2 English reference esophageal perforation
3 disease code ICD:K22.3
4 Classification of general surgical diseases
5 disease overview esophageal perforation (perforation? Yes? Esophagus is one of the most serious gastrointestinal emergencies, and its mortality is reported to be 10% ~ 46%. The most common onset age is 50 ~ 70? Years old (another report is 30 to 55? Years old).
6 disease description esophageal perforation (perforation? Yes? Esophagus is one of the most serious gastrointestinal emergencies, and its mortality is reported to be 10% ~ 46%. The prognosis depends on the etiology, injury site, basic esophageal lesions and the time to start treatment after injury. Early diagnosis and treatment depend on the high vigilance of the disease and the correct judgment of the corresponding clinical manifestations.
7 Symptoms and Signs The clinical manifestations of esophageal perforation are related to the location and time of injury (Table 1).
1. Symptoms and signs
(1) Cervical esophageal perforation: The patient has pain during neck movement, which is often accompanied by tenderness and sternocleidomastoid muscle spasm. There may be dysphonia, dysphagia and hoarseness. At the time of physical examination, 60% patients had subcutaneous emphysema, while X? X-ray examination can make 95% patients diagnosed.
(2) Thoracic esophageal perforation: The patient feels pain in the thoracic region, scapula region and xiphoid process, which can be aggravated when swallowing and breathing deeply. The characteristics of back pain caused by extensive inflammation of posterior mediastinum are very similar to those of thoracic aortic dissection aneurysm. Thoracic esophageal perforation often presents upper abdominal muscle tension, dysphagia, pain during swallowing, dyspnea, hematemesis and cyanosis. Chest auscultation can hear the distortion of mediastinal emphysema. Is it Hyman? Sign. With the progress of inflammation, tachycardia, shortness of breath and fever will occur. Sepsis and shock may occur further if not treated in time.
(3) Abdominal esophageal perforation: mainly manifested as subxiphoid pain, muscle tension, spasm and rebound pain. Once tachycardia, shortness of breath and fever occur, it can quickly develop into sepsis and shock, which is the characteristic of abdominal esophageal perforation. Esophageal pericardial fistula can occur when perforation affects the posterior pericardium. These patients may have cardiac tamponade or systolic water shock when they see a doctor. Esophageal perforation invades the heart cavity (usually the left atrium), which can cause systemic food particle embolism. But this is rare in esophageal perforation.
2. Staging? According to the occurrence process of esophageal perforation, it can be divided into acute, subacute and chronic 3? Kindness
(1) Acute esophageal perforation: Is the symptom within 24 hours after injury? Acute esophageal perforation in the chest. Acute perforation is more common in instruments or spontaneous perforation. The main clinical symptoms are chest pain or abdominal pain, dyspnea, fever and skin distortion.
(2) subacute perforation: 24h ~ 2h after injury? The symptoms in the week are subacute perforation, and the clinical manifestations are chest pain and dyspnea.
(3) Chronic perforation: 2? Chronic perforation occurs when symptoms appear for more than a week. Chronic perforation mostly occurs after surgery, and patients may have dysphagia and atrial arrhythmia. The clinical characteristics of chronic perforation reflect the degree of limitation after perforation, but not the urgency of perforation itself. Chronic perforation is mostly localized, rarely causing extensive mediastinal pollution, and its clinical course is also light.
8 Etiology of disease 1. Etiology? Alcoholism, severe vomiting during pregnancy, severe seasickness, overeating, weight gain, chronic cough or hiccup, asthma status, delivery, seizure. When the esophagus has distal obstruction (such as tumor, stenosis, esophageal ring and esophageal reticular septum), swallowing hard can also lead to stress rupture of esophagus. Nervous system diseases (such as brain tumor, cerebral hemorrhage, cerebral aneurysm and after craniotomy) can increase the incidence of stress esophageal rupture 10? Time magazine.
