The best management for a 48-hour-old distal esophageal perforation is:

C. Primary repair with buttressing.

DISCUSSION: When the esophagus is repaired primarily and covered by well-vascularized autologous tissue, the rates of fistula and death are significantly less than those observed for patients who receive simple repair without any protection. Primary repair with buttressing is the first choice for treatment. Resection is reserved for esophageal perforations with extensive damage to the esophageal wall or with advanced mediastinal infection and sepsis. Exclusion of the perforated esophagus and T-tube drainage of a perforation are alternative approaches that cannot be considered for primary treatment. Antibiotics and drainage as the sole treatment is reserved for a very small, selected population of patients with wellcontained esophageal perforation.