Akaishi Ryujiro, Taniyama Yusuke, Sakurai Tadashi, Okamoto Hiroshi, Sato Chiaki, Unno Michiaki, Kamei Takashi
Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
Surg Case Rep. 2019 May 8;5(1):73. doi: 10.1186/s40792-019-0636-3.
Acute esophageal necrosis is defined as necrosis of the esophageal mucosa causing diffuse black pigmentation of the esophagus, the so-called black esophagus from its endoscopic findings. The prevalence is only 0.001~0.2%, while its mortality rate is up to 32%. However, most of the cases are fatal by comorbidities.
A 67-year-old female with diabetes mellitus was transported to the emergency room with hematemesis and disordered consciousness. She had suffered from nausea and epigastralgia for 2 days. The patient's general status was shock evidenced by vital signs, and she did not respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa, and the condition was diagnosed as acute esophageal necrosis. Antibiotics and plasmapheresis had been started, and the patient gradually stabilized. One week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy revealed an edematous esophagus which was colored black. Esophagectomy with esophagostomy and enterostomy was performed. On resected specimen, mucosal necrosis was found only on the squamous epithelium, with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation or ischemia were found on the gastric mucosa of the esophagogastric junction. After the operation, the patient recovered generally well, except for the severe stenosis of the cervical esophagus. Cervical esophagectomy, tracheotomy, and anterior thoracic route reconstruction with free jejunum interposition and gastric tube were performed 9 months after the first surgery. No postoperative complications occurred; on the 37th day after the operation, the patient was eating well and was transferred to continue swallowing rehabilitation.
It is important to detect the esophagus perforation and mediastinitis early and thereby not to miss the chance of surgical intervention to save the patient's life. Surgery should be minimized, and reconstruction should be considered next. If the cervical esophagus is also affected, reconstruction surgery should be performed by removing cervical esophagus and anastomosing it to the hypopharynx using a gastric tube and free jejunum interposition as needed.
急性食管坏死定义为食管黏膜坏死导致食管弥漫性黑色色素沉着，从内镜检查结果看即所谓的黑色食管。其患病率仅为0.001%~0.2%，而死亡率高达32%。然而，大多数病例因合并症而致命。
一名67岁患有糖尿病的女性因呕血和意识障碍被送往急诊室。她已经恶心和上腹部疼痛2天。患者生命体征显示处于休克状态，补液后无反应。插管后，急诊内镜检查发现食管黏膜黑色色素沉着，诊断为急性食管坏死。已开始使用抗生素和进行血浆置换，患者逐渐稳定。入院一周后，CT扫描显示右侧胸腔积液显著增加，食管壁和纵隔出现游离气体，怀疑有食管穿孔。急诊胸腔镜检查发现食管水肿且呈黑色。进行了食管切除术并做了食管造口术和肠造口术。在切除的标本上，仅鳞状上皮发现黏膜坏死，在胸段食管中下段有三个穿孔区域。食管胃交界处的胃黏膜未发现炎症或缺血迹象。术后，患者总体恢复良好，但颈部食管严重狭窄。首次手术后9个月进行了颈部食管切除术、气管切开术，并采用游离空肠移植和胃管经前胸路径重建。术后无并发症发生；术后第37天，患者进食良好，转至其他科室继续吞咽功能康复治疗。
早期发现食管穿孔和纵隔炎很重要，从而不要错过手术干预挽救患者生命的机会。应尽量减少手术操作，接下来应考虑重建。如果颈部食管也受到影响，应切除颈部食管，并根据需要使用胃管和游离空肠移植将其与下咽吻合进行重建手术。
