今日の臨床サポート

食道穿孔・破裂

著者: 柏木秀幸 富士市立中央病院 外科

監修: 木下芳一 兵庫県立姫路循環器病センター/製鉄記念広畑病院

著者校正/監修レビュー済:2020/09/03
患者向け説明資料

概要・推奨   

  1. 嘔吐、胸部痛、皮下気腫のMacklerの3徴がみられる場合、特発性食道破裂が疑われる(推奨度2)
  1. 食道穿孔が疑われる場合、造影CT検査の感度は高く(92~100%)、周辺臓器の変化の把握や、他の疾患の鑑別に有用である(推奨度1)。
  1. 食道穿孔が疑われる例に対する食道造影には、水溶性造影剤を使用することが推奨される(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
柏木秀幸 : 特に申告事項無し[2021年]
監修:木下芳一 : 講演料(アストラゼネカ,武田,大塚,第一三共)[2021年]

改訂のポイント
  1. 定期レビューを行い、主に内視鏡治療について改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
ポイント:
  1. 食道破裂(穿孔)は原因により、①特発性、②医原性、③外傷後性、④異物性、⑤化学的、⑥食道疾患によるものに分けられる。
  1. 食道穿孔の59%は医原性のもので、特発性は15%、異物性が12%、外傷後性が9%、手術が2%、腫瘍が1%、その他が2%となっている[1]
  1. イギリスからの全国調査2,564例の報告では、特発性81.9%、医原性5.9%、食道癌10%、異物2.2%となっている[2]
  1. 特発性食道破裂は、1724年にオランダのHermann Boerhaaveが最初の剖検例の報告を行ったことから、Boerhaave症候群と呼ばれる[3]
  1. 特発性食道破裂は、嘔吐に際し、上部食道括約部※の弛緩不全に伴う急激な食道内圧上昇による圧外傷で、筋層脆弱部の食道胃接合部より2~3cm口側の下部食道左側部に発生しやすい[4]
  1. 医原性のものは主に内視鏡治療後によるものであるが、心房細動に対するアブレーション治療後の食道穿孔・瘻孔の発生(平均19.3±12.6(範囲6~59)日)が報告されるようになった[5]
  1. 異物性としては、義歯や魚骨によるものが多く、穿孔の80%は頚部食道に生じる[1]。また、摘出時に発生しやすい。
  1. 化学的なものは酸・アルカリ液が原因となるが、小児では誤飲、成人では自殺企図によるものが多い。
  1. 疾患によるものとしては、食道憩室、バレット食道、感染性食道炎、食道がんでみられる。
  1. 20~30歳代男性の特発性食道破裂では、好酸球性食道炎が原因であることがある。
 
  1. 20~30歳代男性の特発性食道破裂の原因として、好酸球性食道炎が関与する(推奨度2O(参考文献:[6]
  1. 原因疾患のない食道穿孔は、特発性食道破裂と呼ばれるが、食道壁に高度の好酸球浸潤がみられる好酸球性食道炎による特発性食道破裂の症例が報告されるようになってきている。これまで、11例の報告があるが、全例男性で20~30歳代である。好酸球性食道炎の持続により、食道粘膜の脆弱化と狭窄を起こしやすく、拡張治療時に穿孔を起こしやすい。若い男性の食道破裂では、原因として好酸球性食道炎が関与する可能性があるので、注意を要する。
 
疫学情報、病態、注意事項
  1. 食道壁に全層性に断裂(disruption)や損傷(trauma、injury)が生じた状態は、食道破裂(esophageal rupture)、食道穿孔(esophageal perforation)やesophageal disruptionとして表現される。
  1. 特発性食道破裂のように、内圧上昇などにより脆弱部の断裂が生じ、その境界が不明瞭な食道破裂と、異物などが原因でみられるように断裂部の境界が明瞭な食道穿孔に、区別して用いられることがある。
  1. 胸痛、呼吸困難、ショックなどの症状を呈し、発症24時間以後の治療例の死亡率が高く、食道破裂が疑われた時点で、救命救急医療として対応しなければならない。
  1. 救急領域のまれな疾患であるため、エビデンスレベルの高いものは限られるが、システマテックレビュー[7][8][9]、ガイドライン[10]も報告されるようになってきた。
 
