Nachiappan Murugappan, Thota Ravikiran, Gadiyaram Srikanth
Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Bengaluru, IND.
Cureus. 2022 Jul 12;14(7):e26784. doi: 10.7759/cureus.26784. eCollection 2022 Jul.
Spontaneous esophageal perforation (SEP) (Boerhaave syndrome) carries high morbidity and mortality. Delay in diagnosis, because of the non-specific complaints and the rarity of the condition, further increases the mortality. While patients diagnosed early can be managed by primary closure of esophageal perforation, those presenting beyond 24 hours often require an esophagectomy with salivary diversion and feeding access with a plan for the reconstruction of the alimentary tract at a later date. In a minority of patients with a controlled esophageal fistula and feeding access, source control could be achieved by endotherapy. Patients with mediastinitis and associated systemic sepsis would be better served by surgical intervention. We present a case of an SEP with a delayed diagnosis, who underwent three unsuccessful endotherapy attempts and decortication before referral for surgical repair. The patient had an established esophageal fistula. He underwent a laparoscopic repair of the fistula. Postoperative recovery was uneventful. At the one-year follow-up, the patient was asymptomatic and had gained weight. Though surgery is the treatment of choice, the optimal management of SEP with delayed diagnosis is not clearly defined. In the current era of advanced endotherapy, more cases are being managed endoscopically. However, they carry a high failure rate, resulting in increased morbidity among the patients. Early involvement of a surgical team in the decision-making is crucial for optimal outcomes of the disease.
自发性食管穿孔（SEP）（博赫哈夫综合征）的发病率和死亡率都很高。由于症状不具特异性且该病罕见，诊断延迟会进一步增加死亡率。早期诊断的患者可通过食管穿孔一期缝合进行治疗，而发病超过24小时的患者通常需要进行食管切除术并进行唾液转流以及建立喂养通道，以便日后重建消化道。少数食管瘘得到控制且有喂养通道的患者，可通过内镜治疗实现源头控制。患有纵隔炎及相关全身感染的患者接受手术干预效果更佳。我们报告一例SEP诊断延迟的病例，该患者在转诊进行手术修复前接受了三次内镜治疗均未成功，还进行了胸膜剥脱术。患者已形成食管瘘。他接受了腹腔镜下瘘管修复术。术后恢复顺利。在一年的随访中，患者无症状且体重增加。虽然手术是首选治疗方法，但对于诊断延迟的SEP的最佳管理尚无明确定义。在当前先进内镜治疗的时代，越来越多的病例通过内镜进行管理。然而，其失败率很高，导致患者发病率增加。手术团队早期参与决策对于该病的最佳治疗效果至关重要。
