Gurgenidze M, Magalashvili D, Akhmeteli L, Nemsadze G, Lomidze N
1The First University Clinic of Tbilisi State Medical University, Department of General Surgery; Department of Surgery №I; Georgia.
1The First University Clinic of Tbilisi State Medical University, Department of General Surgery; Department of Surgery №I; 2Department of Radiology, Georgia 1The First University Clinic of Tbilisi State Medical University, Department of General Surgery; Department of Surgery №I; Georgia.
Georgian Med News. 2021 Sep(318):28-34.
Esophageal perforation (EP) is a devastating condition. In modern times it is still associated with substantial morbidity and mortality. 62-year-old male patient came to Surgical Department of the First University Clinic of Tbilisi State Medical University on 17.10.2018 15:00. The patient complained of pain in the chest cavity, especially after eating, shortness of breath, fever, chills, weakness. The patient felt pain in the chest cavity after eating 4 days before hospitalization. CT scan revealed pneumomediastinum, extravasation of contrast medium at the level of the 8th thoracic vertebra. Esophagogastroduodenoscopy revealed a defect in the esophagus at the level of 32 cm from the incisors. Dimensions of defect were 2.0 - 3.0 cm. An urgent operation was performed. Left-sided posterolateral thoracotomy, mediastinotomy, suturing of the defect, buttressing of the sutures with the mediastinal pleura, washing and drainage of the mediastinum and left pleural cavity were performed. A Witzel gastrostomy was performed. After the operation, the patient's treatment continued in the intensive care unit. Since leakage was noted, it was decided to place an esophageal stent in the area of the defect. Stenting was performed on 05.11.2018. A complication in the form of bleeding was noted on 01.12.2018. Bleeding was controlled conservatively. Finally, stent was removed and the patient was discharged from the clinic in good condition on 07.12.2018. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation. Surgery should be undertaken in all patients who do not meet non-operative management criteria. Buttressing the esophageal repair with surrounding viable tissue has been recommended to decrease the risk of leakage. If direct repair of thoracic EP is not feasible esophageal exclusion, diversion, or resection should be performed. Repair over a large size T-tube can be used to create a controlled esophago-cutaneous fistula and minimize mediastinal and pleural contamination. Thus, esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique.
食管穿孔（EP）是一种严重的疾病。在现代，它仍然伴随着较高的发病率和死亡率。一名62岁男性患者于2018年10月17日15:00前往第比利斯国立医科大学第一大学诊所外科就诊。患者主诉胸腔疼痛，尤其是进食后，伴有呼吸急促、发热、寒战、乏力。患者在住院前4天进食后出现胸腔疼痛。CT扫描显示纵隔积气，第8胸椎水平造影剂外渗。食管胃十二指肠镜检查显示距门齿32 cm处食管有一缺损。缺损大小为2.0 - 3.0 cm。遂进行急诊手术。行左侧后外侧开胸术、纵隔切开术、缺损缝合术，用纵隔胸膜加固缝合处，冲洗并引流纵隔和左侧胸腔。行维泽尔胃造口术。术后，患者在重症监护病房继续接受治疗。由于发现有渗漏，决定在缺损部位放置食管支架。于2018年11月5日置入支架。2018年12月1日出现出血并发症。出血通过保守治疗得到控制。最后，取出支架，患者于2018年12月7日康复出院。在过去几年中，已经开发出了包括内镜夹、覆膜金属支架和腔内负压治疗在内的新的介入性内镜技术来处理食管穿孔。所有不符合非手术治疗标准的患者均应进行手术。建议用周围有活力的组织加固食管修复处，以降低渗漏风险。如果直接修复胸段食管穿孔不可行，则应进行食管旷置、改道或切除术。通过大尺寸T形管进行修复可用于形成可控的食管皮肤瘘，并尽量减少纵隔和胸膜污染。因此，尽管有几十年的临床经验和手术技术创新，但食管穿孔仍然是一个诊断和治疗难题。