上部食道括約部:
  1. 食道の近位端に存在する括約機構。咽頭食道移行部、食道入口部とも呼ばれ、輪状咽頭筋により、高圧帯が形成されている。通常は閉じているが、飲食物が食道入口部に達すると、反射的に弛緩が生じて、食道の蠕動が始まり、飲食物は下部食道へ送られる。
問診・診察のポイント  
  1. 胸痛呼吸困難ショックなどの症状を呈し、特徴的な症状はないが、皮下気腫を伴う場合にはかなり疑いが強くなる。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: Clayton J Brinster, Sunil Singhal, Lawrence Lee, M Blair Marshall, Larry R Kaiser, John C Kucharczuk
雑誌名: Ann Thorac Surg. 2004 Apr;77(4):1475-83. doi: 10.1016/j.athoracsur.2003.08.037.
Abstract/Text Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

PMID 15063302  Ann Thorac Surg. 2004 Apr;77(4):1475-83. doi: 10.1016/j・・・
著者: V J DERBES, R E MITCHELL
雑誌名: Bull Med Libr Assoc. 1955 Apr;43(2):217-40.
Abstract/Text
PMID 14364044  Bull Med Libr Assoc. 1955 Apr;43(2):217-40.
著者: Owen Korn, Juan C Oñate, René López
雑誌名: Surgery. 2007 Feb;141(2):222-8. doi: 10.1016/j.surg.2006.06.034. Epub 2006 Sep 25.
Abstract/Text BACKGROUND: Spontaneous rupture of the esophagus (Boerhaave syndrome) occurs almost invariably at the same anatomic site. A weakness of the distal esophageal wall is suspected but has not been confirmed by anatomic studies. The aim of this work was to determine the existence of a structural abnormality in the esophageal wall.
MATERIAL AND METHODS: In six fresh human cadavers, the left lung was removed and the esophagus was insufflated in situ with air until it burst. The mucosa of the specimens was stripped off, allowing the fibers of the inner muscular coat to be seen. In addition a specimen from a patient who died from this cause was submitted to the same procedure.
RESULTS: The site of the experimental rupture matched the clinical case. The tear was located at the margin of contact between "clasp" and oblique fibers, and extends upwards.
CONCLUSIONS: The connective tissue of the junction between clasp and oblique fibers appears to constitute a weak point in the lower esophagus.

PMID 17263979  Surgery. 2007 Feb;141(2):222-8. doi: 10.1016/j.surg.200・・・
著者: Chirag R Barbhaiya, Saurabh Kumar, Roy M John, Usha B Tedrow, Bruce A Koplan, Laurence M Epstein, William G Stevenson, Gregory F Michaud
雑誌名: J Am Coll Cardiol. 2015 Apr 7;65(13):1377-1378. doi: 10.1016/j.jacc.2014.12.053.
Abstract/Text
PMID 25835452  J Am Coll Cardiol. 2015 Apr 7;65(13):1377-1378. doi: 10・・・
著者: A J Lucendo, A B Friginal-Ruiz, B Rodríguez
雑誌名: Dis Esophagus. 2011 Feb;24(2):E11-5. doi: 10.1111/j.1442-2050.2010.01167.x. Epub 2011 Feb 10.
Abstract/Text Eosinophilic esophagitis (EoE) has been associated with an increased risk of esophageal mucosal tears induced by vomiting to dislodge impacted food or following endoscopic procedures. However, Boerhaave's syndrome or transmural perforation of the organ resulting from vomiting induced to dislodge impacted food has rarely been reported. In this article, we present two male adult patients with long-term esophageal symptoms who suffered from Boerhaave's syndrome after the impaction of food in the esophagus. Both patients required surgical management because of clinical and radiological signs of perforation. This rare complication of EoE has been documented in 11 other reports, predominantly affecting young men in whom EoE had not been previously diagnosed, despite the majority having esophageal symptoms and a history of atopy. There are only two published cases of esophageal perforation that presented in children, which were managed conservatively. Our two patients and 4 out of the 11 described in literature required surgery because of esophageal perforation. Our two cases involved closure of the perforation, while in three published reports, perforation resulted in a partial or complete esophagectomy. No cases have been published on Boerhaave's syndrome caused by EoE that ended in fatalities. It is important to note that esophageal perforation caused by vomiting is a potentially severe complication of EoE that is being increasingly described in literature. Therefore, patients with non-traumatic Boerhaave's syndrome should be assessed for EoE, especially if they are young men who have a prior history of dysphagia and allergic manifestations.

