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。     

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。     

食管穿孔外科治疗33例临床分析

食管穿孔是指食管由各种意外性损伤或自发性破裂所引起的严重危及生命的疾病，其病死率高达20％∽40％，因食管穿孔的原因、部位、诊断延误时间、患者年龄、循环系统状况、纵隔及胸腔污染程度以及食管基础病变等不同，在治疗不同病例时所采用的方法也不尽相同。现就采用不同方法治疗的33例食管穿孔的经验和体会进行讨论。     

113例食管破裂与穿孔的外科治疗

目的总结各种原因所致的食管破裂与穿孔的治疗效果。方法统计1996年至2005年收治的113例食管破裂和穿孔者的各种致伤原因，比较保守治疗与手术治疗的疗效和死亡率、24h以内手术治疗与24h以上手术治疗的疗效和死亡率。结果28例食管颈部损伤均获治愈。85例食管胸部损伤，手术治疗的治愈率83．0％，优于保守疗法的68．7％，P〈0．05。在自发性食管破裂病例中，发病后24h内手术者76．7％治愈，24h以上手术者54．5％治愈，P〈0．05。结论食管颈部损伤无论手术修补或保守治疗，均易治愈，预后较好。食管胸部破裂与穿孔手术治疗疗效优于保守治疗，24h以内手术者疗效优于24h以匕者。     

8例医源性食管穿孔的诊断和治疗

目的探讨医源性食管穿孔的诊断和治疗。方法回顾性分析8例医源性食管穿孔的临床资料。结果8例手术过程顺利,其中1例发现较晚者经加强抗炎支持治疗痊愈。结论食管造影为确诊医源性食管穿孔的主要手段,纤维胃镜检查可弥补食管造影的不足。一旦确诊应及早手术治疗,手术以食管修补为主,所有患者均应行胃造瘘术。     

食管穿孔的外科治疗

目的探讨食管穿孔的手术方法及疗效。方法1950年1月～2001年7月我科共收治各种食管穿孔97例，其中65例采用保守治疗，32例采用手术治疗。结果食管穿孔发生在颈段35例均治愈；发生在胸段的62例，治愈54例(87.1％)，死亡8例(12．9％)。结论治疗方法及效果取决于穿孔的原因、部位、时间、大小，食管同时存在的疾病及病人全身情况等。     

食管穿孔和破裂的诊断与治疗

目的 提高对食管穿孔和破裂的诊断及处理水平。方法 回顾性分析经外科处理的45例食管穿孔或破裂患的临床资料。结果 本组患经胸部平片、胸腔穿刺、上消化道造影及胃镜确诊。15例为自发性食管破裂，6例为医源性穿孔，5例为创伤性穿孔，10例为食管癌并食管支气管瘘，9例为食管憩室并食管支气管瘘。治疗予以食管修补9例；胸腔引流、空肠造瘘9例(其中1例为食管修补失败后改行此手术)；食管切除胃食管吻合术12例(其中3例为食管修补失败)；胃造瘘术4例；置入食管支架4例；食管支气管瘘切除修补3例；食管瘘口修补并肺叶切除2例；食管胃弓上短路1例，颈部引流2例；放弃治疗3例。治愈25例，好转11例，死亡6例。结论 详细了解病史和进行胸腔穿刺、上消化道造影等检查可帮助诊断。尽早手术闭合瘘口和治疗食管原发病变是治疗的关键。     

35例食管破裂与穿孔的诊治

我院1966年12月～2005年12月共收治35例各种原因引起的食管破裂与穿孔，其中手术治疗20例，效果较好。 1临床资料与方法 1．1一般资料全组35例，男26例，女9例；年龄17～64岁，平均年龄42．9岁。自发性食管破裂17例（诱因为：饮酒、进食后呕吐、剧烈运动、原有食管癌、进硬食等），医源性穿孔8例（内窥镜、手术误伤），     

Intrathoracic application of the latissimus dorsi muscle for esophageal cancer operation

In order to reinforce the difficult closure of the bronchial stump, or esophageal anastomosis, a pedicle flap, taken from the latissimus dorsi muscle, was applied to 7 patients with tracheal repairs, and 11 patients with extensively dissected areas, at the time of esophageal cancer surgery. Utilizing this technique, the complications associated with extended esophagectomy could be minimized. Intrathoracic application of the latissimus dorsi muscle flap is a useful method of supporting extended esophagectomy for esophageal cancer.     

Bypass operation for advanced esophageal cancer —An analysis of 93 cases—

From 1973 to 1987, 235 patients with esophageal squamous cell carcinoma were treated at Hiroshima University. Of these patients, 121 (51.5 per cent) were submitted to esophagectomy, 93 (39.6 per cent) to bypass surgery and 21 (8.9 per cent) to either exploratory or no surgery. In this report, the 93 cases who underwent bypass surgery were analysed. Ten patients died within thirty days after their operation (10.8 per cent) and there were 33 cases of hospital death (35.5 per cent). Following the bypass surgery, 49 (59.0 per cent) cases were able to tolerate over 50 per cent of their normal oral intake and 22 cases (26.5 per cent) were able to tolerate between 25 per cent and 50 per cent. For twelve cases (14.6 per cent), however, oral ingestion proved impossible up until the time of death due to such complications as leakage. The overall survival rates were 44.3 per cent at 6 months, 12.7 per cent at 1 year and 2.8 per cent at 5 years, respectively. Two cases survived for over 5 years. Hyperthermia was applied in combination with chemotherapy from 1981, however, no case survived for over one year without radiation therapy. Recently, radiation plus hyperthermia is being performed in combination with immunochemotherapy.     