2. Classification and characteristics? According to the etiology, esophageal perforation can be divided into traumatic esophageal perforation, esophageal rupture caused by shock wave, iatrogenic esophageal perforation, esophageal perforation caused by foreign body and spontaneous esophageal rupture.
(1) Traumatic esophageal perforation: Traumatic esophageal perforation can be divided into open esophageal perforation and closed esophageal perforation. Class. Open esophageal perforation is mainly caused by bullets, shrapnel and sharp instruments. The esophagus has the characteristics of its anatomical position, especially the thoracic esophagus, with the spine in the back, the heart, great vessels, trachea and sternum in the front, and the lungs and ribs on both sides. Therefore, open esophageal perforation in thoracic cavity is very rare. Even if the esophagus is damaged, it is often accompanied by damage to the heart, large blood vessels and trachea. The patient has no time to rescue and dies on the spot. Llic？ Wait for the report 199 1 ~ 1995? Bosnia and Herzegovina War 2494? Only five of the wounded? Cases of esophageal injury accounted for 0.2%. There was a report in China that swallowing a sword during acrobatic performance caused esophageal perforation. Therefore, cervical esophageal perforation is more common in open esophageal injury. Closed esophageal perforation can cause extensive esophageal rupture due to sudden compression between sternum and spine, which is even rarer. There have been reports of esophageal rupture and bronchoesophageal fistula caused by motorcycle collision.
(2) Esophageal rupture caused by shock wave: The high-pressure shock wave was introduced into the esophagus through the oral cavity, which caused the pressure in the esophageal cavity to rise sharply and led to esophageal rupture. There have been many reports of esophageal rupture caused by puncture and air billow impact of oxygen cylinders in China. The mechanism of esophageal rupture caused by shock wave is mainly the direct action of overpressure and negative pressure, and high-pressure shock wave can forcibly enter esophagus through nostril and mouth. Because the cardia is in a state of contraction at ordinary times, a high pressure similar to a blind tube is generated in the esophagus. The airflow has a weak effect on the whole body such as the chest and abdomen, and has no reflective protection on the abdominal wall, chest, diaphragm and glottis. The chest cavity is still under negative pressure, so that the pressure difference between the inside and outside of the esophagus can cause esophageal rupture.
(3) Iatrogenic esophageal perforation: The most common causes of iatrogenic esophageal perforation are perforation caused by endoscopy, esophageal dilatation, tissue biopsy under esophagoscope and paraesophageal surgery. Bo Godina? Report 850? 368 cases of penetrating esophageal injury? Eight cases (43.3%) were caused by instruments, accounting for the first place in esophageal perforation caused by various reasons. Avanoglu( 1998) newspaper 1249? Among the cases of esophageal dilatation and stenosis after burn, 52? Perforation occurred in 4 cases, accounting for 4. 16%. In addition, there are reports of esophageal perforation caused by tracheal intubation, gastric tube insertion, balloon rupture of three-lumen tube and even esophageal dynamic examination. Although tracheotomy is rare, it should still attract the attention of operators. The perforation caused by esophageal endoscope mostly occurs below the cricopharyngeal muscle at the entrance of esophagus, where there is cricoid cartilage in front, cervical vertebra behind and cricopharyngeal muscle around, which is the narrowest part of esophagus. Perforations in the lower esophagus and near cardia often occur on the basis of original esophageal diseases. Berry? The basic pathological changes related to esophageal perforation are mostly hiatal hernia, followed by stenosis, achalasia, spasm and tumor. The mortality rate of iatrogenic perforation is lower than that caused by other reasons. The reasons may be as follows: ① About 40% of perforation occurred in cervical esophagus, and the prognosis of cervical perforation was better than that of intrathoracic perforation; ② This kind of perforation can be found early and treated in time; (3) Prepare for fasting before inspection to reduce pollution; ④ The esophageal perforation caused by examination is mostly small, and the mediastinal and thoracic infection is also light. Mediastinal surgery, esophageal hiatal hernia repair and vagotomy may damage the esophagus and lead to perforation. Common in the lower esophagus or abdominal esophagus, more common in the posterior wall of esophagus. When there is adhesion around the esophagus and blind separation, it is more likely to cause esophageal injury.
