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。     

胸段食管穿孔56例

我们于1950年1月～1997年6月共收治胸段食管穿孔56例,现报告如下。1　临床资料与方法本组56例,男42例,女14例。年龄5～74岁,平均年龄38岁。穿孔原因:异物性穿孔43例,器械性穿孔8例,腐蚀性3例,创伤性、自发性穿孔各1例。穿孔部位:胸上段17例,胸中段35例,胸下段4例。全组病?..     

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。     

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。     

72例食管穿孔手术治疗的疗效分析

目的:目前对于食管穿孔手术治疗的方式尚有争议,本身研究对72例食管穿孔患者手术治疗的疗效进行分析,以评估其临床应用价值.方法:手术治疗72例食管穿孔患者.所有穿孔均使用肌肉瓣或胸膜瓣覆盖或修复,颈段食管穿孔使用胸锁乳突肌瓣,胸段食管穿孔使用横膈膜瓣,由恶性肿瘤或其他严重疾病引起的穿孔则行食管切除术.结果:57例患者进行食管穿孔修补术,15例患者接受食管切除术,穿孔修补术后发生漏的比例为12％,但均已治愈.1例一期接受食管修补术的患者死亡(死亡率1.5％);只有一例患者进行二期食管切除术；15例接受食管切除术的患者中14例获得治愈.结论:食管穿孔患者接受恰当有效的手术治疗,可获得良好的疗效,减少并发症的发生,并可降低死亡率.     

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。     

社区护理食管穿孔1例

自发性食管穿孔较少见,若是胸段食管穿孔可造成严重的胸腔感染,如得不到及时治疗,12～24 h内可发生死亡危险[1].我院收治了1例自发性急性食管穿孔误诊9 d,合并胸腔严重感染的垂危患者,经过3个月积极抢救治疗,并行食管修补术,感染基本控制,但食管穿孔未能愈合而带胃管出院.出院后进行了家庭护理6月余,使食管穿孔完全愈合.报告如下.     

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。     

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。     

食管癌肉瘤14例

依据食管癌肉瘤的临床,病理特点,探讨其可能的组织学来源。方法对１４例食管癌肉瘤病人的临床资料进行了回顾性研究。结果：食管癌肉瘤多为息肉样腔内生长,有细短蒂和食管壁相连,个别呈浸润生长。     

胸骨后横结肠代食管260例报告

报告260例胸骨后横结肠代食管术的临床经验,总并发症率14.2％,死亡率2.3％。根据结肠血管解剖特征,常规选用横结肠作移植肠段,首选左结肠动脉升支供血,行顺蠕动吻合,移植肠段置于胸骨后进行食管重建利于术后放疗。我们认为横结肠长度足够、血运良好、基础代谢率低、体积较小、易游离,足以代替食管全长,且使胃能保持正常生理位置,是食管理想的替代物。文中也对手术操作体会及并发症的预防进行了探讨。     

Management of Esophageal Perforation

Despite recent advances in thoracic surgery, the management of esophageal perforation remains problematical and controversial. Thirty-one patients were treated for an esophageal perforation between 1986 and 1998. The esophageal perforation was iatrogenic in 25 cases, spontaneous in 2, traumatic in 2, and caused by a tumor and tuberculous lymphadenitis in 2 patients. There were 10 cervical, 19 thoracic, and 2 abdominal perforations. The interval from perforation to operation was less than 24 h in 12 patients and more than 24 h in 19 patients. The surgical procedures included a primary repair in 12 patients, a resection in 8, and conservative treatment with minor surgical approaches in 11. The mortality rate was 20% (4/20 patients) in the surgical treatment group and 45.5% (5/11 patients) in the conservative treatment with minor surgery group. The overall mortality was 29% (9/31 patients). The prognosis is thus concluded to depend on the cause and location of the perforation, the presence of underlying esophageal diseases, and the surgical procedure chosen. Received: October 12, 1999 / Accepted: May 30, 2000     

43. Differentialindikation bei der Perforation des gastroduodenalen Ulcus

Zusammenfassung Die Differentialindikation des perforierten gastroduodenalen Ulcus wird zugunsten der absoluten akuten chirurgischen Intervention dargestellt. Im allgemeinen wie auch am eigenen Krankengut (n = 386) überwiegen Wundrandexcision und Übernähung mit einer Letalität von 12,1 %. Bei einzelnen ausgewählten Fällen ist die sog. definitive Therapie die Excision, SPV oder distale Magenresektion. Im Zweifelsfall wird übernäht. Eine absolute akute Indikation zur übernähung besteht auch bei der atypischen Perforation.     

