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。     

Treatment of Thoracic Esophageal Anastomotic Leaks and Esophageal Perforations with Endoluminal Stents: Efficacy and Current Limitations

Background  Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center. Methods  Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured. Results  Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%). Conclusions  Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment. Dirk Tuebergen and Emile Rijcken contributed equally to this work.     

Challenges in reversing esophageal discontinuity operations

BACKGROUND: After catastrophic esophageal or gastric disruption results in esophageal discontinuity, operations to restore swallowing are surgical challenges. METHODS: A retrospective review and assessment of functional results was performed in 40 patients (average age 59.9 years) who had 42 operations to reverse esophageal discontinuity between 1973 and 2002. RESULTS: Esophageal discontinuity resulted from gastric necrosis after esophagectomy and esophagogastrostomy (n = 10) or hiatal hernia repair (n = 4), esophageal perforation complicating dilatation (n = 5), failed colonic or jejunal interpositions (n = 5), caustic ingestion (n = 4), Boerhaave syndrome (n = 4), esophagogastric anastomotic leak (n = 3), and other causes (n = 6). Eighteen patients (43.9%) required prolonged mechanical ventilation. Thirty-one (75.6%) had an end cervical esophagostomy; 6, an anterior thoracic esophagostomy; 2, lateral esophagostomy and in situ native esophagus stapled and divided distally; and 1 each, a stapled, divided esophagus without esophagostomy and a stapled undivided esophagus without esophagostomy. Twenty-six patients (63.4%) had undergone partial or total gastrectomy. Ten (24.4%) had vocal cord paralysis. Operations reestablishing continuity included colonic interposition in 23 (56.1%), substernal gastric interposition in 7 (17.1%), esophagectomy and cervical anastomosis in 6, esophageal reanastomosis in 3, staged jejunal interposition in 1, and Roux-en-Y esophagojejunostomy in 1. There were no hospital deaths. Twenty-eight patients (68.3%) had postoperative complications. Length of stay averaged 20.6 days. Follow-up for 40 patients averaged 54.5 months. Functional results (39 patients) were excellent in 12 (30.8%), good in 15 (38.5%), fair in 10 (25.6%), and poor in 2 (5.1%). CONCLUSIONS: Successful reversal of esophageal discontinuity requires individualized assessment and ingenuity. Despite appreciable morbidity, the ultimate result is generally gratifying.     

同时性多原发食管癌

目的 探讨同时性多原发食管癌的临床特点、诊断和治疗.方法 采用回顾性研究的方法,对收治的32例同时性多原发食管癌的临床资料进行总结、分析.结果 全组食管双原发灶30例,三原发灶2例,共66个病灶,其中位于颈段22个,胸上段10个,胸中段19个,胸下段15个.66个病灶中,鳞癌65个,腺癌1个.32例中术前确诊26例.32例均采用手术治疗,其中4例行探查手术,1例行姑息切除手术,余27例行完全性切除手术.术后病理食管残端阳性2例.术后出现并发症8例.术后随访28例,1、3和5年生存率分别为76.9％、43.3％和14.8％.结论 完善的术前检查可显著提高同时性多原发食管癌的确诊率,手术是其较好治疗方法.     

