先天性食管闭锁手术治疗与术后管理的相关临床研究

发布时间：2018-05-11 06:16

本文选题：先天性食管闭锁 + 手术治疗　；参考：《上海交通大学》2014年博士论文

【摘要】：先天性食管闭锁是一种严重的消化道发育畸型，也是新生儿期具有代表性需要紧急处理的外科疾病之一，国外统计发病率1/3000-1/4000。我国在其诊治、围手术期支持、术后并发症处理以及预后随访等方面仍存在很多问题,与发达国家仍然存在差距。即使是大中城市的儿童医疗中心，仍缺乏规范化模式。如何提高治愈率，将创伤降到最小，以及将并发症发生率降到最低，是目前国内外小儿外科医生共同努力的方向。随着早期诊断率的提高，新生儿麻醉和手术方式的改进，围手术期监护和营养支持的加强，近年来我国先天性食管闭锁治愈率有所上升，但对于合并其他复杂畸形、长段型、低体重儿等病例，在治疗上仍存在困难与争议，且相关的临床研究往往因样本量小、病例异质性大而很难深入。本研究拟回顾整理自1995年10月至2013年10月我科收治的93例先天性食管闭锁病例资料，从术前一般情况分析、手术术式探讨、营养支持选择以及术后随访等各个方面进行分析和讨论，总结在处理先天性食管闭锁方面的临床问题时的重点、要点和难点。研究结果如下：一、术前一般情况与预后 1.总存活率89%（83/93）。男女存活率为91.8%VS84.4%；早产儿存活率为91.7%（VS足月儿88.9%）；低体重儿存活率为92.3%（VS正常出生体重组88.8%）；畸形伴发率为53.8%，伴其他畸形组存活率为84%（VS无伴其他畸形组95.3%）；术前并发肺炎组存活率为80.4%（VS术前无肺炎组97.9%）；Ⅰ、ⅢA、ⅢB的存活率分别为94%、91%、90%，2例Ⅴ型均死亡。 2.对于符合标准的21例Ⅲb型先天性食管闭锁病例，进行术前等待时间与术后住院天数相关性分析，得出两者具有显著性正相关。二、手术治疗 1.共对71例患儿实施了手术治疗。我院明确诊断并完成根治术的59例患儿中，5例患儿术后死亡。外院术后来我院就诊并再次行手术治疗的12例患儿中，10例诊断为食管气管瘘复发，其中10例行食管重建术，2例仅行瘘管结扎术，均存活。 2.对于超长段型食管闭锁，均采用食管替代术，存活率100%。通过对胃代食管术组、结肠代食管术组和舌状瓣翻转代食管术组的比较，可知术后结肠代食管组呼吸机辅助通气时间明显少于其他两组，而舌状瓣翻转代食管组在术后胸腔引流留置、胃管留置、空肠营养及住院天数等明显高于其他两组，预后随访可见胃代食管组胃食管返流发生率高于其他两组。三、营养支持 1.将22例IIIA型先天性食管闭锁病例，排除行分期手术5例、低体重出生儿1例、死亡2例后分成两组：实验组（NFT：Nasointestinalfeedingtube，术中即放置鼻空肠营养管）和对照组（Control未放置），比较术后两周的直接胆红素时，可以发现两组数值具有显著性差异。 2.采用DSA辅助技术放置营养管，平均手术时间为1.14小时，成功率100%，平均放置时间为2.63月。四、并发症 1.71例术后患儿中，41例即伴有不同程度的肺炎及胸腔感染，发生率为57.7%（41/71）。术后吻合口漏13例，发生率为18.3%（13/71）。对存活且出院的患儿进行常规3个月、6个月、1年随访，随访率92.4%（61/66），进奶好，无呕吐，每个月增加体重350-550g。在中远期并发症方面，6例食管气管瘘复发，21例食道狭窄（其中吻合口狭窄18例），3例食道憩室，5例胃食管返流，1例出现肠梗阻，1例反复肺炎，1例重度营养不良，均得到有效治疗。60.6%的患儿（40/66）定期于我院行食管造影检查追踪预后。 2.31例先天性食管闭锁术后食管狭窄患儿行食管球囊扩张术共计86次，78次成功，扩张成功率为90.7%。86次扩张中有8次扩张失败。扩张失败主要原因是球囊扩张过程中，气道受压造成患儿呼吸困难，而停止扩张(共5次)。另1次为狭窄处球囊固定不佳，，造成扩张中球囊多次滑脱而失败，1次为食管破裂。3-6个月随访中，26例患儿治疗有效，总有效率为84%。年龄小于6月的患儿所需扩张次数比大于6月的患儿少。利用DSA辅助技术时，平均手术时间显著少于利用传统方式进行食管扩张，但两种方式下扩张成功率并无区别。以上结果提示： 1.先天性食管闭锁患儿的预后与性别、胎龄、出生体重无关。危险因素包括伴发畸形、合并肺炎以及分型。采用Montreal法评估危险分级简单而实用。 2.明确诊断为Ⅲb型食管闭锁的且术前评估可耐受手术，建议尽早行手术治疗，可有效缩短住院天数，加快术后恢复。合并其他需手术处理的畸形时，应个体化治疗。针对I型超长段型食管闭锁，建议采用舌状瓣翻转代食管术。结肠代食管术后对呼吸道影响较小。胃代食管术后胃食管返流发生率较高。 3.对Ⅲa型先天性食管闭锁患儿术后应用鼻空肠营养管，能够早期开放肠内营养，减少胆汁淤积的发生率。 4.食管闭锁术后并发症较多且复杂，发生率高，需要各科室协作并密切随访，必要时需行食管造影术明确诊断。应用DSA技术辅助球囊扩张可以降低操作难度，缩短手术时间。
[Abstract]:Congenital esophageal atresia is a serious malformation of digestive tract development, and it is also one of the surgical diseases with representative needs for emergency treatment in the newborn period. The statistical incidence rate of foreign statistics 1/3000-1/4000. in China is still a lot of problems in its diagnosis and treatment, perioperative support, postoperative complications treatment and prognosis. There is a gap. Even the children's Medical Center in large and medium-sized cities still lacks a standardized model. How to improve the cure rate, minimize the trauma and minimize the incidence of complications is the direction of the joint efforts of pediatric surgeons at home and abroad.
