儿童食管异物致穿孔的诊治分析-单中心临床经验总结

Treatment of esophageal perforation caused by foreign bodies in children:single center clinical experience

目的回顾性分析各种食管异物嵌顿引起食管穿孔患儿的临床资料,为该类疾病的临床诊治提供理论基础。方法回顾性分析复旦大学附属儿科医院2013年1月1日至2018年12月31日因异物引起食管穿孔患儿的临床资料,总结异物种类、主要早期症状、近远期并发症、外科干预策略及预后情况。结果本研究共纳入15例异物引起的食管穿孔病例,常见的异物种类包括纽扣电池( n =5)、鱼骨( n =4)和硬币( n =3),常见的早期临床症状包括发热( n =9)、呛咳( n =8)、咳嗽咳痰( n =8)、吞咽困难( n =6)、拒食( n =5)和颈部肿胀( n =4)。从穿孔部位来看,12例为食管上段穿孔,1例为食管中段穿孔,2例为食管下段穿孔。15例患儿中有12例发生感染性并发症,最常见为肺炎( n =10)、颈部软组织感染( n =7)和纵膈感染( n =5)。5例因颈部或纵膈感染化脓而行脓肿引流术,其中2例因胸腔积脓引流不畅行开胸脓肿清除术、异物清除术;2例早期行食管破口胃镜下钛夹夹闭术。15例患儿中8例行胃造口术,4例行空肠营养管置入术,2例行胃镜直视下鼻胃管置入术。11例食管穿孔患儿自行愈合,其中3例出现食管狭窄,经扩张治愈,1例因胃瘫而行幽门成形术;2例遗留食管气道瘘于3~6个月后行食管气道瘘修补术;1例因存在持续食管胸膜瘘行食管支架置入术而治愈;1例因感染死亡。10例患儿随访3个月至2年,无其他并发症发生。结论纽扣电池、鱼骨和硬币是常见的引起儿童食管穿孔的消化道异物。发热、呛咳等呼吸道症状是食管穿孔的早期预警症状。多数食管穿孔可不经手术修补而自行愈合,手术干预仅限于清除异物和引流脓肿。经合理治疗大多数异物引起的食管穿孔可获得良好预后。

Objective As a rare pediatric disease,esophageal perforation may lead to such a fatal complication as mediastinal infection.Currently there is no consensus on its treatment. Methods Retrospective analysis was performed for clinical data of 15 children with esophageal perforation caused by foreign body between January 1,2013 and December 31,2018.And the types of foreign body,major symptoms,short/long-term complications,surgical interventions and prognosis were summarized. Results The most common foreign bodies included button batteries ( n =5),fish bones ( n =4) and coins ( n =3).Major presenting symptoms included fever ( n =9),bucking ( n =8),cough with sputum ( n =8),dysphagia ( n =6),refusal of food ( n =5) and neck swelling ( n =4).And the site of perforation was upper ( n =12),middle ( n =1) and lower ( n =2).Severe infections occurred in 12 of them.And the most common complications were pneumonia ( n =10),cervical soft tissue infection ( n =7) and mediastinal infection ( n =5).Surgical drainage of neck or mediastinal abscess was performed in 5 cases.Thoracotomic removal of abscess and foreign body was performed in 2 cases due to inadequate drainage of thoracic empyema.Two cases were treated with titanium clip under gastroscope.The procedures included gastrostomy ( n =8),jejunal nutrition tube implantation ( n =4) and nasogastric tube implantation under gastroscope ( n =2).Esophageal perforation healed spontaneously in 11 children,3 cases of esophageal stenosis were cured by dilatation and 1 child underwent pyloroplasty due to gastroparesis.Esophagotracheal fistula repair was performed in 2 cases after 3-6 months.One case of continuous esophageal pleural fistula was cured by esophageal stent implantation.One child died from infection.Ten children were followed up for 3 months to 2 years and there was no other complication. Conclusion Button batteries,fish bones and coins are the most common foreign bodies causing esophageal perforation in children.Fever,bucking,cough and other respiratory symptoms are early warning signs of esophageal perforation.Most esophageal perforations heal without surgical repair and surgical intervention is limited to removing foreign bodies and draining abscesses.Titanium clip occlusion in early stage may aid the healing of esophageal perforation.With reasonable treatments,most children with esophageal perforation caused by foreign bodies may obtain an excellent prognosis.