© 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.
PMID 21309916  Dis Esophagus. 2011 Feb;24(2):E11-5. doi: 10.1111/j.144・・・
著者: Fausto Biancari, Vito D'Andrea, Rosalba Paone, Carlo Di Marco, Grazia Savino, Vesa Koivukangas, Juha Saarnio, Ersilia Lucenteforte
雑誌名: World J Surg. 2013 May;37(5):1051-9. doi: 10.1007/s00268-013-1951-7.
Abstract/Text BACKGROUND: The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.
METHODS: We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.
RESULTS: Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.
CONCLUSIONS: Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

PMID 23440483  World J Surg. 2013 May;37(5):1051-9. doi: 10.1007/s0026・・・
著者: E Ilias K Sdralis, S Petousis, F Rashid, B Lorenzi, A Charalabopoulos
雑誌名: Dis Esophagus. 2017 Aug 1;30(8):1-6. doi: 10.1093/dote/dox013.
Abstract/Text We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
PMID 28575240  Dis Esophagus. 2017 Aug 1;30(8):1-6. doi: 10.1093/dote/・・・
著者: Mircea Chirica, Michael D Kelly, Stefano Siboni, Alberto Aiolfi, Carlo Galdino Riva, Emanuele Asti, Davide Ferrari, Ari Leppäniemi, Richard P G Ten Broek, Pierre Yves Brichon, Yoram Kluger, Gustavo Pereira Fraga, Gil Frey, Nelson Adami Andreollo, Federico Coccolini, Cristina Frattini, Ernest E Moore, Osvaldo Chiara, Salomone Di Saverio, Massimo Sartelli, Dieter Weber, Luca Ansaloni, Walter Biffl, Helene Corte, Imtaz Wani, Gianluca Baiocchi, Pierre Cattan, Fausto Catena, Luigi Bonavina
雑誌名: World J Emerg Surg. 2019;14:26. doi: 10.1186/s13017-019-0245-2. Epub 2019 May 31.
Abstract/Text The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

PMID 31164915  World J Emerg Surg. 2019;14:26. doi: 10.1186/s13017-019・・・
著者: M Chirica, A Champault, X Dray, L Sulpice, N Munoz-Bongrand, E Sarfati, P Cattan
雑誌名: J Visc Surg. 2010 Jun;147(3):e117-28. doi: 10.1016/j.jviscsurg.2010.08.003. Epub 2010 Sep 15.
Abstract/Text The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.

Copyright © 2010. Published by Elsevier Masson SAS.
PMID 20833121  J Visc Surg. 2010 Jun;147(3):e117-28. doi: 10.1016/j.jv・・・
著者: E A Griffiths, N Yap, J Poulter, M T Hendrickse, M Khurshid
雑誌名: Dis Esophagus. 2009;22(7):616-25. doi: 10.1111/j.1442-2050.2009.00959.x. Epub 2009 Mar 17.
Abstract/Text Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23-86) years. The etiology of the perforations were Boerhaave's syndrome (n= 19), therapeutic endoscopy (n= 9), diagnostic endoscopy (n= 2), gastric lavage injury (n= 1), foreign body (n= 1), blunt chest trauma (n= 1), and spontaneous tumor perforation (n= 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair (n= 9), T-tube drainage (n= 7), emergency esophagectomy (n= 1), or intra-operative stent insertion (n= 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.