(4) Foreign body esophageal perforation: Foreign body incarceration is also a common cause of esophageal perforation. Pa Godina? Waiting for the report of 850? 3 cases of esophageal perforation caused by foreign body. Cases, accounting for 38.6%, second only to the perforation caused by instruments. A little. Most esophageal perforations are caused by sharp, non-plastic or large foreign bodies, such as bone fragments and dentures. At present, electric toys are very popular in developed countries. Children who swallow button cell by mistake will also corrode the esophagus and cause esophageal perforation, especially the lithium battery is more corrosive and more likely to cause esophageal perforation. Foreign bodies puncture or press the esophageal wall to cause necrosis, or forcibly swallow rice balls or large pieces of food to try to push the foreign bodies down, resulting in esophageal perforation, which can also be caused by taking out irregular foreign bodies by endoscope. Esophageal perforation caused by foreign bodies is common in 3? There are three physiological stenosis areas, especially the perforation of aortic arch, which are in danger of fatal bleeding caused by puncture and corrosion of aorta. Therefore, if it is difficult to remove the foreign body through endoscope, it is relatively simple and safe to open the chest in an emergency and cut the esophagus to remove the foreign body before infection.
(5) spontaneous esophageal rupture (Boerhave? Syndrome): spontaneous esophageal rupture is rare, Boerhave in 1724? Initial report 1? A case of esophageal rupture caused by nausea after overeating is also called Boerhave? Syndrome, although its incidence is only 1/6000, accounting for 15% of all esophageal perforation, its mortality is as high as 25% ~ 100%. The cause of this kind of patients is clear, and most of them occur after overeating. In this case, vomiting makes the intra-abdominal pressure suddenly rise, squeezing the stomach makes the pressure in the esophageal cavity suddenly rise, and at the same time, the cricopharyngeal muscle reflexes and contracts, and the esophagus is already in the negative pressure chest. At this time, the pressure in the esophageal cavity and chest cavity is very different in an instant, which leads to the rupture of the whole esophagus. As for the pressure required to cause esophageal rupture, there is no reliable data at present. Some people measured that the pressure that caused esophageal rupture was about 0.90 ~ 2.72kg/6.4438+0cm2. In addition to the causes of vomiting, there are reports of childbirth, convulsions, forced defecation and other reasons. Spontaneous esophageal rupture is more common in the lower end of esophagus. Some people think that the wall of the upper esophagus is mainly striated muscle, which reacts quickly to * * * and contracts quickly and is not easy to rupture, while the lower esophagus is mainly smooth muscle, which reacts slowly to * * * and is easy to rupture. There are both striated muscle and smooth muscle in the middle esophagus, and the rupture may be between them. Spontaneous esophageal rupture is mostly a single longitudinal fissure with a length of 2 ~ 9 cm. No, but there are also two reports of rupture, so we should pay attention to exploration during operation. Vomiting, chest pain and subcutaneous emphysema are typical clinical manifestations of spontaneous esophageal rupture. Doctors are often misdiagnosed as gastric or duodenal perforation, hydropneumothorax, acute pancreatitis, myocardial infarction, acute appendicitis, etc. Even the misdiagnosis rate of acute abdomen was as high as 75%. Delayed diagnosis and treatment is an important cause of death. According to the statistics of the Third National Conference on Benign Esophageal Diseases, there are 12 1 with death records. The mortality rate of spontaneous esophageal rupture is as high as 37.2%.