食管破裂诊断及外科手术方式的选择——附36例临床分析

目的探讨食管破裂的诊断与手术方式。方法 1980-01—2012-06间共收治36例食管破裂与穿孔患者。保守治疗2例,手术治疗34例。单纯食管破裂修补术、食管破裂修补加肋间肌瓣、膈肌瓣、带蒂大网膜覆盖破裂口8例;破裂食管切除、Ⅰ期食管胃胸内或颈部吻合术3例;纵膈引流、胸腔引流或食管"T"管引流加空肠造瘘6例;食管旷置或颈部食管造瘘,加纵膈、胸腔引流及空肠造瘘,Ⅱ期消化道重建2例,其中1例为经胸骨后管状胃与颈部食管吻合;颈部食管旁切开引流术及食管支架置入术各1例。贲门失弛缓症、食管癌、食管癌术后吻合口狭窄扩张或支架置入时破裂5例:姑息性食管癌切除、吻合口狭窄部切除再游离胃行颈部吻合术4例,食管破裂修补术加破裂食管对侧Heller手术1例。合并多发性肋骨骨折肺深部裂伤、脾破裂胃破裂、车祸胸部贯通伤伴胸壁皮肤Ⅱ度烧伤各1例:行肺裂伤修补,胸腹联合切口行脾切除胃破裂修补术加胃空肠造瘘,1例伤后6d,确诊食管破裂,行食管破裂修补及肋间肌瓣加固。1例食管异物40 d,致食管-主动脉瘘(AEF),左心转流下阻断主动脉,修补主动脉破口,切除胸段食管行颈部食管胃吻合,获成功。食管胸中段化学性烧伤致穿孔1例,I期行胸段食管切除食管胃颈部吻合术。食管破裂修补术后再瘘3例:行胸腔廓清、上下胸腔引流及空肠造瘘。结果治愈27例,其中3例并吻合口狭窄,经扩张后好转。死亡9例。结论选择合理方式治疗食管破裂至关重要。要综合考虑食管破裂的原因、部位、时间、大小、原发疾病、并发症、纵隔及胸腔感染情况。     

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.     

Esophagectomy for esophageal disruption

When esophageal disruption occurs in the presence of preexisting esophageal disease or is associated with sepsis or fluid and electrolyte imbalance, aggressive and definitive therapy often provides the only chance for patient salvage. Twenty-four adults (average age, 59 years) with intrathoracic esophageal perforations underwent esophagectomy: 15, transhiatal esophagectomy without thoracotomy; and 9, transthoracic esophagectomy. Restoration of alimentary continuity with an immediate cervical esophagogastric anastomosis was carried out in 13 patients. Eleven underwent a cervical or anterior thoracic esophagostomy, and 10 of them had a subsequent colonic (7) or gastric (3) interposition from 4 to 32 weeks (average time, 8.6 weeks) later. The perforations were due to esophageal instrumentation (9 patients), acute caustic ingestion (2), emesis (2), intrathoracic esophagogastric anastomotic disruption (2), and other causes (9). Preexisting esophageal disease in 20 patients included chronic strictures (10 patients), reflux esophagitis (3), esophageal cancer (3), achalasia (2), diffuse spasm (2), and monilial esophagitis (1 patient). Ten patients were operated on within 12 hours after the injury; 3, within 12 to 24 hours; and 11, within three to 45 days (average interval, 6.6 days). There were three hospital deaths (13%). Nineteen of the 21 survivors were able to swallow comfortably until the time of death or latest follow-up. Aggressive diagnosis and aggressive treatment of life-threatening esophageal perforations are advocated. Conservative procedures (repair, diversion, or drainage) for a perforation with preexisting esophageal disease often inflict more morbidity than esophageal resection, which eliminates the perforation, the source of sepsis, and the underlying esophageal disease. The decision to restore alimentary continuity in a single stage must be individualized.     

Personal management of 57 consecutive patients with esophageal perforation

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.     

Esophagogastrectomy for carcinoma: current hospital mortality and morbidity rates.

Between January 1, 1970, and March 1, 1979, 153 patients with carcinoma of the esophagus or cardia were seen at the Lahey Clinic; 124 (81%) underwent surgical exploration and 102 (82.3%) were found amendable to resection. This report concerns the 82 patients operated on by the senior author, 72 of whom (87.8%) had surgical resection. A variety of resective techniques were used but currently esophagogastrectomy and esophagogastrostomy is preferred, a left thoracotomy being used for low lying lesions; upper thoracic and cervical lesions are approached through a combined abdominal and right thoracic approach or esophagectomy with cervical esophagogastrostomy and without thoracotomy is used. Two deaths occurred within 30 days of operation, a hospital mortality rate of 2.8%. Significant complications developed in 11 patients (15.3%). The average survival was 20.8 months, and satisfactory long-term relief of dysphagia was achieved in 91.2% of patients. An aggressive surgical approach to the management of patients with carcinoma of the esophagus or cardia is justified, for esophagogastrectomy and esophagogastrostomy is applicable to the majority of patients; can now be performed at low risk with a reasonable period of hospitalization; and provides satisfactory long-term palliation.     

Diagnosis and management of esophageal perforations.

