Author/Editor		Veingerl, Bojan; Hojski, Aljaž; Vidovič, Damjan; Zorko, Anton
Title		Zdravljenje iatrogenih in spontanih perforacij požiralnika
Type		članek
Source		Gastroenterolog
Vol. and No.		Letnik 11, št. 24/25
Publication year		2007
Volume		str. 56-60
Language		slo
Abstract		Background. If not diagnosed and treated quickly, iatrogenic and spontaneous (Boerhaave's syndrome) oesophageal perforations are associated with high mortality and morbidity. They are the most lethal perforations of the gastrointestinal tract. Delayed intervention is directly associated with increased mortality. Their management is based on four principles: elimination of the source of soiling, provision of adequate drainage, augmentation of the host defence by antibiotics, and maintenance of adequate nutrition. Methods. Seven cases and spontaneous oesophageal perforations treated in our institution from 2002 to 2006 are presented in this review. In 4 patients the oesophagus was perforated during endoscopic removal of a foreign body and in one during endoscopic oesophageal intervention of a tumour, located in the gastric cardia; Boerhaave's syndrome was the cause of perforation in the other two cases. Results. The only decisive prognostic factor was the time of observation: the patient who was treated more than 24 hours after the injury died because of the delayed diagnosis joined with a concomitant disease. The other patients were treated within 24 hours. Their postoperative status was uneventful and they were discharged on the seventh to twenty-first post-operative day. Conclusions, Oesophageal perforations is a life-threatening condition. Despite advances in surgical techniques and endoscopic therapies, it is associated with high morbidity and mortality rates. Prognosis depends on the time between the diagnosis and treatment. We recommend that the rupture is repaired and covered with a pleural (fundus, omentum) flap within 12 hours of the injury. Oesophagectomy is indicated only when primary repair cannot be carried out, i. e. in extensive perforations with necrosis, and in cases with a concomitant disease.
Summary		Izhodišča. Iatrogena in spontana perforacija požiralnika ogrožata življenje in imata tako veliko mortaliteto in morbiditeto, da sta najusodnejši perforaciji prebavil. Iatrogena perforacija nastane pri približno 0,4 % rutinskih ezofagoskopij z rigidnim ezofagoskopom. Možnost zanjo pri preiskavi,biopsiji ali terapevtski dilataciji je večja, če je požiralnik patološko spremenjen. Čas od poškodbe do njene diagnoze in ukrepanja je najpomembnejši dejavnik ozdravitve. Oskrbo perforacije vodijo štiri načela: odstraniti je treba izvor nečistoč, poskrbeti za zadostno drenažo, podpreti imunski sistem z antibiotiki in zagotoviti zadostno hranjenje bolnika.Metode. V zadnjih pet letih smo na našem oddelku zdravili 7 bolnikov s perforacijo požiralnika, 5 z iatrogeno in 2 s spontano. Iatrogena perforacija je pri štirih nastala pri odstranjevanju tujka, koščka hrane, z rigidnim ezofagoskopom, pri enem pa pri odstranjevanju polipa želodčne kardije. Dva primera spontane rupture sta bili posledica Boerhaavejevega sindroma. Rezultati. Razen enega so bili vsi bolniki operirani v prvih 24 urah po perforaciji; vsi ti so bili odpuščeni kot ozdravljeni v roku enega do treh tednov; perforacijo smo jim prešili in dodatno prekrili z delom želodca, parietalne plevre ali peče. Bolniku, ki ni bil operiran v 24 urah po poškodbi, smo najprej napravili torakalno drenažo, teden dni po nastanku iatrogene perforacije pa smo mu mesto perforacije še prešili in prekrili. Kljub temu je en mesec po perforaciji umrl. Zaključek. Perforacija požiralnika ogroža življenje. Kljub sodobni kirurgiji ima še vedno veliko morbiditeto in mortaliteto. Prognoza je odvisna od časa od nastanka poškodbe do prepoznanja stanja in terapije. Menimo, da je v zdravljenje perforacij požiralnika ključna pravočasna operacija, ki naj bo v prvih 12 urah po poškodbi. Perforacija naj bo prešita in prekrita z dosegljivo vitalno strukturo. (Izvl. skrajšan na 2000 zn.)
Descriptors		ESOPHAGEAL PERFORATION ESOPHAGUS