PMID 19302220  Dis Esophagus. 2009;22(7):616-25. doi: 10.1111/j.1442-2・・・
著者: M J Foley, G G Ghahremani, L F Rogers
雑誌名: Radiology. 1982 Jul;144(2):231-7. doi: 10.1148/radiology.144.2.7089273.
Abstract/Text Iodinated water-soluble compounds have been widely recommended as the most suitable contrast media for diagnosis of gastrointestinal perforations. However, the authors present 6 cases in which mucosal tears and transmural perforations of the upper gastrointestinal tract were either unrecognizable or inadequately shown during initial evaluation with methylglucamine diatrizoate. Re-examination with barium sulfate demonstrated the precise location and extent of the perforations. Reasons for the higher diagnostic yield of barium studies are explained on the basis of experimental and clinical observations.

PMID 7089273  Radiology. 1982 Jul;144(2):231-7. doi: 10.1148/radiolog・・・
著者: A Z Ginai, F J ten Kate, G M ten Berg, K Hoornstra
雑誌名: Br J Radiol. 1985 Jul;58(691):585-92.
Abstract/Text The tissue reaction of seven contrast agents--pure barium sulphate, Micropaque, Hytrast, Dionosil, Gastrografin, Amipaque and Hexabrix-was evaluated on the mediastinum of rats. This work was undertaken to define the most suitable and safe contrast agent for use in the upper gastrointestinal tract in cases where leakage outside the gut into the mediastinum, pleura or peritoneal cavity may be suspected and aspiration may be an accompanying risk. Keeping in mind the danger of aspiration, Hexabrix and Amipaque appear to be the safest contrast media for the mediastinum.

PMID 4016493  Br J Radiol. 1985 Jul;58(691):585-92.
著者: A E James, R J Montali, V Chaffee, E P Strecker, K Vessal
雑誌名: Gastroenterology. 1975 May;68(5 Pt 1):1103-13.
Abstract/Text In order to study the effects of the commonly employed contrast media alone and in combination with bacteria in the mediastinum, various mixtures of barium and meglamine diatrizoate (Gastrografin) with and without flora were instilled in the mediastinum of 29 domestic cats. The animals were killed for pathological studies at serial time intervals following mediastina injection. These data demonstrate that water-soluble contrast media cause no significant histological reaction. Barium causes granuloma formation but has no additional deleterious effects when mixed with flora. Barium has superior physical properties of mucosal coating and radiographic density. It should be employed as the contrast agent of choice in difficult clinical problems with regard to esophageal tears. A water-soluble contrast study of the esophagus may be utilized as the initial diagnostic procedure, but if this is normal a follow-up barium esophagram is recommended.

PMID 1126592  Gastroenterology. 1975 May;68(5 Pt 1):1103-13.
著者: B Horwitz, B Krevsky, R F Buckman, R S Fisher, M A Dabezies
雑誌名: Am J Gastroenterol. 1993 Aug;88(8):1249-53.
Abstract/Text There are few objective data evaluating the role of flexible endoscopy in the management of penetrating esophageal and neck injuries. A retrospective analysis was performed on 13 trauma patients who had undergone emergent esophagogastroduodenoscopy for the evaluation of potential esophageal injuries. Endoscopy resulted in one true positive (esophageal injury detected), 10 true negatives (normal esophagus), two false positives, and no false negatives. This yielded a sensitivity of 100% and specificity of 83%. There were no complications of endoscopy. We conclude that urgent flexible esophagogastroduodenoscopy is a useful diagnostic procedure in the evaluation of penetrating wounds possibly involving the esophagus.

PMID 8338093  Am J Gastroenterol. 1993 Aug;88(8):1249-53.
著者: Madhan Kumar Kuppusamy, Michal Hubka, Chance D Felisky, Philip Carrott, Elizabeth M Kline, Richard P Koehler, Donald E Low
雑誌名: J Am Coll Surg. 2011 Jul;213(1):164-71; discussion 171-2. doi: 10.1016/j.jamcollsurg.2011.01.059. Epub 2011 Mar 23.
Abstract/Text BACKGROUND: Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes.
STUDY DESIGN: Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality.
RESULTS: Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative.
CONCLUSIONS: Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.

Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
PMID 21429768  J Am Coll Surg. 2011 Jul;213(1):164-71; discussion 171-・・・
著者: M Chalumeau, L Le Clainche, N Sayeg, N Sannier, J L Michel, R Marianowski, P Jouvet, P Scheinmann, J de Blic
雑誌名: Pediatr Pulmonol. 2001 Jan;31(1):67-75.
Abstract/Text SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

Copyright 2001 Wiley-Liss, Inc.
PMID 11180677  Pediatr Pulmonol. 2001 Jan;31(1):67-75.
著者: Jon Arne Søreide, Asgaut Viste
雑誌名: Scand J Trauma Resusc Emerg Med. 2011 Oct 30;19:66. doi: 10.1186/1757-7241-19-66. Epub 2011 Oct 30.
Abstract/Text Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

PMID 22035338  Scand J Trauma Resusc Emerg Med. 2011 Oct 30;19:66. doi・・・
著者: Michael Schweigert, Hugo Santos Sousa, Norbert Solymosi, Aleksandar Yankulov, Marta Jiménez Fernández, Rory Beattie, Attila Dubecz, Charlotte Rabl, Simon Law, Daniel Tong, Danail Petrov, Annemaria Schäbitz, Rudolf J Stadlhuber, Julia Gumpp, Dietmar Ofner, Jim McGuigan, José Costa-Maia, Helmut Witzigmann, Hubert J Stein
雑誌名: J Thorac Cardiovasc Surg. 2016 Apr;151(4):1002-9. doi: 10.1016/j.jtcvs.2015.11.055. Epub 2015 Dec 13.
Abstract/Text OBJECTIVE: The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population.
METHODS: In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups.
RESULTS: Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS.
CONCLUSIONS: The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
PMID 26897241  J Thorac Cardiovasc Surg. 2016 Apr;151(4):1002-9. doi: ・・・
著者: Omar A Khan, Clifford W Barlow, David F Weeden, Khalid M Amer
雑誌名: Eur J Cardiothorac Surg. 2005 Jul;28(1):178-9. doi: 10.1016/j.ejcts.2005.04.005.
Abstract/Text Spontaneous esophageal rupture is an uncommon and poorly understood condition. Recurrent rupture is extremely rare, with only one previously reported case in the literature. Here, we present a case series of two patients who had recurrent ruptures, and discuss the principles underlying the management of such cases.

PMID 15951197  Eur J Cardiothorac Surg. 2005 Jul;28(1):178-9. doi: 10.・・・
著者: H J Lujan, P H Lin, S P Boghossian, R F Yario, C J Tatooles
雑誌名: Surgery. 1997 Sep;122(3):634-6.
Abstract/Text
PMID 9308624  Surgery. 1997 Sep;122(3):634-6.
著者: L B Reeder, S E Warren, M K Ferguson
雑誌名: Ann Thorac Surg. 1995 Jan;59(1):221-2. doi: 10.1016/0003-4975(94)00589-Y.
Abstract/Text Boerhaave's syndrome is uncommon and its precise etiology is unclear. Information regarding the long-term outcome of patients surviving this injury is lacking. We present the case of a patient who suffered two spontaneous perforations of the esophagus that occurred 30 years apart.

PMID 7818331  Ann Thorac Surg. 1995 Jan;59(1):221-2. doi: 10.1016/000・・・
著者: Stephen B Vogel, W Robert Rout, Tomas D Martin, Patricia L Abbitt
雑誌名: Ann Surg. 2005 Jun;241(6):1016-21 ;discussion 1021-3.
Abstract/Text OBJECTIVE: To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation.
SUMMARY BACKGROUND DATA: The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress.
METHODS: From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement.
RESULTS: Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2.
CONCLUSIONS: Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.