消化性溃疡急性穿孔手术100例的临床治疗体会

目的:观察不同术式对消化性溃疡急性穿孔的治疗效果.方法:将我院收治入院的100例消化性溃疡急性穿孔患者随机分为观察组与对照组,观察组患者使用腹腔镜进行手术,对照组患者使用传统开腹手术.对两组患者的手术时间、下床活动时间、术后排气时间、住院时间进行记录,同时统计止痛药使用率、并发症发生率、复发率,并对比分析各组数据的差异.结果:经统计学分析可知,观察组患者的手术时间、下床活动时间、术后排气时间和住院时间均明显少于对照组患者;其止痛药使用率、并发症发生率及复发率均明显比对照组患者低,以上差异均有统计学意义(P＜0.05).结论:腹腔镜对消化性溃疡急性穿孔的手术治疗具有干扰小、创伤小、并发症少、术后患者痛苦轻、消化系统功能恢复快及住院时间短等优势,相比传统开腹手术更为理想,可以逐步替代传统开腹手术.     

Expandable stents for iatrogenic perforation of esophageal malignancies

The management of patients with iatrogenic perforation of esophageal cancers is controversial. We reviewed the management of perforated esophageal malignancies at a single institution with a large volume of patients with esophageal cancer. Cases of iatrogenic perforation of the esophagus occurring during a 3-year period were identified from the hospital endoscopy database. Inpatient and outpatient records were reviewed, and subjects were visited to obtain follow-up information. Perforation was suspected after 10 of 492 endoscopic dilatation procedures done in patients with obstructing esophageal malignancies. All patients were diagnosed immediately. One patient with pneumomediastinum and pneumoperitoneum died 7 days after laparotomy. Nine patients with pneumomediastinum were managed endoscopically with delayed (n=1) or immediate (n=8) placement of a self-expanding metal stent. Patients were treated in the hospital for an average of 5.4 days. No patients developed clinical signs of sepsis, and all were discharged tolerating a soft diet. Follow-up data were obtained for seven of nine discharged patients (range 152 to 263 days). None developed signs or symptoms of infection or recurrent dysphagia. Immediate placement of a coated self-expanding metal stent is an effective treatment for iatrogenic perforation of an obstructing esophageal malignancy. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002.     

食管穿孔营养支持方式的探讨

目的探讨不同营养支持方式对食管穿孔患者免疫功能的影响和临床治疗效果评价并归纳出合理的营养支持方式。方法将2001年3月至2005年6月我科收治38例食管穿孔患者按收治时间随机分为两组,对照组18例接受全肠外营养(TPN),实验组20例接受肠外加肠内营养(PN EN),两组根据患者需要提供氮和热量。于治疗前后检测血浆总蛋白、白蛋白、血红蛋白和转铁蛋白浓度,外周血IgAI、gG、IgM、淋巴细胞总数(TLC)及T细胞亚群CD3、CD4百分率和CD4/CD8比值。并比较两组治愈率、平均住院时间和并发症。结果实验组TLC和IgG营养支持前后及与对照组相比其差异均有统计学意义(P<0.05);CD4和CD4/CD8比值也有升高,其差异有统计学意义(P<0.05);其余指标差异无统计学意义(P>0.05)。实验组较对照组治愈率稍高,平均住院时间稍短,但无统计学意义。结论PN EN较TPN更能改善食管穿孔患者机体的免疫功能,促进患者更早康复,是食管穿孔比较合理的营养支持方式。     

Successful application of an omental pedicle flap in delayed repair of a perforated esophageal diverticulum: Report of a case

Mediastinitis resulting from a perforated esophageal diverticulum is a potentially fatal complication and the surgical treatment of persistent esophagomediastinal fistula may be difficult. In this report, we describe the successful application of an omental pedicle flap in the delayed repair of a perforated esophageal diverticulum. A 53-year-old man presented with chest and back pain and a diagnosis of perforated esophageal diverticulum was subsequently confirmed. After receiving conservative treatment, he was referred to our department and underwent surgical repair 6 months following the onset of the perforation. Through a right thoracotomy, the mucosal layer of the esophagus around the diverticulum was sutured, and an omental pedicle flap was used to cover the suture line and obliterate the fistulous tract. His postoperative course was uneventful and the suture line healed well. The successful treatment of this patient reinforces our belief that wider application of the omental pedicle flap can be expected in the field of thoracic surgery.     

经内镜逆行胰胆管造影所致十二指肠穿孔6例诊治分析

目的 回顾性研究探讨经内镜逆行胰胆管造影（ERCP）所致十二指肠穿孔的预防、诊断和治疗。 方法 对2006年1月至2010年12月上海交通大学医学院附属仁济医院普外科6例ERCP相关十二指肠穿孔的临床资料进行分析,探讨合理的诊治方法。 结果 6例穿孔病人中术前证实胆总管结石5例,胰头占位性病变致阻塞性黄疸1例。3例实施了十二指肠乳头括约肌切开术（EST）,术后留置鼻胆管,2例插管失败,其中1例做了预切开后插管仍未成功;另1例为进镜过程中导致十二指肠憩室穿孔。2例保守观察治疗者均治愈;4例手术治疗,3例痊愈,1例死亡。 结论 术后严密观察、及时诊断并根据不同穿孔情况采取恰当的个体化治疗,可有效降低ERCP相关穿孔所造成的危险。