Martinez L, Rivas S, Hernández F, Avila L F, Lassaletta L, Murcia J, Olivares P, Queizán A, Fernandez A, López-Santamaría M, Tovar J A
Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain.
J Pediatr Surg. 2003 May;38(5):685-9. doi: 10.1016/jpsu.2003.50183.
BACKGROUND/PURPOSE: In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has been the usual approach for esophageal perforation (EP) in children. This report aims to assess whether this strategy stands the passage of time.
We reviewed retrospectively the charts of 17 patients aged 5.3 +/- 0.9 years (mean +/- SD) treated at our institution for EP between 1991 and 2001.
Nineteen episodes of EP were caused by stricture dilation in 9 cases, foreign body extraction in 3, and blunt trauma and sclerosis of varices in 2 cases each. The remaining child had multiple gastrointestinal perforations in the course of chemotherapy for leukemia. Vigorous treatment, consisting of nasopharyngeal aspiration, wide spectrum antibiotics, prompt drainage of effusions and either parenteral or infraesophageal nutritition, was implemented immediately after diagnosis. Perforations were closed without direct surgery in 18 of 19 episodes (16 of 17 children). One or more pleural drains were inserted in 12 cases, and pericardial drainage was required once. Seven gastrostomies, 2 jejunostomies, and one esophagostomy were performed. Several major abdominal operations were necessary to repair concomitant lesions in a child who sustained severe blunt abdominal trauma and in the patient with leukemic perforations. All patients survived, and all recovered esophageal function. However, 2 with intractable lye strictures ultimately required esophageal replacement. The only patient in whom a direct approach for esophageal necrosis due to variceal endosclerosis was unavoidable, lost her organ and had a retrosternal colonic interposition after a successful portosystemic shunt. Excluding patients with other concomitant lesions and the patient who underwent surgery, median length of stay was 11 days (range, 6 to 47).
Prompt and aggressive nonoperative treatment of esophageal perforations in children allows survival with conservation of the organ in most cases and remains, in the authors' hands, the first therapeutic choice at this age.
背景/目的：与成人患者首选手术闭合缺损不同，非手术治疗一直是儿童食管穿孔（EP）的常用方法。本报告旨在评估这一策略是否经得起时间的考验。
我们回顾性分析了1991年至2001年间在我院接受治疗的17例年龄为5.3±0.9岁（平均±标准差）的EP患儿的病历。
19次EP发作中，9例由狭窄扩张引起，3例由异物取出引起，2例由钝性创伤和静脉曲张硬化引起。其余患儿在白血病化疗过程中出现多处胃肠道穿孔。诊断后立即实施积极治疗，包括鼻咽抽吸、广谱抗生素、及时引流积液以及肠外或食管下营养支持。19次发作中的18次（17例患儿中的16例）穿孔未经直接手术而闭合。12例插入了一根或多根胸腔引流管，1例需要心包引流。实施了7次胃造瘘术、2次空肠造瘘术和1次食管造瘘术。对于一名遭受严重腹部钝性创伤的患儿和一名白血病穿孔患儿，需要进行几次大型腹部手术来修复伴随的损伤。所有患者均存活，且食管功能均恢复。然而，2例患有顽固性碱液狭窄的患者最终需要进行食管置换。因静脉曲张硬化导致食管坏死而不可避免地采用直接手术方法的唯一一名患者失去了食管器官，在成功进行门体分流术后行胸骨后结肠间置术。排除有其他伴随损伤的患者和接受手术的患者，中位住院时间为11天（范围为6至47天）。
儿童食管穿孔的及时、积极非手术治疗在大多数情况下可使患儿存活并保留器官，在作者手中，仍是这个年龄段的首选治疗方法。
