Safavi A, Wang N, Razzouk A, Gan K, Sciolaro C, Wood M, Vyhmeister E E, Miranda R, Ahn C, Gundry S R
Department of Surgery, Loma Linda University of Medical Center, California 92354, USA.
Am Surg. 1995 Oct;61(10):919-24.
Esophageal leak following primary repair of esophageal perforation is a serious complication that can lead to severe mediastinitis and sepsis. Complete diversion with esophageal exclusion or resection is designed to minimize further mediastinal contamination. However, this approach is not necessarily associated with less morbidity or mortality. Furthermore, a second stage operation is required to restore esophageal continuity. From 1986 to 1994, we performed a one-stage primary repair of the distal esophagus in seven patients with either iatrogenic (n = 5) or spontaneous (n = 2) perforations and reinforced the repair by a fundic wrap. One patient underwent an additional modified Heller myotomy for achalasia. Delay between perforation and operation was less than 6 hours in 3 patients, 6 to 24 hours in 2 patients, and greater than 24 hours in 2 patients. Only one patient (14%) developed a small esophageal leak that spontaneously resolved with adequate mediastinal drainage, intravenous antibiotics, and aggressive nutritional support. One patient (14%), whose repair was delayed by 12 hours, died postoperatively of profound sepsis. This patient was moribund from sepsis preoperatively, and postmortem examination of the esophagus revealed no evidence of esophageal leak. Esophageal continuity was maintained in all patients. The median length of stay was 21 days (range, 15-58 days). We conclude that primary reinforced repair of esophageal perforation using a fundic wrap is an effective method of treatment for distal esophageal perforation, even when the repair is delayed by more than 24 hours.
食管穿孔一期修复术后发生食管漏是一种严重的并发症，可导致严重的纵隔炎和脓毒症。采用食管旷置或切除进行完全转流旨在尽量减少进一步的纵隔污染。然而，这种方法不一定能降低发病率或死亡率。此外，还需要二期手术来恢复食管的连续性。1986年至1994年，我们对7例医源性（n = 5）或自发性（n = 2）穿孔的患者进行了远端食管一期修复，并通过胃底包绕加强修复。1例患者因贲门失弛缓症额外接受了改良的Heller肌切开术。穿孔与手术之间的间隔时间，3例患者少于6小时，2例患者为6至24小时，2例患者超过24小时。仅1例患者（14%）出现小的食管漏，经充分的纵隔引流、静脉使用抗生素及积极的营养支持后自行愈合。1例患者（14%），其修复延迟了12小时，术后死于严重脓毒症。该患者术前因脓毒症已奄奄一息，食管尸检未发现食管漏的证据。所有患者的食管连续性均得以维持。中位住院时间为21天（范围15 - 58天）。我们得出结论，即使修复延迟超过24小时，采用胃底包绕对食管穿孔进行一期加强修复仍是治疗远端食管穿孔的有效方法。
