Department of Cardiothoracic Surgery, University of Alabama School of Medicine, Birmingham, AL 35294, USA.
Eur J Cardiothorac Surg. 2011 Oct;40(4):931-7. doi: 10.1016/j.ejcts.2010.12.066. Epub 2011 Feb 25.
To assess our results of a prospective algorithm applied to patients with thoracic esophageal perforation.
A retrospective review of a prospective algorithm. Patients with esophageal perforation underwent an esophagram. If there was a contained esophageal perforation they were admitted, kept nothing by mouth, and restudied in 3-5 days. If the leak was not contained, they underwent operative repair.
From 1/1998 to 6/2009 there were 81 patients. The gastrograffin swallow showed 56 patients had contained perforations and 25 did not. Twenty-two of the 25 patients with noncontained perforation underwent immediate operative repair (one patient refused surgery, two were not stable enough for the operating room); their morbidity was 68% and there were six (24%) operative mortalities. Median hospital length of stay (LOS) was 11 days (range, 2-120). Of the 56 patients with contained perforations, 26 were managed successfully without surgery. However, 30 of the patients initially treated nonoperatively eventually required operations due to new pleural effusion, mediastinal abscess, or conversion to noncontained perforation. Their morbidity was 41% and there were three operative mortalities (5%). On univariate analysis, these patients were more likely to have undergone previous esophageal procedures (surgical or dilation) (p=0.03), had new or increased pleural effusion (p=0.04), and had greater than 24h between diagnosis and treatment (p=0.02). Only greater than 24h between diagnosis and treatment remained a significant predictor on multivariate analysis. Their median hospital LOS was 21 days (range, 7-77).
Contained thoracic esophageal perforations can usually be safely managed nonoperatively without significant morbidity or mortality. However, careful in-hospital monitoring is needed if surgery is not chosen.
评估我们对胸段食管穿孔患者应用前瞻性算法的结果。
回顾性分析前瞻性算法。食管穿孔患者行食管造影检查。如果存在包裹性食管穿孔，患者将被收治入院，禁止经口进食，并在 3-5 天内复查。如果漏口未被包裹，则进行手术修复。
自 1998 年 1 月至 2009 年 6 月，共有 81 例患者。胃造影显示 56 例患者存在包裹性穿孔，25 例患者不存在。25 例非包裹性穿孔患者中，有 22 例患者立即接受了手术修复（1 例患者拒绝手术，2 例患者因不稳定而无法进入手术室）；其发病率为 68%，有 6 例（24%）患者因手术而死亡。中位住院时间（LOS）为 11 天（范围，2-120 天）。56 例存在包裹性穿孔的患者中，有 26 例患者成功地无需手术治疗。然而，最初接受非手术治疗的 30 例患者最终因新出现的胸腔积液、纵隔脓肿或转为非包裹性穿孔而需要手术治疗。其发病率为 41%，有 3 例患者因手术而死亡（5%）。单因素分析显示，这些患者更有可能既往接受过食管手术（手术或扩张）（p=0.03），出现新的或增加的胸腔积液（p=0.04），以及诊断与治疗之间的时间超过 24 小时（p=0.02）。多因素分析仅显示诊断与治疗之间的时间超过 24 小时是一个显著的预测因素。其中位住院 LOS 为 21 天（范围，7-77 天）。
包裹性胸段食管穿孔通常可以安全地进行非手术治疗，而不会出现显著的发病率或死亡率。然而，如果不选择手术治疗，则需要在住院期间进行仔细监测。