9 Pathophysiology Although the causes of esophageal perforation are different, the pathophysiological changes after perforation are the same. After esophageal perforation, stomach contents, saliva and food with various oral bacteria with strong effects quickly enter the mediastinum through the breach, causing serious mediastinal infection. Inflammation spreads rapidly in the mediastinum, and can erode and penetrate the pleura into the chest cavity, forming one or both hydropneumothorax. Because the entering bacteria contain anaerobic bacteria, it often causes septic empyema. At the same time, when the esophagus ruptures, the pleura has ruptured, pneumothorax appears early, mediastinum and chest cavity are infected, a large amount of fluid is lost, and toxins are absorbed, so patients can quickly enter a state of shock. Due to swallowing, air continuously enters the chest through the breach, which can produce tension pneumothorax and aggravate respiratory and circulatory dysfunction. If not treated in time, the patient will die soon. The reasons for the rapid spread of inflammation in mediastinum are:
(1) The mediastinum is full of loose connective tissue, and there are no other organs and tissues that can prevent the spread of infection except the slightly narrow thoracic entrance. After esophageal perforation, air enters the mediastinum to form mediastinal emphysema, which creates favorable conditions for digestive juice containing various bacteria to enter the mediastinum.
(2) When inhaling, the negative pressure in the mediastinum increases, which is more conducive to the inhalation of air and digestive juice into the mediastinum.
(3) The beating of the heart, the peristalsis of the esophagus and swallowing activities all promote the spread of infection.
(4) There are many kinds of bacteria in the oral cavity, such as spirillum, trace aerobic bacteria, non-hemolytic streptococcus and so on, which play an important role in mediastinal infection and the spread of inflammation, especially in oral infection. Pathophysiological changes after esophageal perforation (Figure1);
10 diagnosis: early diagnosis and timely and correct treatment are the key to reduce mortality.
1. Clinical manifestations? The subcutaneous emphysema in the neck should be suspected of esophageal perforation, and chest X-ray examination should be done. X ray examination
2. Auxiliary inspection? x？ X-ray chest and abdomen film shows mediastinal emphysema, hydropneumothorax and pneumoperitoneum, which is an important basis for diagnosis of esophageal rupture. Esophagography can be diagnosed if it shows contrast agent overflow. But negative results cannot rule out the possibility of perforation. Suspicious cases should be checked repeatedly. In the diagnosis, besides the diagnosis of perforation, we should also know the location and size of perforation, which is very helpful for the formulation of treatment plan.
Laboratory examination:
1. Is pleural effusion pH? Measurement? What is the pH value of normal pleural effusion? The value is around 7.4. If the extracted pleural effusion is acidic, what is the pH value? If the value is less than 6, lower esophageal rupture should be considered.
2. Blood routine? With the development of inflammation, leukocytosis will occur.
3. bacterial culture? Take esophageal secretion or puncture fluid for bacterial culture and drug sensitivity test.
Other auxiliary inspections:
1. Oral methylene blue solution? Pleural effusion is blue, which can be used as strong evidence of esophageal perforation.
2. Esophagoscopy? Suspected esophageal rupture and x? When X-ray examination is negative, esophagoscopy should be performed.
3.x？ X-rays 40% of patients have had X-rays. X-ray examination can find mediastinal emphysema.
(1) Cervical esophageal perforation: Free gas in the cervical fascia layer indicates local swelling and subcutaneous emphysema, and the contrast agent leaks out of the esophagus.
(2) Thoracic esophageal perforation: X? X-ray images show pneumomediastinum or widened mediastinal shadow, unilateral or bilateral hydrops and pneumothorax. If there is a mediastinal abscess, dense shadows and gas planes can be displayed. Iodine oil or water-soluble iodine esophagography shows that the contrast agent overflows (Figure 2 ~ 4).