Esophageal perforation remains a difficult diagnostic and management problem. Recommendations regarding treatment remain controversial. A 15-year experience with perforation of the esophagus from all causes was reviewed at Louisiana State University and Veterans Administration, Medical Centers (Shreveport, LA). The majority of the injuries involved the thoracic esophagus (28 or 54%), followed by the cervical (21 or 40%), and the intraabdominal esophagus (3 or 6%). Iatrogenic causes constituted most of the injuries (52%), followed by external trauma (23%), barogenic rupture (15%), and ingested foreign bodies (10%). Diatrizoate methylglucamine 66 per cent, sodium diatrizoate 10 per cent (Gastrografin; Squibb, Princeton, NJ) contrast studies and flexible esophagoscopy were performed in 44 and 22 patients, respectively. In the cervical esophagus, contrast studies were more sensitive and specific than endoscopy (P less than .01), but both studies were equally effective as diagnostic methods in thoracic perforations. Cervical perforations were treated with either drainage alone (7 patients) or primary repair with drainage (14 patients) with an operative mortality of 4.8 per cent. Several procedures were used in thoracic perforations, which carried a mortality of 36 per cent and were more lethal than cervical tears (P less than 0.2). Any thoracic esophageal perforation treated more than 24 hours after the onset of symptoms, irrespective of what procedure was used, was associated with a significantly higher mortality than if operated on earlier (P less than .001). Five patients with perforated carcinomas were treated by esophageal resection with no mortality. Significantly higher mortality was seen with a delay in diagnosis, thoracic perforations, and Boerhaave's Syndrome. A subset of patients with perforated carcinomas may benefit from esophageal resection with delayed reconstruction.     

Perforation of the esophagus. Experience from a department of thoracic surgery

A series of 39 patients treated for perforation of the esophagus in a department of thoracic surgery is presented and discussed. All but three of the lesions arose from instrumentation within the esophagus. The treatment was mainly operative. There were no deaths among the nine patients with perforation of the cervical esophagus, but the mortality was 63% in the patients with thoracic lesions, partly as a result of frequent presence of serious disease in other organs. The authors stress the importance of more rigorous attention during intra-esophageal instrumentation to early detection and treatment of perforation.     

Rendezvous technique to recanalize a stapled esophagus after esophageal exclusion for salvaging concomitant esophageal and bronchial rupture due to Sengstaken Blakemore tube misplacement: A novel application of an old technique

This is the first reported case on concomitant bronchial and esophageal rupture due to Sengstaken Blakemore tube misplacement. Patient was managed with emergency laparotomy and thoracotomy. Esophageal exclusion and esophagostomy diversion were performed. Spontaneous recanalization of the cervical esophagus was evident 1 month after operation. However, it did not occur at the distal esophagus. A combined antegrade–retrograde rendezvous technique was employed, with two endoscopes approaching from two sides of the oesophagogastric junction, under fluoroscopic guidance, the digestive tract was successfully restored without further operation. Such rendezvous technique to recanalize a stapled esophagus has never been reported. Safety issues of Sengstaken tube insertion were reviewed.     

Strategy in the treatment of hypopharyngeal and cervical esophageal carcinoma

In the period between January 1st, 1978 and January 1st, 2003, 82 unselected patients with hypopharyngeal and cervical esophageal squamocellular carcinoma were treated at the Department of Esophagogastric Surgery, First University Surgical Hospital, Clinical Center of Serbia. In 43 (52.4%) patients operated with curative intent, radical surgical en-block resection and functional neck dissection has been performed. In 26 (60.5%) patient reconstruction was performed with stomach, in 11 (25.6%) left colon, and 6 (14%) free jejunal transfer. The overall 2-year and 5-year survival rate were 55.88% (19 patients) and 26.47% (9 patients), respectively. No patient undergoing nutritive gastrostomy and radiotherapy was alive after two years. At present surgery looks like the treatment of choice for hypopharyngeal and cervical esophageal carcinoma, providing a definitive palliation of dysphagia and better long-term survival. Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx especially with proximal lesions, whereas, gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when the resection extends below the thoracic inlet or when there is a presence of synchronous carcinoma of theesophageal.     

