Abbas Ghulam, Schuchert Matthew J, Pettiford Brian L, Pennathur Arjun, Landreneau James, Landreneau Joshua, Luketich James D, Landreneau Rodney J
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Surgery. 2009 Oct;146(4):749-55; discussion 755-6. doi: 10.1016/j.surg.2009.06.058.
Esophageal perforation is an important therapeutic challenge. We hypothesized that patients with minimal mediastinal contamination at the time of diagnosis could be managed successfully with nonoperative treatment modalities.
We performed a retrospective review of 119 consecutive patients with esophageal perforation from 1998 to 2008. Demographics, cause of perforation, clinical presentation, diagnostic methods, and management results were evaluated. The decision to operate was based on the extent of mediastinal contamination and systemic sepsis rather than cause of perforation.
Median time to diagnosis among all patients was 12 hours (range, 1-120). Spontaneous (Boerhaave's) perforation occurred in 44 (37%) patients. Iatrogenic perforations constituted the remaining patients (n = 75). After instrumental perforation, 9 patients (13%) required esophagectomy, 48 patients were managed with repair and drainage, and the remaining 18 were managed nonoperatively. All 34 patients undergoing operative therapy for spontaneous perforations were treated with esophageal repair. Overall mortality was 14%, with intrathoracic perforations having 18% mortality, cervical 8%, and gastroesophageal junction 3%. Patients undergoing nonoperative therapy had a shorter hospitalizations (13 vs 24 days), fewer complications (36% vs 62%), and less mortality (4% vs 15%) compared with those undergoing operative intervention.
An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, nonoperative management may be successfully implemented in selected patients with a low morbidity and mortality if favorable radiographic and clinical characteristics are present.
食管穿孔是一项重要的治疗挑战。我们推测，诊断时纵隔污染程度较轻的患者可通过非手术治疗方式成功治愈。
我们对1998年至2008年间连续收治的119例食管穿孔患者进行了回顾性研究。评估了患者的人口统计学资料、穿孔原因、临床表现、诊断方法及治疗结果。手术决策基于纵隔污染程度和全身感染情况，而非穿孔原因。
所有患者诊断的中位时间为12小时（范围1 - 120小时）。44例（37%）患者发生自发性（Boerhaave氏）穿孔。其余患者（n = 75）为医源性穿孔。器械穿孔后，9例（13%）患者需要行食管切除术，48例患者接受修复及引流治疗，其余18例接受非手术治疗。所有34例因自发性穿孔接受手术治疗的患者均行食管修复术。总体死亡率为14%，其中胸内穿孔死亡率为18%，颈部穿孔为8%，胃食管交界处穿孔为3%。与接受手术干预的患者相比，接受非手术治疗的患者住院时间较短（13天对24天）、并发症较少（36%对62%）且死亡率较低（4%对15%）。
基于损伤严重程度以及纵隔和胸膜污染程度的食管穿孔治疗方法至关重要。尽管手术治疗仍是大多数食管穿孔患者的标准治疗方式，但对于具有良好影像学和临床特征、发病率和死亡率较低的特定患者，非手术治疗可能会成功实施。
