食管破裂与穿孔15例的临床诊治分析

目的探讨食管破裂与穿孔的诊断与治疗,提高对该疾病的诊治水平。方法总结分析我科15例食管破裂与穿孔的临床病例资料。颈段食管穿孔3例,2例为异物所致,1例为外伤所致,均手术治疗,胸段食管破裂穿孔12例,其中自发性食管破裂穿孔4例,食管异物损伤5例,外伤性食管穿孔2例,医源性损伤1例,根据食管的损伤程度及感染累及范围分别采取食管切开异物取出食管修补,食管部分切除,纵隔引流,瘘口修补等手术治疗12例。结果15例食管破裂与穿孔治愈13例;1例死于合并糖尿病因胸腔和纵隔感染严重,中毒性休克,呼吸衰竭,肾功能衰竭;1例死于食管癌引发食管破裂穿孔致感染性休克,多器官衰竭。结论根据食管破裂与穿孔的大小、时间、部位、纵膈和胸腔污染程度,早期明确诊断,及时采取合适的手术方式是治疗的关键。     

食管异物致食管穿孔的外科治疗

作者对近5年10例食管异物致食管穿孔病例的临床表现、异物种类、穿孔部位及治疗过程进行了详细的分析。重点指出早期诊断、早期手术的重要性。尤其对食管中段位于主动脉弓水平的穿孔并伴有呕血的病人,要格外提高警惕,尽早手术。术前要做好体外循环、人造血管等准备;术中采用低压低温、血管置换、彻底清除病灶、抗生素冲洗胸腔等措施来确保手术的完全成功。     

食管穿孔83例分析

８３例不同原因引起的食管穿孔，保守治疗５７例；手术２６例，行单纯食管修补术２０例、开胸行纵隔和／或胸腔引流２例、切除贲门肿物行胃食管吻合１例、颈部食管外置２例（其中１例并行二期结肠代食管手术）、１例开胸取异物形成食管瘘后，行二期修补瘘术。全组死亡８例，其中死于纵隔胸腔感染和主动脉破裂出血各４例。总治愈率８５％。并指出异物假牙造成食管穿孔的重要性，对严重的腐蚀性食管灼伤应早期行食管镜检，并针对食管穿孔部位、种类、间隔期、纵隔与胸腔的感染程度及病人具体情况采取相应的治疗措施。     

外科手术取食管异物15例

目的探讨外科手术取食管异物的适应证及手术方法。方法采用外科手术摘除尖锐食管异物15例，其中颈段5例，胸段10例。5例颈段异物均合并脓肿，行脓肿切开引流同时取出异物；4例胸段异物摘除后施行改良食管腔内置管术；余6例取出异物后分层缝合食管切口。结果全组无死亡。4例施行食管腔内置管，术后1～2周中毒症状缓解，3～5周拔管后食管X线钡餐造影检查无穿孔或狭窄。1例切开食管取异物后发生右侧脓胸，术后第8d行脓胸廓清术及改良食管腔内置管，1个月后治愈；其余患者术后7～10d恢复经口进食。结论已穿透食管的金属异物和食管镜摘除易引起穿孔的尖锐异物应采用外科手术治疗，改良食管腔内置管对纵隔感染严重、无法修补的穿孔愈合是有帮助的。     

