Flynn A E, Verrier E D, Way L W, Thomas A N, Pellegrini C A
Department of Surgery, University of California Medical Center, San Francisco.
Arch Surg. 1989 Oct;124(10):1211-4; discussion 1214-5. doi: 10.1001/archsurg.1989.01410100117020.
Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.
1977年至1988年期间，加利福尼亚大学旧金山分校收治了69例食管穿孔患者。其中33例（48%）为医源性穿孔，8例（12%）为自发性穿孔，23例（33%）为外伤所致穿孔。临床症状包括：69例患者中有36例（52%）出现胸痛，59例患者中有22例（32%）出现皮下气肿，59例患者中有21例（36%）出现纵隔气肿。43例患者中，食管造影显示穿孔的有40例（93%）。约半数的自发性和医源性穿孔患者治疗延迟超过24小时，但外伤所致穿孔患者很少出现治疗延迟。59例（86%）患者接受了手术治疗，其中44例行一期缝合，9例仅行引流，1例行塞莱斯坦管置入术。4例良性狭窄患者接受了食管切除术，4例贲门失弛缓症患者除穿孔修补外还接受了赫勒肌切开术。8例（12%）患者接受了非手术治疗。对于胸段穿孔，非手术治疗仅适用于诊断较晚但脓毒症证据较少的患者。7例（10%）患者死亡。影响预后的因素包括穿孔原因、解剖位置和患者年龄。我们的研究表明，治疗食管穿孔时，高度的怀疑指数、积极进行食管造影检查以及个体化治疗对于取得最佳治疗效果至关重要。