4.CT？ Scanning? From neck scan to pubic symphysis. CT？ The image shows: esophageal wall thickening, hydrops around esophagus, pneumatosis outside esophageal cavity and pleural effusion, among which pneumatosis outside esophagus is the most valuable sign. Some patients can find the rupture hole. For atypical clinical symptoms, CT? This is helpful for the definite diagnosis of extraluminal lesions. Besides, CT? Subcutaneous emphysema can also be found in mediastinum, neck, chest and upper abdomen. The mediastinum is widened, and there are effusion and abscess around esophagus and mediastinum. Soft tissue swelling in mediastinum, blurred trachea, bronchus and blood vessels, local effusion, etc. (figure 5). The local abscess showed high density in the center and high density in the periphery, and the edge was enhanced after angiography. Mediastinitis and granuloma can cause the displacement of mediastinal tissues and organs. CT？ Scanning can clearly show pneumothorax, pneumonia, atelectasis, bronchial rupture, pericardial effusion, aortic rupture and fracture. Thin-layer scanning can find esophageal defect in perforated area. When complicated with diaphragmatic hernia, CT? The scan showed that the diaphragm was broken and missing. Because the prominent tissue is different, its CT? The performance is different. The density of omentum is similar to that of adipose tissue, but the density of stomach, intestine, kidney and spleen is uneven, and gas-like low density shadow is seen inside.
5. nuclear magnetic resonance? Complications can be fully displayed, and soft tissue swelling, hydrops, tracheal displacement, cervical and thoracic fractures of the anterior cervical mediastinum can be clearly displayed. Sensitive to display mediastinal abscess and pleural effusion. The MRI signal of diaphragmatic hernia is uneven, which can show the relationship between the focus and diaphragm.
1 1 differential diagnosis 1. Cervical esophageal perforation should be differentiated from damaged or unperforated esophageal foreign bodies examined by instruments. Although swallowing or moving the neck can aggravate the neck pain and swelling, the anterior edge of sternocleidomastoid muscle often has tenderness, local swelling and subcutaneous emphysema, and the body temperature and white blood cell count gradually increase. X-ray showed free gas in the fascial layer of the neck.
2. Lower esophageal perforation should be differentiated from gastric and duodenal perforation. After the perforation of the lower esophagus, muscle tension in the upper abdomen often occurs, which can aggravate the pain due to the activity of the mediastinal spine. The infection spreads to the supradiaphragmatic pleura, which can cause shoulder pain.
The success of 12 esophageal perforation treatment scheme often depends on the location of perforation, the size of fissure, admission time and correct treatment measures. If the treatment time is delayed to 24 hours? Above, its mortality rate can be higher than 3? Time magazine.
1. Non-surgical treatment? The treatment plan should be determined according to the specific situation of each patient.
(1) indications: the following conditions are suitable for non-surgical treatment:
① Patients who were admitted to hospital late or whose esophageal perforation was found late and whose perforation was limited.
② Patients with small esophageal perforation and few signs of gastrointestinal contents leakage were treated conservatively under close observation.
③ Partial cervical esophageal perforation can be solved without drainage.
(4) Patients who are older, generally in poor condition, or have cardiopulmonary insufficiency and may be in danger during thoracotomy should also be treated conservatively.
(2) Treatment measures:
① Fasting: All patients with esophageal perforation should fast to prevent food from flowing into the mediastinum or chest cavity from the breach, which will aggravate the spread of infection. Patients are required to spit saliva as much as possible or put a gastric tube above the breach.
② Support therapy: fasting, severe infection and loss of body fluids, dehydration, electrolyte imbalance and general failure. Therefore, in addition to correcting dehydration and electrolyte disorder, nutritional support should be strengthened, whole blood or plasma should be imported and fed through nasal feeding, stomach or jejunostomy.
③ Anti-infection: large-dose broad-spectrum antibiotics were used early after injury, and sensitive antibiotics were selected according to the results after bacterial culture and drug sensitivity test of secretion or puncture fluid.