胸段食管骨性异物穿孔的分类与外科治疗

目的 探讨骨性异物所致胸段食管破裂穿孔的分类及其治疗方法.方法 对57例胸段食管骨性异物破裂穿孔患者根据食管损伤性质和继发感染程度进行分类,分别采取不同手术方式并总结其疗效.结果 Ⅰ类为食管破裂、纵隔无脓肿形成,共计17例;其中直接食管破口连续缝合修补7例,直接缝合修补后,外穿孔部位用肋间肌加强6例,心包和带蒂大网膜加强各2例.Ⅱ类为纵膈脓肿期,共计13例;其中食管穿孔切除、胃代食管10例,纵隔脓肿清除胸腔引流3例.Ⅲ类为脓胸期,即骨性异物穿破食管后感染波及胸腔而形成脓胸,共计21例;其中食管穿孔切除、一期胃带食管12例,食管穿孔切除、二期胃或结肠带食管9例.Ⅳ类为脓肿侵犯周围器官并形成主动脉-食管瘘或气管食管瘘,共计6例;气管瘘修补、大网膜填塞、二期胃或结肠代食管术4例,病变段血管切除、人工血管置换、二期胃或结肠代食管2例.Ⅰ、Ⅱ、Ⅲ类的51例患者50例获治愈,1例死于脓毒症引起的多脏器功能衰竭综合征.Ⅳ类的6例患者术前准备时麻醉诱导过程死亡1例,手术死亡1例,死因皆为食管-主动脉瘘导致的大出血,其余4例治愈.结论 对骨性异物所致胸段食管损伤病变进行分类,并采取相应方法治疗有助于提高疗效;一旦确诊均应采取积极的手术方式.     

外科途径治疗经保守处理无效的食管异物

目的探讨保守治疗无效的食管异物经外科治疗的手术途径和方法,以减少手术对患者的损伤和术后并发症的发生、促进患者快速康复。方法回顾性分析2011年6月至2016年8月我院食管异物经保守治疗无效需外科手术治疗37例患者的临床资料,其中男21例、女16例,年龄17～62(42.00±9.75)岁。8例经颈部切口手术治疗,27例经胸部切口取出异物,2例经胸腔镜取出异物。结果随访3～18(7.95±3.41)个月,4例术后发生消化瘘患者在术后2～5个月能正常进食,其余患者均在术后1个月能正常进软质饮食,术后1.5个月正常饮食。2例手术患者因术后纵隔感染、胸腔感染致脓毒血症,多器官功能衰竭死亡。结论食管异物的外科手术根据其嵌顿的位置不同、穿孔与否、手术路径及方法亦有所不同,采取适宜的手术途径和方法可以提高手术的准确性,减少手术对食管的损伤和术后并发症,减轻患者的痛苦,从而提高患者术后生存质量。     

食管穿孔的诊断及治疗

目的总结食管穿孔的临床特征、诊断及治疗经验方法。方法 回顾分析2000-01～2010-06 23例食管穿孔临床资料及诊治情况结果。结果本组均经钡剂造影、胸部X线平片、CT、胸腔穿刺等检查,并经手术及食管镜证实。23例中,颈段食管穿孔5例,胸段18例。8例为食管自发性破裂,3例为医源性,11例为食管异物致穿孔,1例为外伤性穿孔。治疗颈段3例手术修补、引流,2例保守治疗;胸段15例经开胸手术,其中2例行食管切除、胃食管吻合术,修补13例;2例行可回收带膜食管支架置入封堵术、胸腔闭式引流、空肠造瘘营养支持治疗,1例放弃治疗。全组1例死于严重胸腔、纵膈感染。结论根据发病史及临床特征要及时、准确的诊断是降低食管穿孔病死率的关键。结合穿孔时间、部位、感染程度选择治疗方案,颈段可保守治疗,胸段食管穿孔应以手术治疗为主。     

食管瘘的外科治疗

我院 2 0 0 1年 5月～ 2 0 0 2年 5月收治食管穿孔 1 9例 ,现将具体诊治方法及体会报道如下。1 .临床资料 :1 9例患者中男 8例、女1 1例 ;年龄 1 5～ 58 0岁。食管异物 (头饰、胸针、义齿等 ) 8例 ,其中异物直接导致食管穿孔 7例 ,在外院经口取异物时划破食管导致穿孔 1例 ;贲门失弛缓症球囊扩张导致穿孔 2例 ;自发性食管破裂穿孔 4例 ;食管癌介入治疗或放疗后穿孔 5例。发病至确诊时间 3～ 48h。8例食管异物及 2例自发性食管破裂的患者经手术修补瘘口。食管异物致食管穿孔部位在颈段食管 2例 ,上段食管 4例 ,中段食管 2例 ;瘘口长度 0 5c…     