Etiology,treatment, and outcome of esophageal ulcers: A 10-year experience in an urban emergency hospital

Esophageal ulcers are a rare cause of upper gastrointestinal bleeding. This report describes the etiology, treatment, complications, and outcome of esophageal ulcers. An esophageal ulcer is defined as a discrete break in the esophageal mucosa with a clearly circumscribed margin; esophageal ulcers were seen in 88 patients from a total of 7564 esophagogastroduodenoscopies done by one surgeon at an urban hospital from 1991 to 2001. All hospital reports were reviewed. The etiology of esophageal ulcers included the following: gastrointestinal reflux disease (GERD) (n = 58, 65.9%), drug induced (n = 20, 22.7%), candidal (n = 3, 3.4%), caustic injury (n = 2, 2.3%), and herpes simplex virus (HSV), human immunodeficiency virus (HIV), marginal ulcer, foreign body, and unknown etiology (n = 1 of each, 1.1%). The mean size of GERD-induced esophageal ulcers and drug-induced esophageal ulcers was 2.78 and 2.92 cm, respectively; 80.3% of GERD-induced esophageal ulcers and 13.8% of drug-induced esophageal ulcers were located in the lower thoracic esophagus. Morbidity (n = 44, 50%) included hemorrhage (n = 30, 34%), esophageal stricture (n = 11, 12.5%), and esophageal perforation (n = 3, 3.4%). Nonoperative therapy sufficed in 81 patients (92%). Three patients (3.4%) had a recurrence of esophageal ulcers. Fifteen patients (17.0%) required endoscopic intervention including esophageal dilatation for stricture in 11 patients and endoscopic hemostasis for esophageal bleeding in four patients. Surgery (n = 7, 8.0%) was reserved for esophageal stricture and perforation. Two patients (2.3%) died from complications of esophageal ulcers: hemorrhage in one and perforation in one. Three patients died of their primary disease. GERD and drug ingestion are common causes of esophageal ulcers. Midesophageal ulcers have a greater tendency to hemorrhage compared with ulcers at the gastroesophageal junction; this may reflect the etiology. Strictures complicate GERD-induced esophageal ulcers but not drug-induced esophageal ulcers. Esophageal dilatation is an effective treatment for most strictures associated with esophageal ulcers. Esophageal ulcers rarely cause death. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003     

Hand-Sewn Cervical Anastomosis Versus Stapled Intrathoracic Anastomosis After Esophagectomy for Middle or Lower Thoracic Esophageal Cancer: A Prospective Randomized Controlled Study

Purpose The type of anastomosis and its outcome can affect postoperative morbidity, mortality, and quality of life after esophagectomy. We compared the outcomes of cervical hand-sewn anastomosis (CHS) and intrathoracic stapled anastomosis (ITS) performed after esophagectomy and gastric reconstruction. Methods Thirty-two patients with middle or lower thoracic esophageal cancer were prospectively randomized to undergo CHS (n = 18) or ITS (n = 14) after esophagectomy. We compared clinical data, postoperative symptoms, and long-term survival in the two groups. Results The rates of anastomotic leak and stricture in the CHS and ITS groups were 16.7% versus 7.1% and 0% versus 14.2%, respectively, which do not represent significant differences. The respective rates of recurrent laryngeal nerve palsy were 38.8% versus 7.1% (P < 0.05), and proximal esophageal resection was 15 mm longer (P < 0.05) in the CHS group. There were no significant differences in symptoms 6 months after surgery, or in the overall 5-year survival rates (72.2% and 85.7%, respectively). Conclusions The two methods of anastomosis yielded similar anastomotic outcomes. Although the incidence of recurrent laryngeal nerve injury was higher after CHS, and proximal esophageal resection was longer, this had little impact on postoperative symptoms and long-term survival.     

