Richardson [18] summarized the results of aggressive surgical management for oesophageal perforation. All were treated by operative repairs, buttressed with muscle Proteasome assay or pleura. Sternocleidomastoid muscle was used to buttress or primarily close the defects in the neck, and a flap of diaphragm was often used for thoracic perforation. Patients with perforated cancer or severe underlying disease had an oesophagectomy. With these techniques, 50 of 64 patients underwent preservation of the oesophagus after closure of the perforation and 14 underwent resection. The leak rate was 17%, but all

healed. One patient treated with primary closure died (1.5% mortality) and only 1 patient required subsequent oesophagectomy. Vallböhmer [19] described an institutional experience of 44 patients over a period BMN 673 concentration of 12 years. Iatrogenic injury was the most frequent cause of oesophageal perforation. Eight patients (18%) underwent conservative treatment with cessation of oral intake,

antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, oesophagectomy with delayed reconstruction in 14 patients, and resection of the distal oesophagus and gastrectomy in one patient. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death

occurred in the 25 patients when the diagnosis was made in less than 24 hours. When it was delayed, 19% of 16 patients died (P = 0.05). Keeling et al. [20] in 2010 retrospectively reviewed all cases of oesophageal perforation from 1997 Tobramycin through 2008 at Emory University. Among 91 patients, the perforation was iatrogenic in 50 (52%), spontaneous in 23 (24%), and idiopathic in 22 (23%). The authors concluded that the overall mortality from oesophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Non- operative management, in appropriate patients, can be used in selected patients. Similar results were recorded by the Houston group [21] and two recent meta-analyses [22, 23]. Results and prognostic considerations In the multi-institutional series reported by Asensio [4], a logistic regression of 346 patients reaching the O.R. after penetrating trauma established that a delay in preoperative evaluation, AAST organ injury score > 2 and resection and diversion were independent factors for increased oesophagus-related complications.