Panieri E, Millar A J, Rode H, Brown R A, Cywes S
Department of Paediatric Surgery, University of Cape Town, South Africa.
J Pediatr Surg. 1996 Jul;31(7):890-5. doi: 10.1016/s0022-3468(96)90404-2.
Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.
儿童医源性食管穿孔较为罕见。为评估此类患者的损伤模式、临床表现及治疗选择，作者回顾了1967年至1994年间在其机构接受扩张手术时发生食管全层损伤的11例儿童病例记录。需要扩张的狭窄，8例归因于腐蚀性物质摄入，2例归因于食管闭锁修复，1例归因于先天性狭窄。8例为穿透伤，3例为破裂伤。2例累及颈段食管；9例累及胸段食管。疼痛、发热和心动过速是早期症状。胸段食管近端穿孔导致左胸区域出现体征（胸腔积液/气胸）；远端穿孔则体征出现在右侧。按照传统方法治疗（局部引流、胃造瘘、早期识别后一期修复及抗生素治疗）取得成功，出现2例主要并发症，均为脓胸。最近1例气管食管瘘狭窄破裂病例仅通过口服水冲洗和抗生素治疗即获成功。6例行结肠间置术（均为腐蚀性物质摄入），1例需要对远端狭窄进行食管内切除，4例狭窄得到缓解，3例未再进行扩张。大多数医源性食管损伤儿童可通过保守措施和胸腔引流成功处理，手术仅用于食管严重破裂、腹腔内穿孔及对适当保守措施无反应的病例。食管腐蚀性损伤患者发生穿透伤的风险更高，这可能是瘢痕形成严重程度的一个指标。存在不同的临床表现模式，这取决于食管穿孔的部位。局限性狭窄的扩张破裂对食管具有良好的长期预后，甚至可能治愈狭窄本身。与穿透伤不同，在发生破裂的情况下，口服冲洗的作用仍有待充分评估。
