复杂性食管瘘的治疗

Tailored treatment for complex intrathoracic esophageal fistula

目的：胸内段食管瘘常由食管或周围器官的恶性肿瘤引起,良性病变发生率较低。胸内段食管瘘发生后常引发较复杂的症状,且与周围器官形成相通性瘘后预后更差,故称为凶险性胸内段食管瘘。其治疗有一定困难,因为较易行的食管或气管内支架术对长期生存易出现并发症,而外科手术的创伤令很多患者无法安全度过手术关。作者所在单位经过多年的摸索,对此类患者采用不同的外科手术方法进行治疗,在此进行总结。方法：从2002年1月至2007年11月共收治各种良性病所致的胸内段食管瘘9例,男5例,女4例,年龄从5岁~73岁（平均年龄：49.89岁）。其中交通事故外伤所致巨大食管气管瘘（均从胸廓入口到隆突平面）3例;误吞鱼骨致食管主动脉瘘1例,致食管纵隔瘘引发纵隔脓肿致胸椎破坏后引发高位截瘫1例,致食管右上肺形成右上肺巨大脓肿引发脓毒血症呼吸衰1例;食管重度不典型增生外院行光动力学治疗引发巨大食管气管瘘1例。肺癌术后纵隔淋巴转移行放疗致食管气管瘘1例,食管癌术后胸腔胃气管瘘1例。其中5例行分期手术治疗：对交通意外所至巨大食管气管瘘3例患者一期行胃造瘘和空肠造瘘术达到胃减压减少返流和经空肠管增加营养的目的,患者肺部感染减少和营养改善后,二期行食管原位代气管膜部、食管胃颈部吻合术;食管主动脉瘘患者发生两次量在2 000 m L以上大出血,抢救成功后一期行主动脉内支架植入术,后二期行食管内翻剥脱、食管胃经胸骨后颈部吻合术;食管纵隔瘘致高位截瘫患者一期行经右胸纵隔脓肿清除、椎体部分切除椎管减压术,二期手术经颈上腹二切口将食管内翻剥脱并经胸骨后将胃拉到颈部行食管胃颈部吻合术。食管右上肺瘘并伴有脓肿形成,患者术前经抗菌素抗感染后脓毒血症渐好转,行经右胸右上肺叶切除食管局部修补术。光动力治疗后出现食管气管瘘患者先行食管内支架植入术失败,后取出支架并经右胸气管瘘口修补术,术中发现局部黏连明显,分离后瘘口较术前扩大,气管瘘口用肋间带蒂肌间瓣进行修补,并将食管切除,胃食管行颈部吻合术。放疗后食管气管瘘患者先行食管支架植入失败,取出支架后行术中分离并采用双肌瓣分别修补术。食管癌术后残胃气管瘘患者行气管内支架植入术治愈。结果：9例患者均成功完成手术,手术时间4~9 h（平均时长：5.5 h）,术中出血280~900 m L（平均出血量：380 m L）,术后住院7~20 d（平均住院天数：13 d）,患者术后恢复好,经随访现有7例存活,可正常工作,生活完全自理。1例患者术后出现肺部感染较重,经呼吸机辅助通气15 d后肺部炎症出现好转,后转当地医院继续治疗,于术后第55天死于胃内容物误吸所致多器官功能衰。1例患者术后因修补的肌肉组织堵塞支气管,行支气管镜下电切时出现急性心衰,行体外循环膜肺支持疗法（extracorporeal membrane oxygenation,ECMO）治疗,但患者于术后第18天死于全身多器官功能衰竭。结论：胸内段食管瘘的患者治疗应在积极改善全身状况的前提下进行,其中分期手术治疗为根治性手术创造机会是一种较好的选择。且从本组3例食管气管瘘的患者来看,利用“炎症”黏连的特性进行局部食管代气管治疗是一种创伤小的可行方法;而一期手术时会引起局部瘘口扩大,同时术后会合并较多的并发症。

