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.     

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。     

食管异物致纵隔感染的救治体会

目的总结食管异物致纵隔感染的救治体会。方法分析13例食管异物致纵隔感染的资料。食管穿孔位置4例位于颈段,9例位于胸段。全组病例早期手术清理脓肿,摘取异物后修补穿孔,胸腔冲洗,术后应用足量敏感抗生素,结合营养支持。结果治愈10例,死亡3例。结论早期手术,术后冲洗脓腔是救治食管异物致纵隔感染成功的关键。     

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。     

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。     

自发性食管破裂的诊断与治疗

目的总结自发性食管破裂的诊治经验,提高对该病的诊治水平。方法回顾性分析我院2000年10月至2008年12月收治的21例自发性食管破裂患者的临床资料,男18例,女3例;年龄24~59岁,平均年龄40.5岁。行开胸手术治疗19例,其中行食管裂口修补术13例,食管部分切除、食管胃吻合术4例,单纯胸腔清洗引流2例;11例加做空肠造瘘术,8例置放空肠营养管。未行手术而仅行抗感染对症支持治疗2例。结果 19例开胸手术患者中,痊愈16例(84.21%),死亡3例,分别因严重纵隔感染中毒性休克、吻合口瘘、纵隔感染各死亡1例;经保守治疗的2例患者均死于严重感染、多器官功能衰竭。随访16例,随访时间3个月~8年,随访期间无明显食管反流和食管狭窄等并发症发生。结论自发性食管破裂通过早期、积极、有效的外科治疗,预后良好;术后保证引流通畅、加强营养、预防和控制感染是治疗该病的关键。     

损伤性食管穿孔的诊断和治疗

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例例行颈部、纵隔或胸腔引流术；８例保守治疗。３８例中治愈２９例，治愈率７６．３％，死亡９例（２３７％＿。作者认为早期诊断和及时处理对提高治愈率关系重要，应根据发病时间、病情程度选择不同的治疗措     

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。     

食管异物致主动脉食管瘘1例

74岁女性患者,食管骨性异物穿孔致主动脉食管瘘,行主动脉腔内覆膜支架置入修复术,手术顺利。术后3个月行胃镜检查示食管纵隔瘘伴感染,给予对症治疗,家属拒绝手术。术后6个月复查CTA提示主动脉弓旁支架外出现造影剂渗漏,无法再次行支架置入术。1个月后患者死亡。     

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。     

Management of esophageal foreign bodies: a retrospective review of 400 cases.

OBJECTIVE: A retrospective study was conducted in 400 patients with esophageal foreign bodies (EFB) to assess characteristics of EFB and methods of treatment. METHODS: From 1962 through 1998, 400 patients with EFB were treated in our department on an emergency basis. There were 202 men (50%) and 198 women (49.6%) ranging in age from 1.5 to 95 years. The main symptoms patients complained of were difficulty in swallowing and pain. Detailed anamnesis, oropharynx and hypopharynx examination and finally radiological examination were the diagnostic tools. The location of the FB was in the cervical esophagus in 57% of cases, in the thoracic one in 26% and at the cardioesophageal junction in 17%. The most common objects found were bones, morsels, coins and needles. RESULTS: The treatment consisted of rigid esophagoscopy under general anesthesia in 343 (85.7%) of our cases. In 57 cases (14.3%) other means such as flexible esophagoscopy, Fogarty or Foley catheters and bougienage turned to be very useful. Only 12 patients (3%) were led to surgery because either extraction was impossible or perforation was present. No major complications occurred in the surgical group, whereas in the group of rigid esophagoscopy, there was one iatrogenous esophageal perforation that presented with empyema thoracis successfully treated. Finally, there was a case of an aortoesophageal fistula with mortal outcome perioperatively. CONCLUSIONS: (1) Esophagoscopy is a reliable method in the treatment of EFB impaction. (2) Alternative methods such as bougienage, etc., can be used only in selected cases with smooth foreign bodies. (3) Surgical treatment is unavoidable in cases of irretrievable EFB or esophageal perforation.     

Mediastinal mass and radiolucent esophageal foreign body

The diagnosis of radiolucent esophageal foreign bodies can be difficult, particularly in patients with predominant respiratory symptoms. The consequences of the impaction of a foreign body in the esophagus are serious, and esophageal stenosis, perforation, acquired tracheoesophageal fistulas are among the complications already reported. An unusual complication of a nondiagnosed radiolucent plastic coin that remained impacted for 11 months on the posterior esophageal wall of a 20-month-old child, who presented only with respiratory symptoms, is reported. The foreign body eroded through the esophageal wall, causing an intramural abscess that was initially interpreted as a mediastinal mass, and the patient was operated on with the diagnosis of a foregut duplication. Literature on this situation was reviewed, and the problems associated with the diagnosis and treatment of children with radiolucent esophageal foreign bodies are discussed.     

Video-mediastinoscope: for extracting upper esophageal foreign bodies

Patients with esophageal foreign bodies require prompt diagnosis and therapy. The proximal dilatation method using a video-mediastinoscope is safe and effective in removing sharp foreign bodies from the upper esophagus, avoiding surgery and possible perforation. The technique using a video-mediastinoscope proved to be effective and safe; this may be the first use of this procedure in the literature. We recommend using video-mediastinoscope for extracting foreign bodies involving the upper esophagus narrowing.     

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。     

Endoscopic removal of impacted magnetic foreign bodies in the gastroesophageal junction

Ingestion of foreign bodies is common in gastroenterology practice. Most of them are spontaneously passed through gastrointestinal tract. However, ingestion of multiple magnets can cause serious complications, because magnets attract each other and they hold the gastrointestinal wall. Here, we describe a patient who ingested multiple magnets that attracted each other between distal esophagus, and a part of them was impacted into the esophageal wall. In general, impacted magnetic foreign bodies should be removed by surgical intervention because of a high perforation risk. But, in this case, we used an insulated-tip knife for endoscopic submucosal dissection technique to make an incision to expose the impacted magnetic foreign bodies, and removed them successfully without surgery. With this report, we hope to encourage gastroenterologists to consider this new technique as one of procedures for difficult cases, including impacted foreign bodies.     

Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.     

食管异物的外科治疗

目的总结食管异物的临床特征和外科治疗经验，明确食管异物的性质及食管损伤程度，提高对该病的诊治水平。方法对31例食管异物患者临床特点、诊断方法及治疗措施进行分析。结果死亡1例，自动出院3例，其余痊愈出院。结论对食管镜取出困难或易造成2次损伤的食管异物采用手术治疗。对于食管异物，应尽早取出，可有效减少并发症。正确的处理是减少并发症的关键。