2. Diversion from below: Some authors recommended looping the distal oesophagus with a prolene suture that is brought out of the abdomen along with a gastrostomy. After the oesophageal perforation healed, the Prolene suture was removed, without laparotomy, restoring oesophageal continuity . The problem of exclusion-diversion
procedures is that the majority of these patients require a secondary procedure to restore continuity of the GI tract after the fistula had healed. These procedures involve a colon or gastric interposition, depending on the surgeon’s preference. In many instances, the exclusion becomes permanent. Oesophageal exclusion is now reserved for the very poor risk patient who cannot tolerate any major surgical procedures. Perforation with learn more pre-existing pathology: FK506 Oesophageal Resection: Emergency resection of the perforated oesophagus is undoubtedly the treatment of choice when there is associated distal obstruction. The results of oesophagectomy for simple or delayed perforations with or without
associated oesophageal disease have been poor in most series. A more optimistic evaluation of emergency oesophagectomy for oesophageal disruption was reported by Orringer and Stirling . A diverse group of 24 patients was presented including 20 with preexisting oesophageal diseases (chronic strictures, achalasia, reflux esophagitis, carcinoma, diffuse oesophageal spasm and monilial esophagitis). Forty-five percent of the patients had a delay of > 3 days prior to oesophagectomy. Alimentary tract continuity was restored in 13 Ro 61-8048 research buy of the 24 by oesophagogastric anastomosis. In 11 patients, the oesophagus was resected preserving as much of the normal Bay 11-7085 esophagus as possible. The proximal oesophagus was then delivered into the neck, tunnelled
in front of the clavicle and the end was constructed as an ostomy on the chest wall. The authors felt that the risk of oesophageal resection in these patients was less than that from repair or exclusion procedures. Recent series of oesophageal injury: Eroglu  performed a retrospective clinical review of 44 patients treated for oesophageal perforation in 2009. Perforation occurred in the cervical oesophagus in 14 patients (32%), thoracic oesophagus in 18 patients (40%), and abdominal oesophagus in 12 patients (27%). The perforation was treated by primary closure in 23 patients (52%), resection in 7 patients (16%), and nonsurgical therapy in 14 patients (32%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%). 2 of 14 patients (14.3%) died in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. Describing a single surgeon experience, Kiernan et al.  reported on 48 patients with a survival of 96% with early surgical treatment. Even when the diagnosis was delayed > 24 hours, hospital survival was 82.6%, increasing to 92.3% when treated with surgery.