Wang N, Razzouk A J, Safavi A, Gan K, Van Arsdell G S, Burton P M, Fandrich B L, Wood M J, Hill A C, Vyhmeister E E, Miranda R, Ahn C, Gundry S R
Department of Surgery, Loma Linda University Medical Center, Calif. 92354, USA.
J Thorac Cardiovasc Surg. 1996 Jan;111(1):114-21; discussion 121-2. doi: 10.1016/S0022-5223(96)70407-5.
The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older (p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome.
延迟诊断的胸段食管穿孔的处理是一个存在争议的话题。由于一期修复作为一种简单的单阶段手术具有明显优势，该技术被优先用于连续22例食管穿孔患者中的18例。这些患者根据穿孔与修复之间的时间间隔分为三组：A组，少于6小时，5例患者（28%）；B组，6至24小时，6例患者（33%）；C组，超过24小时，7例患者（39%）。A组患者年龄较大（p<0.05），B组医源性穿孔较少（B组，17%；A组，80%；C组，57%，p<0.1）。三组均使用额外组织支撑修复部位（A组，3/5例患者，60%；B组，4/6例患者，67%；C组，6/7例患者，86%；p无统计学意义）。7例患者（39%）使用胃底折叠术加强一期修复部位。对三组的结果进行了分析。A组术后漏出比例最低（A组，0/4例患者，0%；B组，4/6例患者，67%；C组，5/6例患者，83%；p<0.05），术后发病率也最低（A组，2/5例患者，40%；B组，6/6例患者，100%；C组，6/7例患者，86%；p<0.1）。然而，漏出和发病率的增加并未导致死亡率上升。每组均有1例死亡，总体死亡率为17%（A组，1/5例患者，20%；B组，1/6例患者，17%；C组，1/7例患者，14%；p无统计学意义）。我们得出结论，在重症监护能力先进的时代，大多数胸段食管穿孔患者无论穿孔与手术之间的时间间隔如何，都能安全地完成一期修复。除非立即进行一期修复，否则缝合部位漏出很常见。然而，术后漏出通常无关紧要，不一定会导致不良后果。
