食管闭锁术后食管气管瘘复发再手术的临床分析

Clinical analysis of reoperation for esophageal atresia with recurrent tracheoesophageal fistulas

目的：分析食管闭锁（EA）术后食管气管瘘复发（RTEF）再手术的临床资料，总结RTEF的原因、诊断方法及再手术的经验。方法回顾性分析2005年1月至2013年12月我们收治的10例EA术后RTEF患儿的临床资料，其中男7例，女3例，再手术平均年龄为19个月，平均体重为8.3kg，所有病例均为GrossⅢ型；10例中有9例曾接受经右胸食管气管瘘结扎＋食管端端吻合术。结果在初次手术中有4例（4/10）瘘管并未切断。9例（9/10）复发瘘管的食管端开口于原食管吻合口狭窄处或近端食管。8例（8/10）术后存在不同程度吻合口狭窄，1例合并吻合口瘘。再手术前所有患儿行食管欧乃派克造影检查，确诊和疑似RTEF分别为5例（5/10，50％）、4例（4/10，40％）。所有RTEF通过胃镜及支气管镜确诊（10/10，100％）。患儿均接受再次进胸手术，平均手术时间3.2h，平均术后住院时间为15.8d。术后均获随访3～96个月，食管造影提示所有病例均治愈，未再发生RTEF。结论 EA术后RTEF与初次手术瘘管处理不当、食管吻合口局部炎症反应等因素有关，需再次手术治疗，再手术的疗效及患儿预后良好。

Objetive To summarize the reoperative experience for esophageal atresia （EA）with recurrent tracheoesophageal fistulas （RTEF）. Methods A retropective analysis was given to the 10 RTEF patients underwent reoperation in our center from Jan.2005 and Dec.2013.Male to female ratio was 4：1.The median age and average weight at reoperation were 19 months and 8.3 kilograms respectively.All cases were Gross type Ⅲ.9 cases underwent the primary repair of EA. Results During the primary repair,TEF were not cut in 4/10 cases.Esophageal orifices of the fistula in 9 of 10 cases were located around the anastomotic site or the proximal esophagus.8 cases had anastomotic stricture and 1case had anastomotic leakage after the primary repair.All cases had pre-operative esophagogram,esophagoscopy and bronchoscopy.RTEF were confirmed in 5/10 cases and suspected in 4/10 cases according to esophagogram results.All cases were diagnosed of RTEF by esophagoscopy and bronchoscopy.All RTEF cases underwent reoperation.The average reoperative time was 3.2 hours,and the average post-operative stay in hospital was 15 .8 days.We also followed up several esophagogram for all the cases from 4 to 96 months after reoperation. No recurrent fistula was showed. Conclusion TEF recurrence is caused by many factors including failure to cut the fistula in primary repair, anastomotic leakage,anastomotic stenosis as well as anastomotic inflammation.TEF recurrence is the significant indication of reoperation after EA primary repair.Preoperative esophagoscopy and bronchoscopy are very important to make the diagnosis of TEF recurrence.The reoperation is safe and improves patient’s quality of life.