胸段食管破裂的早期外科治疗

Surgical treatment of thoracic esophageal perforation at early phase

目的总结胸段食管破裂的诊断治疗经验,探讨手术修补或切除治疗食管破裂的手术方法及适应证。方法回顾性分析1996年4月～2010年11月收治的14例胸段食管破裂患者的临床资料,分层缝合或全层缝合行食管修补术10例,分别应用大网膜瓣、膈肌瓣、胸膜瓣以及胃底包埋加固缝合。4例行食管部分切除、食管胃胸内吻合术。结果 14例患者经手术治疗均痊愈出院。食管修补术10例中修补成功1期愈合者5例,另5例在术后首次造影发现修补口残留小漏口,经延长禁食时间及营养支持后痊愈;因合并贲门失弛缓、早期食管癌及食管异物造成食管多处损伤行食管切除食管胃吻合术4例术后均顺利恢复,无吻合口漏。结论尽早行食管修补是治疗食管破裂的主要措施,应用不同组织瓣加固修补有重要作用;对于合并食管远端狭窄疾患及食管多处损伤的食管破裂患者,应积极行食管切除、食管胃吻合术。

Abstract： [Objective] To summarize the experiment of diagnosis and treatment of thoracic esophageal perforation, to study the surgical methods and clarify indication. [Methods] The clinical records of 14 cases （11 males and 3 female, aged from 19-72 years, median age 54 years） perforation of thoracic esophagus between April 1996 and November, 2010 in Third hospital, Peking university were reviewed retrospectively, include 10 patients of spontaneous esophagus perforation, 2 patients injured by foreign body ingestion, 2 patients caused by iatrogenic reason. The principle treatment of 10 patients were primary repair, and reinforce ment with different tissues include pedicaled great omentum flap 2 cases, diaphram flap 3 cases, gastric fundus 3 cases, with pleuro flap 2 cases. Another 4 cases treated by esophagectomy and esophagogastrostomy. [Results] 13 cases had correct diagnosis before operation, 1 case misdignosed as acute diffuse peritonitis following exploratory laporotomy.among the 14 cases, 12 cases （86%） were admitted within the first 24hr after the rupture, and 2 （14%） after. All cases underwent esophagus repair and resection had good results without mortality. 5 of 10 cases cured after primary esophageal repair without any complications, 5 of 10 cases found fistula at the repair line by esophagogram with water soluble contrast material postotJeration 7 days, and final- ly cured after enlonging fasting time and active nutrition support. 3 of 6 （50%） esophageal repair closed by one-layer method healing by first intention, and 2 of 4 （50%） cases esophageal repair closed by two-layers healing by first intention, 4 cases recovered smoothly after esophagectomy and esophagogastrostomy due to comorbidity such as achalasia,early stage esophageal cacinoma and severe esophageal injury. Followed up 6 cases, one found esophageal stenosls and fistula after primary repair 4 years later, and successfully treated by esophageal stent. [Conclusions] Primary repair as early as possible is the main method to treat esophageal rupture, reinforcement with different tissues can play an important role to get a good result; esophagectomyand esophagogastrostomy should be aggressive performed when perforation in an obstructed esophagus or in jured seriously.