Chiu Chien-Hung, Leow Osbert Qi Yao, Wang Yu-Chao, Chen Wei-Hsun, Fang Hsin-Yueh, Chao Yin-Kai, Lin Jules
Division of Thoracic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan.
Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan.
J Thorac Dis. 2023 Mar 31;15(3):1228-1235. doi: 10.21037/jtd-22-1316. Epub 2023 Mar 10.
Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations.
We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material.
There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation.
A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.
自发性食管穿孔是一种具有挑战性的外科急症，发病率和死亡率均较高，及时进行一期修复可取得良好效果。然而，对延迟性自发性食管穿孔进行直接修复并不总是可行的，且死亡率较高。食管支架置入术可为食管穿孔的治疗带来益处。在本研究中，我们回顾了我们采用食管支架置入联合微创外科引流治疗延迟性自发性食管穿孔的经验。
我们回顾性分析了2018年9月至2021年3月期间延迟性自发性食管穿孔患者。所有患者均采用综合治疗方法，包括跨越胃食管交界（GEJ）置入食管支架以减少持续污染、采用腔外缝合进行胃减压以防止支架移位、早期肠内营养以及积极进行微创胸腔镜清创和引流感染物质。
5例延迟性自发性食管穿孔患者采用了这种综合治疗方法。症状出现至诊断的平均时间为5天，症状出现至食管支架置入的间隔时间为7天。经口进食和食管支架取出的中位时间分别为43天和66天。未发生支架移位或院内死亡。3例患者（60%）出现术后并发症。所有患者均成功恢复经口进食并保留了食管。
内镜下食管支架置入联合腔外缝合以防止支架移位、胸腔镜剥脱术联合胸腔闭式引流、胃减压以及置入空肠造瘘管进行早期营养的综合治疗方法，对于治疗延迟性自发性食管穿孔是可行且有效的。该技术为一个传统上发病率和死亡率较高的具有挑战性的临床问题提供了一种侵入性较小的治疗方法。
