使用經食道心臟超音波監測心臟瓣膜置換手術後併發延遲診斷的食道破裂之病例報告

Delayed Diagnosis of Esophageal Perforation Following Intraoperative Transesophageal Echocardiography during Valvular Replacement-- A Case Report

案例報告的是一位62歲男性病患，在主動脈瓣膜及二尖瓣膜置換手術中曾接受過經食道心臟超音波掃瞄監測，術後發生食道破裂。敗血性休克出現在術後第十二天，經胸部電腦斷層掃描確定診斷，病患在緊急手術及後續的重症照護後存活下來。由整個病程與事件間的關係來推論，我們認為發生食道延遲性破裂的原因應非超音波探頭直接的機械性損傷，而是來自食道長時間的缺血傷害，這與術中超音波探頭的壓迫，病患極度擴大的心房及體外循環時非脈衝式的血流供應有關。所以，基於進行開心手術患者的某些特殊危險因素考量，如心房擴張、手術時間過長、體外循環時易發生腸胃道缺血等，我們強烈建議，在開心手術中，有上述情況疑慮，食道超音波探頭於體外循環時，不用時應取出，另外，若在放置超音波探頭時曾遇到阻力，病患術後又有發燒及胸部X光不正常等表現，應考慮食道破裂發生的可能性。

A 62 year-old man sustained esophageal perforation following intra-operative transesophageal echocardiography (TEE) in a valvular replacement surgery. Septic shock developed on the 12th postoperative day (POD) and the esophageal perforation was diagnosed with chest CT. Emergent operation together with intensive care saved the patient's life. We speculate that the mechanism of perforation was not due to manipulation of the probe, but rather due to ischemia of the esophagus resulting from the combination of probe compression, non-pulsatile flow and the distension of the atria during a lengthy procedure. It is advisable that in patients with operative risk factors, such as distension of atria, long cardiac procedure and likely ischemia of organs due to cardiopulmonary bypass, the monitoring probe of TEE should not constantly rest in the esophagus and be withdrawn when it is idle or not in actual use. In addition, if resistance has been met during the intraoperative manipulation of the probe in a patient without previous history of esophageal disease, perforation might suspected if he or she sustains postoperative fever with positive chest X-ray findings.