Perforation of intestinal leiomyosarcoma: A case report

Introduction and ImportanceThe majority of gastrointestinal sarcoma is gastrointestinal stromal tumors and intestinal leiomyosarcoma is rare. Small intestinal mesenchymal tumors are often large at diagnosis, and they commonly present with bleeding or intussusception. We report a perforation associated with intestinal leiomyosarcoma.Case PresentationA 66-year-old man presented with severe epigastric pain. A physical examination showed tachycardia and a diffusely tender and rigid abdomen. Computed tomography showed a massive tumor and free air. A laparotomy was performed to treat lower digestive perforation. Massive tumor, which invaded surrounding intestine, was 20 cm in size at the ileum. The involved intestine was perforated. We confirmed that feeding artery was superior mesenteric artery and performed partial intestinal resection. His clinical course was uneventful and discharged 10 days postoperatively. The pathological findings showed spindle shaped and the tumor invaded the mucosa at the perforated site. Immunohistochemical spectrum resulted c-kit negative, S-100 negative, Desmin positive, alpha smooth muscle actin(αSMA) positive and Ki-67 30–40 %. The pathological findings were leiomyosarcoma.DiscussionGastrointestinal sarcoma is sometimes found by bleeding. In our patient, leiomyosarcoma invaded surrounding intestine, it made the intestine wall frail and caused perforation. The intestinal perforation which was involved by leiomyosarcoma has been rarely reported to the best of our knowledge since WHO refined leiomyosarcoma.ConclusionsAlthough intestinal leiomyosarcoma is rare, we should know that it can involve surrounding intestines and make them perforated.     

瘢痕食管切除胃代食管治疗腐蚀伤后瘢痕狭窄

收治食管及胃腐蚀伤１０５例，对病变位于食管中下段１２例采用瘢痕食管切除胃代食管术治疗。术中解剖较松动，出血少，无术后并发症；２例病变明显高于术前估计，切除食管至颈部吻合，手术甚为困难。结论：中下段的瘢痕狭窄可行瘢痕食管切除，胃代食管也甚方便，对中段以上狭窄，仍以旷置狭窄段食管结肠代食管为宜。     

半硬质输尿管镜操作引起输尿管或肾实质穿通损伤的分析

目的提高对半硬质输尿管镜操作中的穿通性损伤发生的认识及预防能力。方法回顾性分析2004年9月至2008年10月间我科收治的半硬质输尿管镜操作所致泌尿系统损伤11例,其中输尿管穿孔4例,输尿管假道2例,结石穿出输尿管3例,肾实质穿通性损伤2例。结果输尿管损伤者中6例接受手术修补输尿管并留置双J管,3例输尿管假道或结石穿出者在输尿管镜下放置双J管。术后三至四周拔除双J管,均恢复良好。对肾实质穿孔者,1例采用手术引流,1例证实为肾结核而行患’肾切除并抗结核治疗而治愈。结论输尿管或肾实质穿孔是半硬质输尿管镜操作中的较重并发症。正确的病例选择、良好的手术视野和尽可能低的灌注压力有利于避免这些并发症的发生。     

Perforation of the colon in neonates

Purpose

Gastrointestinal perforation is a catastrophic condition in neonates, especially in premature neonates. Although perforation is commonly observed in the small intestine during the neonatal period, perforation of the colon is a rare condition. This study analyzed the clinical findings and results of perforation of the colon in neonates.

Methods

Between 1989 and 2004, 8 neonates were treated for spontaneous perforation of the colon at our institute. These patients were retrospectively reviewed.

Results

Gestational ages ranged from 36 to 41 weeks. Seven patients weighed above 2500 g, whereas one patient weighed 1800 g at birth. Perforations developed within 7 days after birth in 6 patients and before birth in two. Associated bowel diseases included rectosigmoid type of Hirschsprung's disease in two patients, immature ganglia in one, imperforate anus in one, colonic atresia in one, and necrotizing enterocolitis in one. An obvious cause was not identified in the remaining two. Six patients without definite anatomic obstructions, such as imperforate anus or colonic atresia, required evaluations for suspected Hirschsprung's disease. All 8 patients underwent colostomy and recovered from peritonitis. Seven survived, but one died of sudden infant death syndrome.

Conclusions

In this study, perforation of the colon during the neonatal period mostly occurred in term or near-term neonates and carried a good prognosis. During management, it was important to identify Hirschsprung's and its allied disorders as a cause of perforation.