With the improvement of early diagnosis rate, improvement of neonatal anesthesia and operation mode, perioperative monitoring and strengthening of nutritional support, the cure rate of congenital esophageal atresia in our country has increased in recent years, but there are still difficulties and disputes in the treatment of other complicated malformations, long segment type and low weight infants, and the related clinical studies are still found. In this study, 93 cases of congenital esophageal atresia admitted from October 1995 to October 2013 were reviewed and analyzed from the general situation analysis, surgical approach, nutritional support selection and postoperative follow-up. The key points, key points and difficulties in clinical problems of congenital esophageal atresia.
The results of the study are as follows:
First, preoperation general situation and prognosis
The 1. total survival rate was 89% (83/93), the survival rate of male and female was 91.8%VS84.4%, the survival rate of premature infants was 91.7% (VS 88.9%), the survival rate of low weight infants was 92.3% (VS normal birth weight group 88.8%), the abnormal accompanying rate was 53.8%, and the survival rate of other malformed groups was 84% (VS without other malformed group 95.3%), and the survival rate of pneumonia group was 80.4% (VS) before operation. There was no pneumonia in group 97.9% before operation. The survival rates of type I, III, A and III B were 94%, 91%, 90%, respectively, and 2 cases died of type V.
2. for 21 cases of type III B congenital esophageal atresia, the correlation between the pre operation waiting time and the number of postoperative hospital days was analyzed.
Two, surgical treatment
1. a total of 71 children were treated with surgical treatment. Of the 59 children with definitive diagnosis and complete radical surgery, 5 children died after operation. Of the 12 children who had been treated in our hospital and retreated again in our hospital, 10 cases were diagnosed as the recurrence of esophageal tracheal fistula, including 10 cases of esophagus reconstruction and 2 cases of fistula ligation.
2. for the super long segment esophageal atresia, esophageal replacement was used. The survival rate of 100%. was compared to the group of gastroesophagoesophagus, colonic replacement esophagus and tongue flap transposition, and the time of ventilator ventilation was obviously less than that of the other two groups. Indwelling, gastric tube indwelling, jejunum nutrition and the number of days in hospital were obviously higher than those of the other two groups. The prognosis of gastroesophageal reflux in the gastric esophagus group was higher than that of the other two groups.
Three, nutritional support
1. 22 cases of type IIIA congenital esophageal atresia were excluded, 5 cases of staging operation, 1 cases of low birth weight infants and 2 cases of death were divided into two groups: the experimental group (NFT:Nasointestinalfeedingtube, the nasal jejunum nutrient tube in the operation) and the control group (Control unplaced), and compared with the direct bilirubin of two weeks after the operation, two groups of numerical values could be found. Significant differences.
2. the DSA assisted technique was used to place the nutrient tube. The average operation time was 1.14 hours, the success rate was 100%, and the average placement time was 2.63 months.
Four, complications
