Altorjay A, Kiss J, Vörös A, Bohák A
Department of Surgery, Postgraduate Medical University, Budapest, Hungary.
Ann Surg. 1997 Apr;225(4):415-21. doi: 10.1097/00000658-199704000-00011.
Experiences obtained with nonoperative treatment (NOT), i.e. total prohibition of per oral food intake for a minimum of 7 days, administration of combinations of broad-spectrum antibiotics, and parenteral hyperalimentation, are described in the management of esophageal perforations.
The place, value, and indication of NOT in the management of esophageal perforation has not yet been unequivocally defined. As a result, contradictory data have been published regarding the outcome of NOT.
During the past 15 years (1979 to 1994), 20 of 86 patients (23.3%) with esophageal perforation have been treated nonoperatively from the outset. In this group, perforations were located to the upper, middle, and lower third of the esophagus in 50%, 30%, and 20%, respectively. In the operative management group (OT)--in which conservative (drainage, endeprothesis), reconstructive (suture, reinforced suture), and radical (resection) surgical methods were applied--lesions were preponderantly located in the lower one third of the esophagus (56.1%--37/66). As to the interval between the perforation and the onset of treatment, 14 patients had been diagnosed within 24 hours, whereas in 6 cases treatment had been begun beyond 24 hours.
NOT could be successfully carried out in 16 patients; the decision to use NOT had to be revised in 4 other cases (Table 1). Two patients were lost; the mortality rate was 10% (2 of 20). The rate of complications was lower in the NOT group (20%, or 4 of 20) than in the OT group (50%, or 33 of 66).
NOT can be suggested for the treatment of intramural perforations. In the case of transmural perforation, this approach should be taken into consideration if the esophageal lesion is circumscribed, is not in neoplastic tissue, is not in the abdominal cavity, and is not accompanied by simultaneous obstructive esophageal disease; in addition, symptoms and signs of septicemia should be absent.
描述非手术治疗（NOT），即至少7天完全禁止经口摄入食物、使用广谱抗生素联合治疗以及胃肠外高营养，在食管穿孔治疗中的经验。
NOT在食管穿孔治疗中的地位、价值和适应证尚未明确界定。因此，关于NOT治疗结果的资料相互矛盾。
在过去15年（1979年至1994年）中，86例食管穿孔患者中有20例（23.3%）从一开始就接受了非手术治疗。在该组中，穿孔分别位于食管上、中、下三分之一处的比例为50%、30%和20%。在手术治疗组（OT）中，采用了保守（引流、内置假体）、重建（缝合、加强缝合）和根治（切除）手术方法，病变主要位于食管下三分之一处（56.1%，即66例中的37例）。至于穿孔与治疗开始之间的间隔时间，14例患者在24小时内被诊断出来，而另外6例患者在24小时后才开始治疗。
16例患者成功实施了NOT；另外4例患者不得不更改使用NOT的决定（表1）。2例患者死亡；死亡率为10%（20例中的2例）。NOT组的并发症发生率（20%，即20例中的4例）低于OT组（50%，即66例中的33例）。
NOT可用于治疗壁内穿孔。对于全层穿孔，如果食管病变局限、不在肿瘤组织中、不在腹腔内且不伴有同时存在的食管梗阻性疾病，并且没有败血症的症状和体征，则应考虑采用这种方法。
