Bass K D, Meagher D P, Haase G M
The Children's Hospital, University of Colorado Health Science Center, Denver, USA.
J Pediatr Surg. 1998 Nov;33(11):1720-2. doi: 10.1016/s0022-3468(98)90618-2.
An 11-year-old boy presented moribund, with massive abdominal distension. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsuccessful, the old gastrostomy site was used to gain percutaneous access to the stomach resulting in release of gastric contents and stabilization of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was performed with stapled closure of the distal intraabdominal esophagus and prepyloric region. Sump suction was placed in the proximal esophagus and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscopy. A nasoesophageal tube was passed into the abdomen, tied to a Jackson-Pratt drain, and the composite tube repositioned in the midesophagus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, with the remainder delivered overnight via tube feedings. This case describes gastric necrosis after gas bloat syndrome as a late complication of Nissen fundoplication. A novel approach to the management of distal esophageal perforation allowed preservation of a functional, intact native esophagus.
一名11岁男孩就诊时情况危急，腹部极度膨隆。他在2岁时接受了nissen胃底折叠术和胃造瘘术。在尝试插入鼻胃管未成功后，利用原胃造瘘部位经皮进入胃内，引出胃内容物，血压和灌注得以稳定。手术中发现胃极度扩张并伴有胃坏死。行胃次全切除术，用吻合器闭合腹段食管远端和幽门区。在食管近端放置了一根吸引管，并广泛引流腹腔。术后第19天经影像学和内镜检查证实食管远端穿孔。将一根鼻食管管插入腹腔，系在一根杰克逊-普拉特引流管上，然后将复合管重新放置在食管中段，实现近端和远端的可控引流。6个月后，制作了一个亨特-劳伦斯食管空肠袋。13岁时，该患儿临床状况良好，经口摄入50%的营养需求，其余通过夜间管饲提供。本病例描述了气胀综合征后胃坏死作为nissen胃底折叠术的晚期并发症。一种处理食管远端穿孔的新方法使功能性完整的原生食管得以保留。