PMID 15912051  Ann Surg. 2005 Jun;241(6):1016-21 ;discussion 1021-3.
著者: J L Cameron, R F Kieffer, T R Hendrix, D G Mehigan, R R Baker
雑誌名: Ann Thorac Surg. 1979 May;27(5):404-8.
Abstract/Text Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).

PMID 110275  Ann Thorac Surg. 1979 May;27(5):404-8.
著者: James T Wu, Kenneth L Mattox, Matthew J Wall
雑誌名: J Trauma. 2007 Nov;63(5):1173-84. doi: 10.1097/TA.0b013e31805c0dd4.
Abstract/Text Despite significant advances in modern surgery and intensive care medicine, esophageal perforation continues to present a diagnostic and therapeutic challenge. Controversies over the diagnosis and management of esophageal perforation remain, and debate still exists over the optimal therapeutic approach. Surgical therapy has been the traditional and preferred treatment; however, less invasive approaches to esophageal perforation continue to evolve. As the incidence of esophageal perforation increases with the advancement of invasive endoscopic procedures, early recognition of clinical features and implementation of effective treatment are essential for a favorable clinical outcome with minimal morbidity and mortality. This review will attempt to summarize the pathogenesis and diagnostic evaluation of esophageal injuries, and highlight the evolving therapeutic options for the management of esophageal perforation.

PMID 17993968  J Trauma. 2007 Nov;63(5):1173-84. doi: 10.1097/TA.0b013・・・
著者: Valentino Fiscon, Giuseppe Portale, Flavio Frigo, Giovanni Migliorini, Piero L Fania
雑誌名: Surg Endosc. 2010 Nov;24(11):2900-2. doi: 10.1007/s00464-010-1056-4. Epub 2010 May 13.
Abstract/Text Spontaneous rupture of the esophagus (so-called Boerhaave's syndrome) is considered a medical emergency. It carries a significant mortality rate and requires prompt treatment. The treatment of choice involves surgical repair of the esophageal defect, usually accomplished via laparotomy, thoracotomy, or both to accomplish esophageal repair and mediastinal debridement. We have treated an elderly patient with severe comorbidities with a minimally invasive approach, achieving a successful complete repair. Long-term endoscopic and radiologic follow-up confirm the good results.

PMID 20464427  Surg Endosc. 2010 Nov;24(11):2900-2. doi: 10.1007/s0046・・・
著者: S Landen, I El Nakadi
雑誌名: Surg Endosc. 2002 Sep;16(9):1354-7. doi: 10.1007/s00464-001-9185-4. Epub 2002 May 23.
Abstract/Text BACKGROUND: Boerhaave's syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives.
MATERIALS AND METHODS: Over a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting.
RESULTS: Esophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively.
CONCLUSIONS: Boerhaave's syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.

PMID 12023725  Surg Endosc. 2002 Sep;16(9):1354-7. doi: 10.1007/s00464・・・
著者: M B Orringer, M C Stirling
雑誌名: Ann Thorac Surg. 1990 Jan;49(1):35-42; discussion 42-3.
Abstract/Text When esophageal disruption occurs in the presence of preexisting esophageal disease or is associated with sepsis or fluid and electrolyte imbalance, aggressive and definitive therapy often provides the only chance for patient salvage. Twenty-four adults (average age, 59 years) with intrathoracic esophageal perforations underwent esophagectomy: 15, transhiatal esophagectomy without thoracotomy; and 9, transthoracic esophagectomy. Restoration of alimentary continuity with an immediate cervical esophagogastric anastomosis was carried out in 13 patients. Eleven underwent a cervical or anterior thoracic esophagostomy, and 10 of them had a subsequent colonic (7) or gastric (3) interposition from 4 to 32 weeks (average time, 8.6 weeks) later. The perforations were due to esophageal instrumentation (9 patients), acute caustic ingestion (2), emesis (2), intrathoracic esophagogastric anastomotic disruption (2), and other causes (9). Preexisting esophageal disease in 20 patients included chronic strictures (10 patients), reflux esophagitis (3), esophageal cancer (3), achalasia (2), diffuse spasm (2), and monilial esophagitis (1 patient). Ten patients were operated on within 12 hours after the injury; 3, within 12 to 24 hours; and 11, within three to 45 days (average interval, 6.6 days). There were three hospital deaths (13%). Nineteen of the 21 survivors were able to swallow comfortably until the time of death or latest follow-up. Aggressive diagnosis and aggressive treatment of life-threatening esophageal perforations are advocated. Conservative procedures (repair, diversion, or drainage) for a perforation with preexisting esophageal disease often inflict more morbidity than esophageal resection, which eliminates the perforation, the source of sepsis, and the underlying esophageal disease. The decision to restore alimentary continuity in a single stage must be individualized.