Of 1.71 cases, 41 cases were associated with different degrees of pneumonia and thoracic infection, the incidence was 57.7% (41/71). Postoperative anastomotic leakage was 13 cases, the incidence was 18.3% (13/71). The patients who survived and discharged were followed up for 3 months, 6 months, 1 years follow-up, the follow-up rate was 92.4% (61/ 66), the milk was good, no vomiting, and the weight of 350-550g. was increased in medium and long term each month. In the case of complications, 6 cases had recurrent esophageal tracheal fistula, 21 cases of esophagus stenosis (18 cases of anastomotic stenosis), 3 cases of esophageal diverticulum, 5 cases of gastroesophageal reflux, 1 cases of intestinal obstruction, 1 cases of repeated pneumonia and 1 cases of severe dystrophy, all of which were effectively treated with.60.6% in our hospital (40/66) to follow up the prognosis of esophagography in our hospital.
2.31 cases of children with esophageal stricture after congenital esophageal atresia underwent esophageal balloon dilatation in total 86 times, 78 successful and 8 dilatation failures in 90.7%.86 expansion. The main reason for the failure of the dilatation was due to the balloon dilatation, the airway pressure caused the children's dyspnea, and the expansion was 5 times. The other 1 was the narrowing of the balloon. In the 1 month follow-up of the 1 months of esophageal rupture, 26 cases were treated effectively, and the total effective rate of children with 84%. age less than June was less than those in June. The average operation time was significantly less than the traditional way of esophageal dilatation when the DSA assisted technique was used. There is no difference in the rate of success in the two ways.
The above results suggest that:
1. the prognosis of children with congenital esophageal atresia is not related to sex, gestational age and birth weight. Risk factors include concomitant malformation, pneumonia and classification. The risk classification is simple and practical using Montreal method.
2. a definite diagnosis of type III B esophagus atresia and preoperative assessment can be tolerated. It is suggested that early operation should be performed to shorten the days of hospitalization and accelerate postoperative recovery. Individualized treatment should be taken when other surgical malformations need to be treated. For I type super long esophagus atresia, it is suggested that the tongue flap turn over esophagectomy and colon esophagectomy is recommended. It has little effect on the respiratory tract. The incidence of gastroesophageal reflux after gastric esophagectomy is high.
3. the application of nasojejunal feeding tube for children with type III congenital esophageal atresia after operation can open enteral nutrition early and reduce the incidence of cholestasis.
The complications of 4. esophagus atresia are more complicated and complicated and the incidence is high. It is necessary to cooperate with each department and follow up closely. It is necessary to make a clear diagnosis of esophagography when necessary. The application of DSA technique to assist the balloon dilatation can reduce the difficulty of operation and shorten the operation time.

【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R726.5

【参考文献】