Surgical treatment of spontaneous rupture of esophagus
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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.
Key words:
Esophagus; Rupture, spontaneous; TherapyKeywords:
Esophageal hiatus
Diaphragm (acoustics)
FROM THE DEPARTMENT OF SURGERY AND THE THORACIC STUDY UNIT, YALE UNIVERSITY SCHOOL OF MEDICINE † Senior Fellow, American Cancer Society, as recommended by the National Research Council. Associate in Surgery, New Haven Hospital
Haven
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Introduction: As one of the short-term complications after inguinal hernia repair, mesh infection frequently occurs but rarely leads to ileocutaneous fistula. We present a rare case of ileocutaneous fistula 8 years after inguinal hernia plug repair with polypropylene mesh. Case Presentation: The patient was a 67-year-old male who underwent a plug repair with polypropylene mesh of the right inguinal hernia. Eight years after the primary repair, skin ulceration with pus presented in the right groin area, and the final diagnosis was enterocutaneous fistula. According to laparoscopic exploration, the ileum below the fistula closely adhered to the abdominal wall. After gently separating the bowel loop, a defect area of about 2 × 3 cm was observed on the surface of the ileum. In laparotomy, the plug was found embedded in the ileum and then was completely removed, and an ileum side-to-side anastomosis was performed. The patient was discharged 2 weeks after the surgery, and follow-up at the sixth month revealed complete healing of the wound and no evidence of hernia recurrence. Conclusion: Late-onset ileocutaneous fistula should be considered in the differential diagnosis in patients who present inflammation and abscess formation after hernia repair. Besides, for patients with suspected intestinal fistula after hernia repair, laparoscopic exploration should be given priority, and the mesh removal approach should be tailored according to the results of laparoscopic exploration.
Enterocutaneous Fistula
Hernia Repair
Groin
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Electrical conduit
Esophagectomy
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Perforation
Cardiothoracic surgery
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症例は71歳，男性．直腸癌に対し低位前方切除術を施行．術後に急性腎不全，心不全，誤嚥性肺炎，腹腔内膿瘍を併発したが保存的加療にて改善した．術後15カ月頃から下腹部膨満感が出現し，左下腹部のドレーン挿入部周囲の皮下気腫，および腹部単純CT検査で腹腔内にfree airを認めた．症状および炎症所見が軽度であったため腹腔穿刺・吸引を行い経過観察としていたが，症状が増悪したため精査を行った．下部消化管内視鏡検査で盲端部（S状結腸）に２mm大の穿孔部を認めたため，クリップによる閉鎖を施行した．経口摂食開始後，腹腔内の気体の微増と軽度の腹部膨満感を認めたが保存的に加療した．完全閉鎖は得られなかったが腸管内容の腹腔内への流出は認めなかったため外来で経過観察とした．穿孔後約１年経過したが全身状態は良好で現在通院加療中である．直腸切除術15カ月後の端側吻合盲端部に微小穿孔を認めた症例を経験したため報告する．
Perforation
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To resolve the disadvantages of jejunal Roux-en-Y reconstruction following total gastrectomy, we attempted the use of left colon substitution with all anastomoses conducted using mechanical stapling devices. A His’ angle was formed to reduce regurgitation esophagitis. About 25 cm of the left colon with the ascending branch of the left colic artery with an adequate blood supply was brought up to the remnant esophagus without tension on the mesentery. The colon graft was interposed between the esophagus and duodenum in an isoperistaltic fashion. Three anastomoses, esophagocolic, duodenocolic and colocolic, were completed with a circular stapling device. An end-to-side esophagocolonostomy was positioned about 3 cm distal from the blind end of the proximal colon stump. The proximal end of the left colon was pexied to the esophagus using 3–4 stitches to make a new His’ angle. Gastrointestinal continuity was restored by a side-to-end colonoduodenostomy and an end-to-end colonocolonostomy. Fifteen gastric cancer patients underwent left colon substitution following total gastrectomy. The circular staple used for esophagocolonostomy and colonoduodenostomy was 25 mm in all patients, and for colonocolonostomy was 29 mm in 9 patients and 33 mm in 6 patients. No problems were encountered in any steps of the procedure, and faulty stapling was avoided. Neither anastomotic leakage nor necrosis of the interposed colon segment was seen, nor was late anastomotic stricture, in any patient. Barium radiograms of the interposed colon segment showed that the capacity and passage of the interposed colon were adequate, and regurgitation did not occur. Diet volume was satisfactory and weight loss minimal.
Transverse colon
Reflux esophagitis
Ascending colon
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特発性食道破裂は，嘔吐などに伴う食道内圧の急激な上昇により食道壁全層が穿孔する救急疾患で，早期に適切な治療が行わなければ重症化して致命的となる．今回，我々は術前食道造影で穿孔部位と大きさの確認を行い，胸腔鏡下食道単純縫合閉鎖+ドレナージで軽快した特発性食道破裂の1例を経験したので報告する．症例は52歳の女性で，嘔吐後の急激な上腹部痛を主訴に発症より4時間後に当院へ救急搬送された．CTで縦隔気腫と両側胸水を認め，食道造影で胸部下部食道左壁に約20 mmの穿孔部を認め特発性食道破裂と診断した．発症より12時間後に胸腔鏡下での緊急手術を開始した．食道穿孔部は長軸方向に約25 mmで挫滅・汚染は軽度であったため，食道の全層一層縫合で食道を縫合閉鎖し，閉鎖部の被覆は追加しなかった．重篤な合併症は認めず，術後23日目に退院となった．
Closure (psychology)
Thoracoscopy
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A 78-year-old woman vomited blood on the next day after endoscopic removal of esophageal foreign body (fish bone) . So, she was admitted emergency to our hospital. The Chest radiogram revealed massive free air in the abdominal cavity. We diagnosed a perforation of the gastrointestinal tract. Endoscopic examination revealed a laceration about 3 cm in diameter located from cardia to the upper body of the lesser curvature. So we performed operative treatment laparoscopically. The laceration was appeared at the same location as endoscopic findings. This wound was performed knotted suturing and covered by lesser omentum. The postoperative course was good. Here we present this case because spontaneous rupture of the stomach in an adult is rare. In our country, this disease was reported only 12 cases. The cause of the rupture was various, but in most case, dilatation of the stomach was existed before. Our case was speculated that excessive releasing air during endoscopic examination was the cause.
Radiogram
Fish bone
Abdominal cavity
Perforation
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