食管内牵引延长治疗长段缺失型食管闭锁

Efficacy of delayed internal traction for long gap esophageal atresia

目的长段缺失型食管闭锁（long gap esophageal atresia，LGEA）的治疗仍是全球小儿外科医生的挑战。尽可能利用自身食管以重建食管已经成为共识。本文应用食管内牵引技术延长食管，从而达到利用自身食管重建食管的目的。方法自2015年全年本院收治LGEA患儿5例。Ⅲa型1例，Ⅰ型4例。5例患儿经综合评估后行食管内牵引延长方案，近远端利用胆道探条予以合适力量进行延伸，并利用食管造影定期进行距离评估，内牵引延伸期间均持续通过胃造瘘提供患儿营养支持，近端食管持续负压吸引排除分泌物，避免吸入性肺炎的发生。结果5例患儿食管盲端之间的距离最初为5.0～7.5个椎体不等，内牵引食管延长后两盲端距离为0～2.5个椎体不等，内牵引持续总时间在6～14周。最终5例患儿均成功施行食管重建术，其中1例行食管端端吻合术，3例行食管肌层环形切开吻合术（Livaditis），1例行食管肌瓣翻转吻合术。术后均未发生吻合口漏，未见明显胃食管反流，吻合口狭窄3例，分别予以3～7次食管球囊扩张后好转。随访至今5例患儿均已完全经口喂养，无明显呕吐或喂养困难，生长发育相较同龄人无落后，无需特殊饮食食谱。结论通过内牵引技术可以有效地达到延长食管的目的，使利用食管本身完成一期食管重建术成为可能。

ObjectiveOptimal treatment of long gap esophageal atresia （LGEA） is demanding in neonatal surgery. Consensus dictates conserving autologous esophagus for reconstructing esophagus in LGEA patients. Internal traction by stress bouige for elongation was achieved by utilizing native esophagus for esophageal continuity.MethodsFrom January 2015 to December 2015, 5 neonatal cases with LGEA were recruited. The clinical types were Ⅰ（n=4） and Ⅲa （n=1）. Internal traction was performed after comprehensive evaluations. After inserting a bougie into upper and lower esophageal pouches through oral cavity, gastrostomy was performed with appropriate longitudinal force for increasing esophageal length. The gap length was evaluated regularly by esophagram. All of them were fed by gastrostomy for maintaining a proper nutritional status and continuous suction in upper pouch was applied for avoiding aspiration pneumonia during traction.ResultsThe initial gap length ranged from 5 to 7.5 vertebral bodies. After internal traction, gap distance was decreased to 0 to 2.5 vertebral bodies. The duration of elongation process starting from initial stretching until anastomosis varied from 6 to 14 weeks. Finally, the anastomosis was performed successfully. The specific procedures were end-to-end anastomosis （n=1）, flip-flap （n=1） and Livaditis （n=3）. Such postoperative complications as leak of anastomosis and overt gastroesophageal reflux disappeared. Three cases of anastomotic stricture improved greatly after 3-7 sessions of balloon dilations. Resuming full oral intake without vomiting or other feeding difficulties, all of them had the same patterns of growth and development as normal same-age counterparts. There was no need for special feeding.ConclusionsDelayed internal traction is effective for elongating esophageal segments during primary anastomosis for LGEA.