食管自发性破裂手术治疗

摘要

目的 探讨改良手术治疗食管自发性破裂(spontaneous rupture of esophagus,SRE),以提高临床治疗水平. 方法 回顾性分析1999年2月-2011年6月收治的16例SRE患者相关临床资料及手术方式.中段食管破裂4例,下段食管破裂12例.16例均为1处破口,破裂长度为1.5 ～5 cm,中位长度2.5 cm；破入左胸11例,右胸2例,无胸腔破入3例；液气胸10例,皮下气肿5例.均采用可吸收线间断缝合食管黏膜层,不缝合食管肌层,大网膜包埋固定于破裂口边缘的食管肌层,胃底悬吊固定于膈肌顶,下段食管破裂患者重建膈肌裂孔于破裂口之上. 结果 发病至手术时间1h～3d,全组24 h内修补11例,24 h后修补5例.均顺利度过围术期,无死亡患者,治愈率100％.中位住院时间为18.5 d.随访1～10年,无食管狭窄及癌变；反流2例,采用保守治疗均明显缓解. 结论 间断缝合食管黏膜层、大网膜包埋替代食管肌层、同时抗反流手术治疗SRE可以明显降低术后食管瘘、食管狭窄及反流等并发症,提高治愈率.%Objective To investigate the effect of the modified surgery for spontaneous rupture of esophagus (SRE) so as to improve treatmeut level.Methods Clinical data and surgical methods of 16 SRE patients including four patients with mid-esophagus ruptures and 12 with lower esophagus ruptures treated between February 1999 and June 2011 were analyzed retrospectively.All patients had only one laceration with the gap length of 1.5-5 cm (median 2.5 cm).Eleven patients had rupture into the left breast,two had rupture into the right chest,with no rupture into the chest in three patients.Ten patients suffered from hydropneumothorax and five from subcutaneous emphysema.Thc esophageal mucosas rathcr than muscular layers of all patients were sutured disconnectedly with absorbable thread.Omentum majus were embedded and fixed to muscular layer on the edge of esophagus rupture site.Fundus ventriculi were suspended and fixed to the dome of diaphragm.In the meantime,diaphragmatic hiatus were reconstructed above the esophagus rupture site for lower esophagus ruptures.Results The time from SRE attack to operation ranged from one hour to three days.Eleven patients were repaired within 24 hours of SRE onset and five patients were repaired after 24 hours of SRE onset.All patients got through the perioperative period smoothly and survived the operation with cure rate of 100％.The median hospital stay was 18.5 days.No esophageal narrow or canceration were found during follow-up (range,1-10 years),but two patients suffered from reflux which were relieved significantly after conservative treatment.Conclusion For treatment of SRE,interrupted suture for esophageal mucosal layers,omentum majus embedding instead of esophageal muscular layer suture and simultaneous anti-reflux operations can significantly reduce incidence of complications like esophageal fistula,stenosis and reflux and improve the cure rate.