Objective： Intrathoracic esophageal fistula （iTEF） is a severe clinical condition which is mainly caused by invasion of malignant tumor of esophagus or vicinal organs, as well as by traumatic or inflammatory perforation with surrounding blood vessel or airway. This condition is arguably the most lethal complication, especially when a fistula is emerged between esophagus and surrounding blood vessel or airway. Though stent implantation has been proven to be an effective approach for emergent salvage, most patients need a second stage operation due to the consistent leakage of digestive juice from the esophageal fistula and probable enlargement of the fistula. Given the compromised physical condition caused by this condition, most patients might not be able to survive the reconstruction surgery. We report here the experience of tailored surgical approach for different types of esophageal fistula. Methods： Between January 2002 and November 2007, nine benign iTEF patients were treated in the First Affiliated Hospital of Guangzhou Medical University. Among the patients, there were five males and four females, and the median age was 48 （5-73） years old. Three of these patients suffered from large esophago- tracheal fistula （ETF） caused by traffic accident, one from aorto-esophageal fistula （AEF） induced by fish bone, one from esophago-mediastinal fistula （EMF） induced by mediastinal abscess which further induced collapsed thoracic vertebra and high paraplegia, one from esophago-bronchus fistula （EBF） which further induced abscess of right upper lung and respiratory failure, one from large ETF caused by medical maloperation of photodynamic therapy for esophageal severe atypical hyperplasia, one from ETF caused by radiotherapy for mediastinal lymphatic metastasis of lung cancer, one from thoracogastric-tracheal fistula （GTF） after esophagectomy. There were seven different types of surgical approach for restoration of alimentary tract. The three patients with large ETF caused by traffic accident underwent gastrostomy and jejunostomy as first stage treatment, and the second stage treatment included substituting impaired esophagus in situ for impaired membranaceous trachea and cervical gastroesophagostomy. After salvage from twice more than 2 000 mL volume of haematemesis, the AEF patients was stabilized by thoracic endovascular aortic repair, and the second stage treatment included removal of thoracic esophagus and cervical gastroesophagostomy through the retrosternal routine. The EMF patient underwent elimination of mediastinal abscessus and rachitomy as the first stage treatment, and the second stage treatment included transhital esophagectomy and cervical gastroesophagostomy through the retrostemal routine. After stabilized by antibiotic administration, the EBF patient underwent right upper lobectomy and local repair of esophageal fistula. The patient with ETF caused by medical maloperation of photodynamic therapy experienced a failed first stage treatment of esophageal stent implantation, and the second stage treatment included extracting of esophageal stent, repair of enlarged tracheal fistula with pedicle intercostal muscle flap, removal of thoracic esophagus and cervical gastroesophagostomy. The ETF patient caused by radiotherapy also experienced a failed first stage treatment of esophageal stent implantation, and the second stage treatment was repair of esophageal and tracheal fistula with pedicle muscle flap separately. The GTF patient was cured by tracheal stent implantation. Results： Complete treatment was performed in all nine patients. The median operative time was 5 （4-9） hours,the median estimated blood loss was 380 （280-900） mL, the median postoperative hospital stay was 13 （7- 20） days. No major postoperative complication was found in seven of the patients, and the seven patients were discharged with desirable physical condition and led a normal life thereafter. The 90 days mortality was 22.2% （2/9）. The patient received mechanical ventilator because of postoperative pneumonia. Though the pneumonia recovered after 15 days of mechanical ventilator, the patient died of multi-organ failure due to aspiration of gastric content. The patient experienced a bronchial obstruction due to a failed pedicle muscle flap for trachea. A acute heart failure happened when the patient underwent bronchoscopy electroblation for the bronchial obstruction. Though extracorporeal membrane oxygenation was performed, the patient died of multi-organ failure 18 days after surgery. Conclusion： The treatment for iTEF should be performed after the improvement of patients＇ physical condition, and staging surgery might be a better option for these patients. Based on the experience of the three ETF patients caused by traffic accident, the ＂inflammatory adhesion＂ theory of substituting impaired esophagus in situ for impaired membranaceous trachea might be a feasible and less invasive option for this situation, while one stage operation may encounter an enlarged fistula or undesirable complication.