2. Surgical therapy
Commonly used surgical methods are:
(1) Cervical esophageal perforation:
① Surgical indications: The perforation of cervical esophagus is mostly caused by instrument injury, and the perforation is often small and found earlier. About 80% cases can be cured by non-surgical treatment, but surgical treatment should still be considered in the following cases: a. perforation caused by large fissure penetrating injury, 24 hours after injury? Esophageal fissure can be sutured in one stage; 24h？ Primary suture and drainage are not recommended in the future. B the perforation lasts for a long time, or the patient has fever and leukocytosis after conservative treatment. x？ X-ray examination showed infection and abscess formation in neck and mediastinum. Generally speaking, for the fourth kind? Mediastinal infection above the level of thoracic vertebra can be treated by neck incision and drainage and nasogastric feeding, and most wounds heal quickly. C. the foreign body formed a local abscess in the perforation of the cervical esophagus. Perforation with distal obstruction should be removed by surgery.
② Operation method: If the cervical esophageal perforation is repaired, an oblique incision can be made through the front edge of the left sternocleidomastoid muscle, and the anatomical incision will enter the esophageal space layer by layer, and then it will be released from the esophagus, repaired by intermittent suture, and the incision will be washed and drained. If you cut and drain, you should decide according to the swelling and tenderness. Before incision, puncture should be performed to further determine the location of abscess. If the lump and tenderness diffuse on both sides of the neck, it can be drained through the right neck incision, because the esophagus is far away from the right pleura, and its gap is wide, so it is not easy to injure the pleura by accident. Incise the abscess and suck out the pus. If it is a foreign body perforation, take out the foreign body. You can put two cigarette-type drainage pipes, or use cigarette-type drainage pipes at the top and soft rubber pipes at the bottom.
(2) Thoracic esophageal perforation: Thoracic esophageal perforation has poor prognosis and high mortality. Most people advocate early surgical treatment. The purpose of thoracotomy is to fully drain pleural effusion and esophageal leakage, repair cracks and prevent further pollution of mediastinum and pleura.
① Surgical path: According to the location of perforation, determine the transthoracic approach. The perforation of the lower esophagus mostly breaks into the left thoracic cavity, so the left thoracotomy should be performed. Above the middle section, multiple right thoracotomy. After entering the chest cavity, fully expose the mediastinum and remove necrotic and inflammatory tissues.
② Surgical methods:
A. Primary suture repair: mainly suitable for 24 hours after perforation? But there are also many more than 24 hours? The thread repair wins the winner. Therefore, the time after perforation is not the only criterion to measure whether it can be repaired surgically, but the severity of esophageal wall infection and inflammatory edema is an important determinant. During suture repair, the edge of the wound can be slightly trimmed, and the esophageal mucosa and muscle layer can be sutured intermittently with thin lines. If you can't sew in layers, you can sew in full thickness. After the repair of lower thoracic esophageal rupture, pleural flap, pedicled intercostal muscle flap, pericardial flap, pedicled diaphragm flap and gastric bottom cover can be used to strengthen the repair. Recently, it was reported that spontaneous esophageal rupture 1 1? Example, 9? All cases were cured after 24 hours (the longest was 18? Days) Open chest repair, fold several layers with pedicled omentum to cover the fissure and its surroundings. 1 1? All cases were successful. Pediceless omentum can also be used as a prosthesis to repair esophageal fissure.
B. Closed defect: the esophageal perforation lasts for a long time, the inflammation and edema of the esophageal wall are obvious, and the cracks can no longer be directly sutured. If the perforation is in the lower thoracic or abdominal segment, it can be repaired by diaphragm flap, gastric fundus or jejunum transplantation. It is not necessary to sew the edges of the perforation together, but to cover a patch or graft around the perforation and sew it on the healthy muscle layer of the esophagus. If covered with pedicled jejunum transplantation, it can be free for about 8cm for a long time. The jejunum with vascular pedicle was led out from the back of colon, and the intestinal tube was cut on the opposite side of mesentery to remove the mucosal layer. Intermittent suture was led out from the esophageal cavity at the edge of esophageal perforation, and the jejunum graft was covered on the defect, and the suture was ligated and fixed outside the jejunum seromuscular graft, and then the edge of the graft was closed on the healthy esophageal muscular layer.
