a intervenção cirúrgica foi possível em 21 estudos, 504 participantes. Não houve diferença no risco de morte entre sutura e esofagectomia (RR 0,62; IC 95% 0,32 a 1,20; I2= 24%). Não foi possível combinar os estudos quanto ao tempo de internação em enfermaria e UTI. A qualidade da evidência pelo sistema GRADE foi considerada muito baixa e a força da recomendação avaliada pelos oito itens que a regem mostra que os dois tratamentos podem ser recomendados. Conclusão: conclui-se que tanto o tratamento conservador como o tratamento cirúrgico pode ser recomendado. Não foi possível mostrar diferenças entre os subgrupos e nem do tempo de internação entre os dois tratamentos.
SUMMARY Introduction: Esophageal perforation is a very serious event and requires immediate intervention so that it is not fatal. The treatment of this disease can be both conservative and repairing the lesion. Objective: To assess which of the interventions leads to the lowest mortality. Method: A systematic review of studies was performed that contemplated both types of treatment in patients with non-neoplastic esophageal perforation and studied the mortality outcome. The main databases without language restrictions were searched using the terms “esophageal perforation” AND “surgical treatment” AND “conservative treatment”. Meta-analysis was performed with the Review Manager 5.4.1 program using random effect. The analysis of subgroups was also planned: cervical versus thoracic perforation, perforation time longer and shorter than 24h, iatrogenic versus non-iatrogenic perforation, and suture versus esophagectomy in the reparative intervention. The quality of evidence and strength of recommendation were assessed using the GRADE system. Results: 40 studies were selected with 1673 participants. All studies are case series that, by their nature, present a critical risk of bias due to potential confounders associated with perforation and also with the patient. The mortality outcome was evaluated by the 40 studies. There was no difference in the risk of death between the two types of treatment (RR= 1.15; 95% CI 0.88 to 1.52; I2= 0%). In 11 studies it was possible to separate mortality according to etiology. In the iatrogenic etiology, 201 participants, there was no difference in mortality between interventions (RR 1.36, 95% CI 0.64 to 2.91, I2= 4%). In the non-iatrogenic etiology, 165 patients, there was no difference in mortality between interventions (RR 0.92, 95% CI 0.43 to 1.95, I2= 0%). There was no difference in mortality when comparing iatrogenic and non-iatrogenic etiologies (RR 0.68, 95% CI 0.42 to 1.10, I2= 8%). Comparison of mortality from cervical perforation with thoracic perforation was only possible in eight studies, 306 participants, and there was no difference in mortality between the groups (RR 0.69, 95% CI 0.27 to 1.76, I2= 24 %). Mortality according to surgical intervention was possible in 21 studies, 504 participants. There was no difference in the risk of death between suture and esophagectomy (RR 0.62; 95% CI 0.32 to 1.20; I2= 24%). It was not possible to combine the studies regarding the length of stay in the ward and the ICU. The quality of evidence by the GRADE system was considered very low and the strength of the recommendation evaluated by the eight items that govern it shows that both treatments can be recommended. Conclusion: it is concluded that both conservative treatment and surgical treatment can be recommended. It was not possible to show differences between the subgroups or the length of stay between the two treatments.
SUMMARY Introduction: Esophageal perforation is a very serious event and requires immediate intervention so that it is not fatal. The treatment of this disease can be both conservative and repairing the lesion. Objective: To assess which of the interventions leads to the lowest mortality. Method: A systematic review of studies was performed that contemplated both types of treatment in patients with non-neoplastic esophageal perforation and studied the mortality outcome. The main databases without language restrictions were searched using the terms “esophageal perforation” AND “surgical treatment” AND “conservative treatment”. Meta-analysis was performed with the Review Manager 5.4.1 program using random effect. The analysis of subgroups was also planned: cervical versus thoracic perforation, perforation time longer and shorter than 24h, iatrogenic versus non-iatrogenic perforation, and suture versus esophagectomy in the reparative intervention. The quality of evidence and strength of recommendation were assessed using the GRADE system. Results: 40 studies were selected with 1673 participants. All studies are case series that, by their nature, present a critical risk of bias due to potential confounders associated with perforation and also with the patient. The mortality outcome was evaluated by the 40 studies. There was no difference in the risk of death between the two types of treatment (RR= 1.15; 95% CI 0.88 to 1.52; I2= 0%). In 11 studies it was possible to separate mortality according to etiology. In the iatrogenic etiology, 201 participants, there was no difference in mortality between interventions (RR 1.36, 95% CI 0.64 to 2.91, I2= 4%). In the non-iatrogenic etiology, 165 patients, there was no difference in mortality between interventions (RR 0.92, 95% CI 0.43 to 1.95, I2= 0%). There was no difference in mortality when comparing iatrogenic and non-iatrogenic etiologies (RR 0.68, 95% CI 0.42 to 1.10, I2= 8%). Comparison of mortality from cervical perforation with thoracic perforation was only possible in eight studies, 306 participants, and there was no difference in mortality between the groups (RR 0.69, 95% CI 0.27 to 1.76, I2= 24 %). Mortality according to surgical intervention was possible in 21 studies, 504 participants. There was no difference in the risk of death between suture and esophagectomy (RR 0.62; 95% CI 0.32 to 1.20; I2= 24%). It was not possible to combine the studies regarding the length of stay in the ward and the ICU. The quality of evidence by the GRADE system was considered very low and the strength of the recommendation evaluated by the eight items that govern it shows that both treatments can be recommended. Conclusion: it is concluded that both conservative treatment and surgical treatment can be recommended. It was not possible to show differences between the subgroups or the length of stay between the two treatments.
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Palavras-chave
Perfuração esofágica, Tratamento cirúrgico, Tratamento conservador, Revisão sistemática, Systematic review, Esophageal perforation, Surgical treatment, Surgery, Conservative treatment