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Successful Treatment of Multiple Esophageal Perforations with Delayed Diagnosis in a Cirrhotic Patient: Report of a Case

延遲診斷之多處食道破裂於肝硬化病患之成功治療經驗:病例報告

Abstracts


本篇報導描述以手術成功的治療一位酒精性肝硬化之54歲男性(Child B),因食道靜脈瘤出血而接受上消化道內視鏡檢查及血管結紮治療,而引起多處食道破裂。病患首先以頸部食道破裂表現而接受內科治療,而後第二次食道破裂由於延遲診斷導致嚴重右側膿胸與敗血症。事發兩週之後,病患接受右胸開放式引流及左頸局部引流手術。再加上減壓性的胃造瘦與灌食空腸造瘦,後來爲了改善頸部食道破裂處唾液之引流,我們在頸部食道破裂處置放-T型管。在廣效抗生素治療與食道破裂處持續吸引式引流之下,病患雖於術後因急性腎衰竭接受短暫血液透析,然其情況逐漸改善,並於三個月後施行胸部成型術以背擴肌皮瓣填滿並關閉胸腔之缺陷處。到目前爲止(食道破裂一年之後),病患已可以順利地經口進食。食道破裂一旦延遲診斷,則爲高死亡率之危險併發症,而本例幸而獲救,所以我們報告此一罕見多處食道破裂病例,希望能爲此類病患的治療提供參考意見。

Keywords

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Parallel abstracts


This report describes our experience of successful surgical intervention of multiple esophageal perforations with delayed diagnosis in a 54 year-old male with alcoholic cirrhosis of the liver (Child B) resulting from endoscopic variceal ligation for bleeding. The patient presented with two episodes of perforation. The initial one was that of acute cervical esophageal perforation which was treated medically. During the second episode, delayed recognition led to right empyema and profound sepsis. Two weeks after the event, primary repair of the perforated esophagus plus local drainage for the cervical esophageal perforation and open window-drainage of the empyema resulting from thoracic esophageal perforation were carried out; decompressive gastrostomy and feeding jejunostomy were also performed. A second surgical operation was performed to place a T-tube at the site of cervical perforation because of poor drainage. Under broad spectrum-antibiotic treatment and continuous suction drainage of the perforation sites, the patient’s condition gradually improved, although he required a transient hemodialysis for acute renal failure during the postoperative course. The thoracic wound was closed with thoracoplasty and latissimus dorsi muscular transposition three months later. The oral intake was smooth without any esophageal symptoms at 1-year follow up. Multiple esophageal perforation is rare, and esophageal perforation is a potentially lethal condition, and a delay in diagnosis is the major factor contributing to its high morbidity and mortality. We hope that our experience will serve to improve the management of similar cases of multiple esophageal perforation, whether with or without delayed diagnosis, in the future.

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