Ⅲ型食管闭锁腔镜手术与开放手术对比研究

Comparative study of endoscopic and open surgery for type Ⅲ esophageal atresia

目的比较胸腔镜手术与开胸手术治疗先天性食管闭锁并气管食管瘘的疗效差异。方法回顾性分析2008年6月至2016年10月首都儿科研究所附属儿童医院收治的Ⅲ型食管闭锁59例患儿的临床资料,其中胸腔镜手术组(A组)30例,开胸手术组(B组)29例。A组食管闭锁ⅢA型12例,ⅢB型18例;B组ⅢA型14例,ⅢB型15例。对比两组患儿的术前资料及术后恢复情况,比较腔镜手术与开放手术相关并发症、治愈率及复发率。结果两组患儿的日龄[(3.2±0.2)d vs.(3.4±0.5)d,P=0.910],体重[(2.83±0.63)kg vs.(2.81±0.64)kg,P=0.910],先心病比例[(18例(60.0%)vs.19例(65.5%),P=0.661]差异无统计学意义,具有可比性。A组除1例33周早产儿重症肺炎,麻醉不能耐受,一期仅行胸腔镜下气管食管瘘修补术,延期3周胸腔镜下完成食管端端吻合术,其余29例均一期完成气管食管瘘修补及食管吻合术,无中转手术。B组27例一期手术完成气管食管瘘修补及食管吻合术,2例因食管盲端间距过长,行食管气管瘘缝扎,胃造瘘术,延期行经胸食管吻合术。与开胸手术组比较,A组手术时间[207(142,240)min vs.170(150,170)min,P=0.058],术后呼吸机使用时间[120(72,168)h vs.72(48,180)h,P=0.086];术后住院时间[14.00(12.75,26.25)d vs.14.00(10.00,14.50)d,P=0.100],差异无统计学意义。A组的治愈率(93.3%vs.82.8%,P=0.209),术后并发症吻合口漏发生率高于B组[7例(23.3%)vs.3例(10.3%),P=0.299],但差异无统计学意义;吻合口狭窄发生率大致相同(36.7%vs.34.5%,P=0.861)。A组患者术后1例气管食管瘘复发,B组无复发,差异无统计学意义(P>0.05)。结论胸腔镜手术治疗先天性食管闭锁合并气管食管瘘是安全可行的,要求术者具备熟练的微创手术技术和相关手术技巧。

Objective To evaluate the outcomes of the thoracoscopic versus open techniques for esophageal atresia （EA） and tracheoesophageal fistula （TEF）. Methods A retrospective review of 59 type- Ⅲ EA/TEF patients was performed from June 2008 to October 2016. Definite diagnosis and complete operation were accomplished for these patients. Group A induded 30 patients who underwent thoracoscopic operation, group B induded 29 patients who underwent traditional repair through thoracotomy. The clinical data including preoperative data, treatment and postoperative management were retrospectively reviewed. The clinical data, outcome, complication, and recurrence were analyzed and compared be- tween the two groups. Results There was no inter-group difference in age[（3.2±0.2） d vs. （3.4±0.5）d, P = 0.910], body weight [（2.83±0.63） kg vs.（2.814-0.64）kg, P = 0.910], and the proportion of congenital heart disease （60.0% vs. 65.5%, P = 0.661 ）. One case in group A was a 33 weeks premature infant who could not tolerate anesthesia due to severe pneumo- nia, so the repair of esophagotracheal fistula and the esophageal end to end anastomosis were performed at the second stag- es, the remaining 29 cases completed in one stage tracheoesophageal fistula repair and esophageal anastomosis, no conver- sion. In group B, 27 patients underwent one-stage repair of tracheoesophageal fistula and esophageal anastomosis, and the other 2 cases were treated with the suture of the esophago tracheal fistula, the gastrostomy, and the delayed esophagecto- my due to the long distance between the blind ends of the esophagus. Compared with the open surgery group, there was no difference in operative time of laparoscopic operation group[207（ 142, 240）min vs. 170（ 150, 170）min, P = 0.058], postoperative ventilation time [120（72, 168）h vs. 72（48, 180）h, P = 0.086], hospital stay was [14.0（12.75, 26.25）d vs. 14.00 （10.00, 14.50）d, P = 0.100] between the two groups. The cure rate of laparoscopic group was slightly higher （93.3% vs.82.8%, P = 0.209）. The incidence of postoperative anastomotic leakage was significantly higher than that of open sur- gery group （23.3% vs. 10.3%, P = 0.299）, but the difference was not statistically significant. Anastomotic stenosis was approximately the same （36.7% vs. 34.5%, P = 0.861 ）. One patient had postoperative recurrence of tracheoesophageaI fistula in group A, none in group B（P 〉 0.05）. Conclusion Thoracoscopic surgery is safe and feasible in the treatment of congenital esophageal atresia and tracheoesophageal fistula. Skill of minimally invasive surgery and related surgical techniques is mandatory.