食管、贲门、膈

食管癌患者术后早期肠内营养的临床研究；电视胸腔镜辅助食管癌切除术；胸段食管鳞癌淋巴结转移强度和淋巴结清扫手术方式分析；犬自体肺组织瓣替代胸段食管部分缺损的实验研究；腹腔镜联合纵隔镜在食管癌根治术中的应用；结肠代食管手术68例临床分析；不同肠道准备法对结肠代食管术并发症的影响；36例食管癌穿孔的手术治疗；     

医源性食管穿孔的原因及临床治疗

目的：探讨医源性食管穿孔的发生原因，并提出预防和治疗对策。方法：对1981年1月－2001年12月收治的18例医源食管穿孔病人的临床资料进行回顾性分析。结果：医源必食管穿孔种类：硬质食管镜取异物术10例（55．6％），机械性食管扩张术4例（22．2％），Heller's手术2例（11．1％），纤维食管镜取异物术2例（11．1％），全部病人均经手术治疗，痊愈16例（88．9％），死亡2例（11．1％）。结论：硬质食管镜下取异物是导致医源性食管穿孔的最常见原因，其次为食管狭窄时采用机械性扩张术，Heller's手术和纤维食镜所致者少见，早期诊断，合理的手术方式是提高医源性食管穿孔的治愈率的关键。     

胸食管异物损伤病变的分级和外科治疗

目的探讨异物性胸食管损伤病变的分级及其治疗方法。方法对84例异物性胸食管损伤患者根据其病变程度进行分级,其中食管非穿透性损伤（Ⅰ级）18例;食管穿透性损伤伴食管周围炎或纵隔炎（Ⅱ级）39例;食管穿透性损伤并发严重纵隔和（或）胸内感染（Ⅲ级）17例;食管穿孔炎症累及邻近大血管（Ⅳ级）10例。根据食管损伤程度和炎症累及范围分别采取经胸食管切开异物摘取（Ⅰ级患者）,食管修补、食管部分切除、纵隔引流、瘘口修补（Ⅱ、Ⅲ级患者）或大动脉置换（Ⅳ级患者）等手术。结果Ⅰ级和Ⅱ级异物性胸食管损伤57例均治愈,Ⅲ级患者中死亡1例（1／17）,Ⅳ级患者中死亡9例（9／10）。结论对异物性胸食管损伤病变进行分级有助于制定科学、合理的治疗方案,降低病死率的关键是预防食管-主动脉瘘的发生。     

损伤性食管穿孔的诊断和治疗(附38例报告)

1966年2月至1993年8月治疗38例损伤性食管穿孔。损伤性食管穿孔以食管异物引起为最多见,共23例,占60.5％;其次为外伤性8例,器械性和手术误伤7例。行食管修补术12例,11例成功(91.7％);18例行颈部、纵隔或胸腔引流术;8例保守治疗。38例中痊愈29例,治愈率76.3％;死亡9例(23.7％)。作者认为早期诊断和及时处理对提高治愈率至关重要,应根据发病时间、病情程度选择不同的治疗措施。     

Esophageal Perforation during Gastric Bypass: Delayed Diagnosis and Management

Mediastinitis secondary to esophageal perforation is usually a life-threatening problem associated with high morbidity and mortality.We present a 44-year-old morbidly obese female who underwent laparoscopic gastric bypass, during which she suffered perforation of the distal thoracic esophagus diagnosed 5 days later during progression of mediastinitis. She was treated with left posterolateral thoracotomy, drainage of a peri-esophageal abscess and primary repair of the esophagus with intercostal muscle reinforcement, and cervical esophagostomy. Thereafter, she had an uneventful hospital course, and remains well on 12-month follow-up.     

