新生儿食管闭锁的外科治疗

Surgical treatment of congenital esophageal atresia in neonates

目的总结新生儿食管闭锁的诊断和治疗经验。方法回顾性分析我院2002年6月至2010年6月收治的新生儿食管闭锁61例，男34例，女27例。手术年龄18h～7d，平均（2．5±0．6）d，体重1500-4000g，其中低体重儿（〈2500g）16例。61例中按Gross病理解剖分类：Ⅰ型2例，Ⅲa型32例，Ⅲb型27例，Ⅲa型中有1例远端食管有局限狭窄，开口约0．2cm；合并畸形：先天性心脏病15例，肠道畸形4例，泌尿系畸形3例。结果61例中2例Ⅰ型食管闭锁先行近端食管引流、胃造瘘，2周后行结肠代食管手术，59例Ⅲ型均Ⅰ期食管气管瘘切断缝扎、食管端端吻合术，Ⅲa型中远端食管有1例局限性狭窄，行纵切横缝解除狭窄。术后并发单侧或双侧严重肺炎42例，硬肿症3例，近期吻合口狭窄24例，吻合口瘘3例。除1例术后2d合并肠穿孔死亡，3例放弃治疗（均为早期病例：1例为术后1周出现核黄疸，2例术后合并严重肺部感染不能脱离呼吸机），余57例均痊愈出院。术后随访3个月～8年，轻度胃食管反流3例，余均进食良好，生长发育正常。结论尽早诊断、及时手术，积极预防和治疗并发症，新生儿食管闭锁可取得良好的效果。

Objective To summarize the diagnosis and treatment for congenital esophageal atresia （CEA） in neonates. Methods From June 2002 to June 2010, 61 neonates with congenital esophageal atresia underwent surgery at this center. Of these patients, 34 were boys and 27 were girls. Their age ranged from 18 hours to 7 days （mean, 2. 5 ± 0. 6 days）. Their weight ranged from 1500 grams to 4000 grams. Sixteen patients were very low-birth-weight infants （〈1500 g）. According to the anomalies of CEA, 2 were diagnosed with type Ⅰ CEA, and the other 59 were type Ⅲ CEA （32 type Ⅲ a and 27 type Ⅲb）. The most common associated anomalies were cardiac anomalies （16, 26%）, followed by intestinal anomalies （5, 8%） and renal anomalies （3, 5%）. Results The 2 cases with type I CEA underwent proximal drainage of esophagus and gastrostomy to stabilize their conditions. Two weeks later, they underwent the second stage surgery to replace esophagus with colon. The 59 patients with type Ⅲ CEA underwent fistulectomy and end-to-end esophagus anastomosis via thoracic approach. A stenosis in the medial-distal esophagus was found on 1 type Ⅲ a CEA patients, and was repair with longitudinal incision and transverse suture. Postoperative complications included pneumonia on 42 patients （68. 8%）, scleredema on 3 patients （4. 9%）, mild anastomosis orifice stenosis on 24 patients （39. 3%）, and anastomosis orifice fistula on 3 patients （4. 9%）. One patient died of intestinal perforation 2 days after surgery. Three patients were given up including 1 developed kernicterus l week after surgery, and the other 2 had serious pulmonary infection and couldn＇t be withdrawn from mechanical ventilation. The other 57 cases were discharged from hospital. The patients were followed up for 3 months to 8 years. Three patients had mild gastroesophageal reflux. The others ate and drank normally during follow-up. Conclusions Early diagnosis and carefully management of postoperative complications are important to improve clinical outcomes and prognosis of congenital esophageal atresia in neonates.