Salo J A, Isolauri J O, Heikkilä L J, Markkula H T, Heikkinen L O, Kivilaakso E O, Mattila S P
Department of Thoracic and Cardiovascular Surgery, Helsinki University Central Hospital, Finland.
J Thorac Cardiovasc Surg. 1993 Dec;106(6):1088-91.
Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.
1970年至1992年间，我们机构对90例食管穿孔患者进行了手术治疗。其中34例在延迟诊断（>24小时）后就诊，伴有胸段食管穿孔引起的纵隔感染。有18例为自发性破裂，11例为器械性穿孔（包括1例剖腹手术期间造成的穿孔），3例为异物导致的穿孔。1例患者食管溃疡穿孔进入心包，另1例患者食管憩室穿孔进入纵隔。19例患者接受了穿孔的一期修复，并对纵隔和胸腔进行了清洗和引流。其余15例患者接受了胸段食管一期切除、用抗生素冲洗纵隔、颈部食管造口术、胃造口术以及纵隔和胸腔引流。34例患者中有19例存活（医院死亡率44%）。接受一期修复的患者中，仅6例存活（住院死亡率68%），而接受食管切除术治疗的患者仅2例死亡（住院死亡率13%）。差异具有高度显著性（p = 0.001）。最常见的死亡原因是败血症导致的多器官功能衰竭。接受一期修复治疗的4例患者出现了术后并发症（2例败血症、1例脓胸和1例无尿），接受食管切除术治疗的7例患者出现了术后并发症（2例脓胸、2例败血症、1例肺炎、1例纵隔脓肿和1例脑脓肿）。纵隔炎愈合后，11例患者用结肠重建了食管胃连续性，2例患者用胃重建了食管胃连续性。在伴有纵隔感染的延迟性食管穿孔的治疗中，食管切除术优于单纯一期修复，单纯一期修复往往导致纵隔渗漏、持续败血症和死亡。
