食管癌穿孔的外科治疗

SURGICAL TREATMENT OF PERFORATION IN ESOPHAGEAL CARCINOMA

目的探讨外科手术治疗食管癌穿孔的可行性与理想手术方法。方法对食管癌穿孔１８例（其中穿入右肺６例，穿入纵隔９例，穿入气管３例）进行外科手术治疗。开胸手术１７例，其中右胸三切口术式１１例，分期手术６例。１７例中经胸骨后间隙胃或结肠代食管１３例。结果１５例获得手术成功，手术死亡２例（１１．１０％）。术后随访２～３６个月，其中存活７～１２个月９例，２４个月１例，３６个月１例，疗效满意。结论外科手术治疗食管癌穿孔效果明显，优于一般保守治疗。其优点是：①切除癌肿；②消除胸内感染污染源；③术中彻底清洗胸腔，有效控制胸内感染。手术方式以右胸三切口术式（胸骨后胃或结肠代食管）或分期手术为佳。气管瘘口以用带血管蒂肋间肌或背阔肌修补为好。

PURPOSE To study the feasibility and ideal method of surgery for surgical treatment of perforation in esophageal carcinoma.METHODS 18 cases of perforation in esophageal carcinoma were treated surgically in this series,among which perforation occurred into the right lung in 6 cases,the mediastinum in 9 cases and trachea in 3 cases.Open thoracic surgery was performed in 17 cases ,in which the right thoracic approach with 3 incisions method was applied in 11 cases ,and operation by stages in 6 cases.Of the 17 cases,retrosternal substitution of esophagus with stomach or colon was performed in 13 cases.RESULTS Surgery was successful in 15 cases and operative death occurred in 2 cases (11 1%).The postoperative followup study was from 2～36 months,among which 8 cases were alive at 7～12 months,1 cases 24 months,and 1 case 36 months.The results can be considered satisfactory.CONCLUSIONS The therapeutic results of surgical treatment of perforation in esophageal carcinoma was markedly superior to that of conventional conservative treatment.Its advantages are (1)excision of cancer mass,(2)removal of intrathoracic source of infection,(3)thorough cleansing of the chest cavity during the operation effectively controls intrathoracic infection.The authors suggest that surgical intervention without delay should be undertaken for patients with perforation in carcinoma of the esophagus Right thoracic approach with 3 incisions method (retrosternal replacement of esophagus with stomach or colon) or operation by stages is preferable.The fistula opening in the trachea is best repaired by vascular pedicled intercostal muscle or latissimus dorsi muscle.