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					Postoperative Complication of Esophageal Rupture
Surgical Therapy

Surgical techniques used for esophageal rupture include the following:
     •    Tube thoracostomy (Drainage with a chest tube or operative drainage alone)
     •    Primary repair
                                                                                                                      [16]
     •    Primary repair with reinforcement with pleura, intercostal muscle, diaphragm, pericardial fat, pleural flap
     •    Diversion
     •    Diversion and exclusion
     •    Esophageal resection
                                   [2]
     •    Thoracoscopic repair
                             [17, 18]
     •    Esophageal stent
                                                 [19]
     •   Endoscopic placement of fibrin sealant
Follow-up

Further inpatient care (conservative management)
     • Consider early surgical repair when indicated because delayed repair (>24 hours) may alter the surgical approach and increases the
          mortality rate.
     • Maintain nasogastric suction until evidence exists that esophageal perforation has healed, is smaller, or is unchanged.
     • Deterioration in a patient's condition should prompt consideration of surgery, the need for which may be confirmed by contrast
          esophagrams to look for leakage or CT scans to detect an abscess.

Complications
   • Mediastinitis
   • Intrathoracic abscess
   • Sepsis
   • Respiratory failure
   • Shock

Outcome and Prognosis
Esophageal perforation remains a highly morbid condition with a high mortality rate if not diagnosed and treated promptly. Mortality rates are
reported from 5-89%, based predominantly on time of presentation and etiology of perforation. Postemetic perforation has a higher reported
mortality rate of 2% per hour and an overall mortality of 25-89%, while iatrogenic instrumental perforation has a lower mortality of 5-26%. If
treatment is instituted within 24 hours of symptoms, reported mortality rates are 25%; rates rose to above 65% after 24 hours and 75-89% after 48
hours. The mortality rates are higher in patients with delayed presentation or treatment, thoracic/abdominal rupture, spontaneous rupture, and
underlying esophageal disease.

Future and Controversies
                                                                               [7, 9, 20, 21, 15, 22]
Controversy exists regarding indications for surgery for esophageal rupture.                          However, operative therapy depends on a number of
factors, including etiology, location of the perforation, and the time interval between injury and diagnosis. Other considerations include the
extension of the perforation into an adjacent body cavity and the general medical condition of the patient. Currently, no randomized trials exist for
the appropriate treatment of esophageal perforation in regard to this controversy; therefore, future studies could be considered.

References

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                                                                                             rd
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                                                                                        th
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