PMID 2297275  Ann Thorac Surg. 1990 Jan;49(1):35-42; discussion 42-3.・・・
著者: M D Iannettoni, A A Vlessis, R I Whyte, M B Orringer
雑誌名: Ann Thorac Surg. 1997 Dec;64(6):1606-9; discussion 1609-10.
Abstract/Text BACKGROUND: The functional results after treatment of intrathoracic esophageal perforations have been poorly documented.
METHODS: A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed.
RESULTS: Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%).
CONCLUSIONS: In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a "normal" esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.

PMID 9436543  Ann Thorac Surg. 1997 Dec;64(6):1606-9; discussion 1609・・・
著者: Philipp Horvath, Jessica Lange, Dietmar Stüker, Dörte Wichmann, Julia Hilbert, Martin Götz, Alfred Königsrainer, Maximilian von Feilitzsch, Marty Zdichavsky
雑誌名: Surg Laparosc Endosc Percutan Tech. 2018 Aug;28(4):232-238. doi: 10.1097/SLE.0000000000000549.
Abstract/Text PURPOSE: Esophageal perforation constitutes a potentially life-threatening condition, and this study aimed to evaluate the indications and outcome for the different treatment modalities.
PATIENTS AND METHODS: In total, 43 patients with esophageal perforation were considered for this retrospective analysis. Age, sex, length of hospital stay and intensive care treatment, in-hospital mortality, localization of perforation and etiology, treatment modality, and 90-day morbidity were analyzed.
RESULTS: Most patients suffered from Boerhaave syndrome and from iatrogenic esophageal perforation. In total, 63% of patients (26/41) received successful nonoperative treatment, whereas 36% required additional surgery. Two patients (5%) underwent primary surgery. In all cases no esophagectomy was necessary. In-hospital mortality was 7%. During the 90-day follow-up 1 patient with stenosis required repetitive dilatations.
CONCLUSIONS: Initial endoscopic treatment, either by stent or by endosponge, alone or combined with an additional operative treatment, seems feasible in patients suffering from esophageal perforation. In all patients, there was no need for esophagectomy.

PMID 29975355  Surg Laparosc Endosc Percutan Tech. 2018 Aug;28(4):232-・・・
著者: Gabie K B Ong, Richard K Freeman, Anthony J Ascioti, Raja S Mahidhara, Vijay Nuthakki, Megan Dake, Daryl Eckstein
雑誌名: Ann Thorac Surg. 2018 Sep;106(3):830-835. doi: 10.1016/j.athoracsur.2018.05.010. Epub 2018 Jun 5.
Abstract/Text BACKGROUND: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients.
METHODS: Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed.
RESULTS: Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement.
CONCLUSIONS: Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.

Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
PMID 29883642  Ann Thorac Surg. 2018 Sep;106(3):830-835. doi: 10.1016/・・・
著者: Jeffrey R Watkins, Alexander S Farivar
雑誌名: Thorac Surg Clin. 2018 Nov;28(4):541-554. doi: 10.1016/j.thorsurg.2018.07.002.
Abstract/Text Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Copyright © 2018 Elsevier Inc. All rights reserved.
PMID 30268300  Thorac Surg Clin. 2018 Nov;28(4):541-554. doi: 10.1016/・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから