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The four main causes of esophageal perforation are spontaneous perforation associated with protracted vomiting, also known as Boerhaave's syndrome, iatrogenic injury from instrumentation, breakdown of esophageal reconstructions after esophagectomy, and penetrating trauma.1–4 Regardless of the etiology, mediastinal contamination from salivary, gastric, and biliary secretions, as well as associated bacteria, leads to both local and systemic inflammatory responses that, if not controlled promptly, give rise to sepsis and, if left untreated, result in 100% mortality within 1 week.1,4,5 Despite advances in surgical technique and critical care over the past decades, esophageal perforation remains a challenging clinical problem. Early diagnosis and prompt surgical treatment are the hallmarks of successful outcome after spontaneous (i.e., Boerhaave's syndrome) and iatrogenic esophageal perforation. Advocates for primary esophageal repair, drainage with a T-tube, esophageal exclusion, esophageal diversion, and esophagectomy with upfront reconstruction for perforations can be found. This chapter describes the indications and techniques for esophageal exclusion.

The extent of the inflammatory response is modulated by the location of the injury and the length of time from the injury, both of which correlate with extent of mediastinal contamination. Cervical perforations often are limited to the neck, resulting in minimal to absent mediastinal contamination. Such perforations are best managed by local drainage techniques.1,6 However, intrathoracic and intraabdominal perforations generally cannot be managed successfully by drainage alone and require either repair with diversion or exclusion in addition to drainage procedures. The choice whether to proceed with primary repair or with esophageal exclusion rests on multiple factors.

Numerous studies have shown that the length of time from injury to diagnosis is an important determinant of outcome. Cases diagnosed more than 24 hours after injury are associated with increased mortality.1,2 The length of time from injury to diagnosis is proportional to the degree of mediastinal or abdominal contamination, the severity of inflammation and tissue edema, and ultimately, the need for esophageal diversion. Rather than focusing on absolute lengths of time, however, when formulating a plan for treatment, it is better to evaluate the patient as a whole, considering the extent of injury, the overall physiologic status of the patient, the quality of the tissues on exploration, and the underlying esophageal pathophysiologic process. Otherwise healthy patients who sustain iatrogenic perforation to the intrathoracic or intraabdominal esophagus and are diagnosed immediately are ideal candidates for primary repair with drainage. Elderly, malnourished, septic patients on vasopressors who go undiagnosed for several days after perforation and on exploration are found to have “woody,” edematous, and inflamed tissues remain poor candidates for primary repair and are best served by diversion and drainage procedures.

Primary esophageal resection for perforation has been touted by some to produce superior mortality results to primary repair or diversion.1,2,7 For the most part, however, these opinions emanate from older nonrandomized, retrospective studies that often do not adequately account for patient comorbidity. Clearly, resection ...

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