Clinical outcomes of extended esophagectomy with three-field lymph node dissection for esophageal squamous cell carcinoma

OBJECTIVE: Opinions are conflicting about 3-field lymph node dissection (3FLND) during esophagectomy for esophageal cancer. In the current study, we sought to determine the prevalence of cervical and upper thoracic lymph node metastasis in patients with squamous cell carcinoma of the thoracic esophagus and to determine the impact of 3FLND on mortality, morbidity, survival, and recurrence rate. MATERIALS AND METHODS: Among 287 patients with squamous cell carcinoma of the thoracic esophagus seen between November 1985 and December 2001, 141 (49%) underwent extended esophagectomy with 3FLND (cervical, mediastinal, and abdominal lymph node dissection). Patients were observed and clinicopathologic information collected prospectively on all patients until death or August 2002. The median follow-up was 41 months, ranging from 10 to 173 months. RESULTS: Hospital mortality and morbidity rates were 6.4% and 80%, respectively. Thirty-four of 70 node-positive patients had cervicothoracic nodal involvement. Sixteen patients (11%) had nodal involvement confined only to the cervicothoracic nodes, and no patients with lower thoracic esophageal carcinoma showed cervicothoracic involvement alone. The frequency of cervical nodal disease was correlated with nodal status within the mediastinum (P <0.01). The 1-, 3-, and 5-year overall survival rates for all 141 patients were 76%, 58%, and 48%, respectively. Among significant variables verified by univariate analysis, independent prognostic factors for overall survival determined by multivariate analysis were number of lymph node metastasis (P <0.01), amount of blood transfusion (P <0.05), length of operation (P <0.05), and presence of pulmonary complications (P <0.05). CONCLUSIONS: Extended esophagectomy with 3FLND can be performed with an acceptable mortality. Metastases frequently involved the upper thoracic and cervical lesions, and cervical nodal disease was correlated with thoracic nodal status. 3FLND proved to be an important staging system in 11% of patients. An excellent overall survival suggests a superiority of 3FLND when performed at experienced centers.     

Acquired nonmalignant tracheoesophageal fistula

Acquired tracheoesophageal fistula (TEF) caused by cuffed tracheal tubes, surgical trauma, and blunt injuries is an unusual and serious problem. Several differing approaches to management have been proposed. We have repaired such fistulas in 20 patients; 14 of them were related to tracheal intubation, three to blunt trauma, two followed anterior cervical spine fusions, and one resulted from a foreign body. Fistula closure on ventilator-dependent patients was usually delayed until they were weaned from respiratory support. Four patients had esophageal diversion before repair of their fistulas. There was sufficient tracheal damage to require resection and end-to-end anastomosis in 13 patients. The esophageal defect was closed directly in 16 patients, and end-to-end reconstruction of the esophagus was accomplished in four. There were two deaths, and one fistula recurrence required reoperation. These results support our recommendations to delay fistula closure in most ventilator patients, to use esophageal diversion selectively, to employ tracheal resection when there is evidence of extensive damage, and to directly repair the esophagus.     

多环黏膜切除术治疗食管高级别上皮内瘤变的临床疗效

目的 探讨多环黏膜切除术（MBM）治疗食管高级别上皮内瘤变的疗效和安全性.方法 回顾性分析2011年4月至2012年10月河南宏力医院收治的24例食管高级别上皮内瘤变患者的临床资料.24例患者均行MBM,分析患者手术时间、病变切除及并发症情况.术后1、3、6、12个月分别复查胃镜.随访时间截至2013年4月.结果 24例患者共26个病灶均顺利完成MBM治疗（其中2例行2次MBM治疗）,平均手术时间为42 min.病灶长径为0.8 ～6.0 cm,平均3.1 cm,最宽占食管周径3/4.分别使用套扎环1～6发,平均4发.术中4例患者出现明显出血,经热火检钳电灼后出血停止,未并发食管穿孔.术后病理检查结果提示重度不典型增生22例,原位癌2例.术后随访6 ～ 24个月,22例患者愈合良好;1例患者（病变范围占食管周径3/4）术后1个月出现食管瘢痕狭窄,行内镜下球囊扩张治疗症状缓解;1例患者（2处病变,分2次完成手术）术后3个月复查胃镜示病变复发,再次活组织检查考虑鳞状细胞癌,遂行外科手术治疗,术后12个月复查胃镜未见狭窄及新生物.结论 MBM是内镜下切除食管高级别上皮内瘤变安全有效的治疗方法.但是切除病变范围不宜过大,对于病变范围超过食管周径3/4,多源病变不能一次性行MBM切除治疗的患者,术后容易出现食管狭窄及病变复发,应慎重选择.     

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

BackgroundIatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program.Patients and methodsFrom January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported.Results24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement.ConclusionPreserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life.Level IV of evidence