Ⅰ型食管闭锁延期根治手术临床经验总结

Clinical experiences of delayed primary anastomosis for type I congenital esophageal atresia

目的：总结Ⅰ型食管闭锁延期食管吻合的临床经验。方法7例Ⅰ型食管闭锁患儿出生体质量2170~2665 g；产前均有羊水过多,5例产前B型超声检查疑似食管闭锁。4例合并先天性心脏病、2例先天性肛门直肠畸形。出生后均行胃造瘘,造影示两断端距离〉3个椎体；生后8~16周行经胸食管-食管端端吻合术。分析延期手术食管断端生长与体质量的相关性；观察术中断端距离与采用不同手术方式的判断；随访术后并发症和生长发育、喂养情况。结果7例8~16周体质量平均增长2.98 kg,造影示两断端生长1.0~2.5 cm,生长长度与体质量增长无明显相关性（R=0.171,P=0.713）；与两次手术间隔无明显相关性（R=0.084,P=0.858）。根治手术充分游离两断端,3例距离〈1.0 cm者完成食管-食管端端吻合；3例距离1.5~2.0 cm采用内牵引法,5~7 d后行食管吻合；1例距离仍有3 cm者外牵引,第七天行食管吻合。术后4例内、外牵引术二期吻合患儿吻合口漏,经胸腔闭式引流均自愈；7例均获定期随访,随访时间14~66个月,5例术后吻合口狭窄、4例胃食管反流,其中2例在1岁时行胃大弯延长＋胃底折叠抗反流手术。目前生长发育和体质量均在正常范围,进食固体食物。结论延期食管吻合治疗Ⅰ型食管闭锁可达到使用自身食管修复的目的；内牵引和外牵引方法短期内可诱导食管迅速生长；术后存在较高的并发症。

Objective To summarize our experiences of delayed primary anastomosis for type Ⅰcongenital esophageal atresia.Methods A retrospective review was performed for 7 patients with typeⅠ congenital esophageal atresia.There were 5 females and 2 males with a birth weight of 2.170 to 2. 615 kilograms.All had a prenatal diagnosis of hydramnios.And esophageal atresia was suspected in 5 cases by ultrasonic examinations.There were congenital heart disease （n=4）and congenital anal-recta malformation （n=2）.Gastrostomy was performed after birth and the gap between proximal and distal esophagus measured radiologically. Second surgery was performed by end-to-end esophageal anastomosis at weeks 8-16.The correlation was analyzed between the growth body weight and the growth of blind esophagus during delayed operation period.The intra-operative blind end distance was observed and different operative approaches were selected. Then follow-ups were conducted for postoperative complications,long-term growth and development,including feedings.Results During 8-16 weeks,7 cases grew well with an average growth weight of 2.98 kg.The esophageal growth of two blind sides was 1-2.5 cm.Esophageal growth length and weight gain had no significant correlation （R=0.171,P=0.713）.And there was no obvious correlation with two surgical intervals （R=0. 084,P=0.084）.During second surgery,after a full separation of two blind esophageal sides,the gap was 〈1.0 cm and end-to-end esophageal anastomosis was completed （n=3）;1.5-2.0 cm,internal traction after 5-7 days （n=3）;3 cm,external traction at Day 7.Internal and external tractions were applied for post-operative anastomotic leakage and healed by drainage （n=4 ）.Seven cases were followed up for 14-66 months.Five cases of postoperative anastomotic stricture underwent dilation under gastroscopy.Among 4 cases of gastro-esophageal reflux,2 underwent anti-reflux surgery at the age of one year and their growth and weight returned to normal and could eat solid food.Conclusions Delayed esophageal anastomosis for type I esophageal atresia can achieve the purpose of using their own esophagus;Internal and external tractions induce rapid short-term esophageal growth.And more postoperative complications occur for type I esophageal atresia.