C. Esophageal catheterization: For patients with advanced intrathoracic esophageal perforation who cannot be sutured or patched, all contaminated necrotic tissues should be removed after thoracotomy, and T tube should be placed in the esophageal cavity through esophageal perforation. Tube-shaped, leading out from the chest wall, so that the esophageal contents flow out, and closed drainage is placed near the perforation and chest cavity. T tube placement 3 ~ 4? After the fistula was formed, it was removed and changed to open drainage (Figure 6). Gastrostomy decompression and jejunostomy feeding after esophageal intubation are feasible, group one 10? Example 36 ~ 94h? Advanced esophageal perforation, with this therapy, 8? Only 2 cases were cured? Death.
D. External cervical esophagus (or stoma) combined with gastrostomy: For patients with advanced esophageal perforation, severe thoracic infection or poor patient condition who can't tolerate thoracotomy, external cervical esophagus (or stoma), closed thoracic drainage, small abdominal incision, cardia ligation, gastrostomy or jejunostomy are given. The purpose of this surgical method is to prevent the infection brought in from the mouth and the reflux of stomach contents from affecting the chest cavity, control the infection and close the fistula. However, in most cases, a second operation is needed to reconstruct the esophagus.
E. Total thoracic esophagectomy: Total thoracic esophagectomy is feasible for cases with severe mediastinal infection and extensive esophageal injury that cannot be controlled by thoracic drainage and antibiotics. The cervical esophagus is placed outside, the cardia is sutured and closed, and gastrostomy or jejunum feeding is performed. After the patient's general condition improved, esophageal reconstruction was carried out. Total thoracic esophagectomy can be performed by thoracotomy or esophageal inversion.
F. Treatment of primary esophageal diseases complicated with perforation: When the distal end of esophageal perforation has basic diseases such as stenosis, achalasia, hiatal hernia, etc., if the early patient's condition permits, the perforation can be treated surgically for the basic diseases after suture and repair. For example, achalasia can be treated by incision of cardiac muscle, repair of hiatal hernia, resection of stenosis and esophagogastrostomy. Fulton? In the past, cases of stenosis and perforation were treated with endovascular catheter (Celestin? Tube) to prevent saliva and stomach contents from polluting the mediastinum. If the above measures cannot be implemented, some people use the external cervical esophagus to make it about 150ml per day. Saliva does not pass through the ruptured esophagus, which is beneficial to the healing of the fissure. You can also dilate the stenosis or insert a catheter into the esophageal cavity, and then repair the esophageal perforation. According to 4 cases of esophageal perforation reported in related literature, 2? 1 case underwent esophagoscopy due to esophageal corrosion injury, 2? A case of esophageal perforation caused by esophageal foreign body was treated by improved mill. Endoesophageal intubation was successful. This method can reduce the pollution of saliva and stomach contents to the mediastinum, and has the functions of supporting the lumen and preventing esophageal scar stenosis (Figure 7).
13 complications 1. Difficulty breathing? When the thoracic esophagus is perforated, the patient may have severe dyspnea and cyanosis due to one or two hydropneumothorax.
2. shocked? Severe shock may occur due to the loss of body fluids and the absorption of toxins.
14 prognosis and preventive prognosis: the prognosis of esophageal perforation is related to the following factors:
1. The most important factor affecting the total mortality of esophageal perforation is delayed diagnosis (Table 2). The mortality rate of patients who received surgical treatment within 24 hours after perforation was 26% ~ 64%. The mortality rate of patients receiving surgical treatment within 24 hours is 0% ~ 30%. Ne *** itt and Sawyers found that since 1975, the mortality rate of patients who received surgical treatment 24 hours after perforation decreased from 56% to 26%. This may be due to the use of more effective antibiotics, better nutritional support and perioperative care. They also noticed that since 1975, the mortality rate of patients diagnosed and treated within 24 hours after perforation has not decreased significantly compared with before (1 1.4% and 13% respectively).
2. The mortality rate of cervical esophageal perforation is 0% ~ 14%, while the mortality rate of thoracic or abdominal esophageal perforation is as high as 13% ~ 59%. This is because when the cervical esophagus is perforated, the pollutants can be wrapped by the cervical tissue, and there is no reflux of stomach contents. Moreover, cervical perforation is mostly instrumental perforation, which can be diagnosed and treated in time.
3. Etiology of perforation The etiology of esophageal perforation also affects the prognosis. The mortality rate of iatrogenic and instrumental perforation is 5% ~ 26%. The mortality rate of spontaneous perforation is the highest, ranging from 22% to 63%. Recently, Sabanathan et al reported 5 cases of Boerhaave syndrome. After thorough debridement, mediastinal irrigation and primary suture of pedicled greater omentum, no 1 case died. They attributed this unexpected result to timely resuscitation and intensive repair of esophagus with blood-rich tissue flap. This emphasizes the importance of blood supply to pollute the chest. According to Michel et al., the mortality of esophageal perforation increased by 6 times due to primary esophageal diseases. The mortality rate of esophageal perforation in patients with esophageal cancer is higher than that in patients with benign esophageal disease or patients without esophageal disease. Experience of some authors in treating esophageal perforation in recent 5 years (Table 3). Except for 6 reports, all the other reports adopted different treatment methods. Some patients received medical treatment because they could not operate, which affected the total mortality of non-surgical treatment. When patients choose drug treatment first, the mortality rate is 0% ~ 33%. In these reports, the mortality rate of open secondary surgery is high, which may be due to the lack of experience in using this technology. In addition, it is also related to the fact that this method is mostly used in patients with extensive esophageal contusion and perforation for more than 24 hours. Some authors report that the best result of applying this method is to use or strengthen the primary closure at the same time. The total mortality rate of esophageal perforation in the last five years is 24% (Table 3), which is not much different from the mortality rate (22%) reported in 1980 ~ 1990.
Prevention: There is no relevant content description at present.
15 epidemiology The incidence of spontaneous esophageal perforation is extremely low. In Kish( 1980), 300 cases reported worldwide were reviewed. Bladergroen and Postlethwaita( 1986) summarized 127 cases, of which 1 14 was advanced. All races on all continents have the disease, most of them are men, and the ratio of male to female is 2 ∶ 1 ~ 5 ∶ 1. The most common onset age is 50-70 years old (another report is 30-55 years old). According to the literature, 80% of the cases are middle-aged men, and there have also been reports of newborns and elderly people over 90 years old. Although the cause is unknown, studies have shown that 1 ~ 17-year-old children have the lowest incidence.
For the treatment of esophageal perforation, oblique needling is prohibited for those with epiglottis at acupoints. At this time, lifting and inserting method or thick needle can not be used to avoid gastrointestinal perforation or suppurative peritonitis. Be careful not to eat too much after the injection. Pregnant women should use it with caution. Moxibustion: Yes ...
The person in charge forbids oblique stabbing. At this time, lifting and inserting method or thick needle can not be used to avoid gastrointestinal perforation or suppurative peritonitis. Be careful not to eat too much after the injection. Pregnant women should use it with caution. Moxibustion: Yes ...
Discipline, it is forbidden to oblique stab. At this time, lifting and inserting method or thick needle can not be used to avoid gastrointestinal perforation or suppurative peritonitis. Be careful not to eat too much after the injection. Pregnant women should use it with caution. Moxibustion: Yes ...
Oblique needling is prohibited for patients with gastric tube insertion. At this time, lifting and inserting method or thick needle can not be used to avoid gastrointestinal perforation or suppurative peritonitis. Be careful not to eat too much after the injection. Pregnant women should use it with caution. Moxibustion: Yes ...
Stomach cavity