One-stage operation for esophageal perforation of a thoracic aortic aneurysm

The patient was a 65-year-old man. Preoperative computed tomography showed a ruptured thoracic aortic aneurysm that formed a submucosal hematoma in the thoracic esophagus with perforation near the esophageal-cardiac junction. A one-stage operation was performed. The aortic arch and proximal descending aorta were replaced with rifampicin-soaked synthetic grafts, followed by subtotal esophagectomy with primary reconstruction using a gastric tube. His early postoperative course was uneventful, and he started oral intake on postoperative day (POD) 15; however, dysphagia occurred on POD 20, and an esophageal fistula and mediastinitis developed more than 1 month after the operation. The patient recovered from mediastinitis after 4 months of mediastinal drainage and administration of antibiotics. Thus, a one-stage operation for esophageal perforation of a ruptured thoracic aortic aneurysm with primary esophageal reconstruction is possible in selected patients. Care must be taken to avoid postoperative compression of the reconstructed esophagus by a mediastinal hematoma.     

Airway injury during anesthesia: a closed claims analysis

BACKGROUND: Airway injury during general anesthesia is a significant source of morbidity for patients and a source of liability for anesthesiologists. To identify recurrent patterns of injury, the authors analyzed claims for airway injury in the American Society of Anesthesiologists (ASA) Closed Claims Project database. METHODS: The ASA Closed Claims database is a standardized collection of case summaries derived from professional liability insurance companies closed claims files. All claims for airway injury were reviewed in depth and were compared to other claims during general anesthesia. RESULTS: Approximately 6% (266) of 4,460 claims in the database were for airway injury. The most frequent sites of injury were the larynx (33%), pharynx (19%), and esophagus (18%). Injuries to the esophagus and trachea were more frequently associated with difficult intubation. Injuries to temporomandibular joint and the larynx were more frequently associated with nondifficult intubation. Injuries to the esophagus were more severe and resulted in a higher payment to the plaintiff than claims for other sites of airway injury. Difficult intubation (odds ratio = 4.53, 95% confidence interval [CI] = 2.36, 8.71), age older than 60 yr (odds ratio = 2.97, 95% CI = 1.51, 5.87), and female gender (odds ratio = 2.43, 95% CI = 1.09, 5.42) were associated with claims for pharyngoesophageal perforation. Early signs of perforation, e.g., pneumothorax and subcutaneous emphysema, were present in only 51% of perforation claims, whereas late sequelae, e.g., retropharyngeal abscess and mediastinitis, occurred in 65%. CONCLUSION: Patients in whom tracheal intubation has been difficult should be observed for and told to watch for the development of symptoms and signs of retropharyngeal abscess, mediastinitis, or both.     

Acute mediastinitis: clinical features and review of a case load

The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. All patients except one--managed medically--were submitted to mediastinal drainage (surgical or by mediastinoscopy), combined with cervical debridement and drainage in cases of descending necrotising mediastinitis, alimentary tract diversion (cervical oesophagostomy + feeding jejunostomy + gastric decompression) in cases of large oesophageal lesions or if the lesion occurred more than 24 hours before observation, and uni- or bilateral tube thoracostomy. Furthermore, antibiotic therapy was always administered, initially choosing broad-spectrum medications, and subsequently adjusting according to bacterial cultures. Four patients died. In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).     

肠腔内异物所致机械性小肠梗阻的CT诊断

【摘要】 目的 探讨CT对肠腔内异物所致机械性小肠梗阻诊断的价值。 资料与方法 回顾性分析8例经手术证实的肠腔内异物所致机械性小肠梗阻的CT表现。 结果 8例患者均有程度不等的肠梗阻，术前均能正确诊断肠梗阻。其中，小肠食入性异物小肠梗阻3例，粪石性小肠梗阻 3例，胆石性小肠梗阻 2例，均无肠缺血坏死、穿孔等并发症。 结论 通过典型的征象分析，CT能术前诊断肠腔内异物所致机械性小肠梗阻。