长段缺失型食管闭锁的治疗体会

Experiences of treating long-gap esophageal atresia

目的：长段缺失型食管闭锁患儿在出生后不同时期根据患儿不同病情采取不同手术方案,通过近远期的结果分析,总结治疗经验,制定相应的治疗策略。方法我院2003年1月至2013年6月,收治长段型食管闭锁（LEA）29例,男20例,女9例。其中Ⅰ型食管闭锁（EA）10例,Ⅲa 型19例。Ⅰ型 EA中施行的手术方法包括胃管成形代食道、胃代食道、近端食管翻转成形术以及食管端端吻合术；Ⅲa型 EA中采取的手术方法包括结肠代食道术、食道肌层螺旋形切开延长、以及一期端端吻合术。结果27例治愈出院,死亡1例,1例术后家属放弃治疗死亡。术后近期并发症中肺部感染13例,吻合口漏7例,吻合口狭窄9例,反复气胸1例,胸腔感染5例,应激性溃疡消化道出血1例,术后出院前行钡餐检查提示7例存在胃食管反流。随访2个月至10年,术后3个月内12例存在呕吐现象,3个月后则呕吐症状明显好转。术后1年以上得到随访14例,2例胃管成形代食道以及2例胃代食道患儿进食速度快时易出现胸闷症状。食管泛影葡胺造影9例存在胃食管反流,但24 h食管pH 监测7例中,4例存在夜间反流,均未行抗反流手术。结论食管本身作为替代物优势明显,术后功能建立快,远期效果较好；结肠代食道是成熟安全的手术方法,对于早期施行食管颈部造瘘和胃造瘘的患儿可作为首选的治疗方法。胃代食道和胃管成形代食道可作为新生儿期的手术选择,但应慎重考虑。

Objective To explore the short-term and long-term postoperative outcomes and formulate individualized treatments for long-gap esophageal atresia （LEA）after birth.Methods From January 2003 to June 2013,29 LEA patients were admitted into our hospital.There were 20 boys and 9 girls.The types were isolated esophageal atresia （type Ⅰ,n=1 0 ）and esophageal atresia with trachea-esophageal fistula （type Ⅲa,n=19）.For type I patients,gastric tube esophagoplasty,gastric transposition,esophageal flap esophagoplasty and end-to-end esophageal anastomosis were performed respectively.For type Ⅲ a patients, esophageal replacement with colon, circular myotomy for esophagus lengthening and end-to-end esophageal anastomosis.Results Twenty-seven cases survived and two died.The postoperative complications were pneumonia （n=13）,anastomotic leakage （n=7）, stenosis （n=9）,pneumothorax （n=1）,chest infection （n=5）and digestive bleeding cause by stress ulceration （n=1 ）.The gastro-esophageal reflux was found by contrast study before discharge in 7 cases.The overall follow-up period was 2 months to 10 years and 14 cases for over 1 year.And 12 cases vomited within 3 months and improved obviously later.Chest distress occurred in 4 cases during rapid ingestions. Gastric tube esophagoplasty （n= 2 ） and gastric transposition （n= 2 ） were performed.Gastric-esophageal reflux was found in 9 cases by contrast study.Among 7 cases of 24-hour esophageal pH monitoring,reflux appeared at midnight in 4 cases and underwent no anti-reflux operation.Conclusions For esophageal replacement,autologous esophagus has the best functions. Eesophageal replacement with colon is an effective treatment for cervical esophagostomy and gastrostomy.And gastric tube esophagoplasty and gastric transposition may be used discreetly in neonates with LEA.