儿童食管异物致气管食管瘘的临床表现及原因分析

Clinical manifestations and causes of tracheoesophageal fistula caused by esophageal foreign body in children

目的 总结小儿食管异物致气管食管瘘的临床表现、病因、处理方式及转归。方法 回顾性分析2014年5月至2019年10月首都医科大学附属北京儿童医院收治的13例食管异物致气管食管瘘患儿的临床及影像学资料。记录患儿性别、年龄、主要症状、异物类型、异物存留时间、瘘口部位、治疗方法、合并其他并发症、预后等情况,对上述指标进行总结分析。结果 13例食管异物致气管食管瘘患儿,其中男性8例,女性5例;年龄13~100个月,中位年龄20个月;主要症状:饮水或进食呛咳,痰鸣。异物类型:钮扣电池11例,X线不显影异物2例,其中1例为圆形塑料片、另1例为塑料带齿玩具。异物存留时间:6小时至1年余。瘘口部位:10例位于食管上段,3例位于食管中段。未发现食管下段异物所致的瘘口。13例患儿均于全身麻醉下行硬质食管镜检查+异物取出术,其中7例为外院取出食管异物后至首都医科大学附属北京儿童医院进一步治疗,6例于首都医科大学附属北京儿童医院行食管异物取出术。13例患儿中,5例经抗感染、抑酸、雾化、保留胃管或空肠喂养管、胃造瘘后痊愈,1例带空肠喂养管处于随访中,1例患儿行气管切开后带空肠喂养管处于随访中,3例患儿行颈外入路食管气管瘘修补术,1例患儿钮扣电池取出术后1年出现双侧声带麻痹行气管切开术,1例患儿异物取出术后29天放置食管支架6天后因突发呼吸困难抢救无效而死亡。并发症情况:1例患儿食管气管瘘修补术后食管狭窄,2例患儿出现声带麻痹,1例患儿死亡。结论 纽扣电池是导致气管食管瘘最常见的异物类型,此类患儿应尽快就医、尽早取出异物、留置胃管、补充营养、防止感染,在确定食管黏膜痊愈前不宜过早进食,避免术后气管食管瘘发生。对其他X线不显影异物,此类患儿常不能提供明确异物史,当患儿出现食欲差、进食呛咳等症状时应考虑到异物可能,可采用胸部CT、纤维喉镜、食管造影等多种方法检查,必要时可于全身麻醉下行硬性食管镜检查尽早明确诊断取出异物。

Objective To summarize the clinical manifestation,etiology,treatment and outcome of tracheoesophageal fistula caused by esophageal foreign body in children.Methods The clinical and imaging data of 13 children with tracheoesophageal fistula caused by esophageal foreign body were analyzed retrospectively from May 2014 to October 2019 in Beijing Children's Hospital,Capital Medical University.The children's gender,age,main symptoms,foreign body types,foreign body retention time,fistula sites,other complications,treatment methods,prognosis,etc.,were recorded,summarized and analyzed.Results There were 13 children with tracheoesophageal fistula caused by esophageal foreign body,including 8 males and 5 females,aged from 13 months to 100 months,with a median age of 20 months.Main symptoms:cough due to drinking or eating,and phlegm.Types of foreign body:button battery in 11 cases and X-ray negative foreign body in 2 cases(a round plastic piece and a plastic toothed toy).Foreign body retention time:6 hours to more than 1 year.Fistula site:10 cases located in the upper esophagus and 3 cases in the middle esophagus.No fistula caused by foreign body in the lower esophagus was found in this study.All the 13 children underwent esophagoscopy for foreign body removal under general anesthesia,7 cases were referred to our hospital after the esophageal foreign body removed in other hospitals,6 cases were removed in our hospital.Of the 13 children,5 were recovered after the treatments of anti-infection,acid suppression,atomization,retention of gastric tube or jejunal feeding tube and gastrostomy;1 was in follow-up with jejunal feeding tube;1 was in follow-up case with jejunal feeding tube after tracheotomy;3 underwent esophagotracheal fistula repair through external cervical route;1 underwent tracheotomy for bilateral vocal cord paralysis one year after button battery removal;1 died of sudden respiratory failure 29 days after removal of foreign body and 6 days after esophageal stent placement.Complications:1 case of esophageal stenosis after esophagotracheal fistula repair,2 cases of vocal cord paralysis and 1 case of death.Conclusion Button battery is the most common type of foreign body that causes tracheoesophageal fistula.Such children should seek medical treatment and take out the foreign body as soon as possible,keep the stomach tube,supplement nutrition and prevent infection.They should not eat too early before the esophageal mucosa recovered,so as to avoid the occurrence of tracheoesophageal fistula after operation.For the X-ray negative foreign bodies,such children often can not provide a clear history of foreign bodies.When the children have poor appetite,or cough during eating,the possibility of foreign bodies should be considered.Chest CT,fiber laryngoscope,esophageal radiography and other methods can be used for examination,and if necessary,hard esophageal endoscopy can be used under general anesthesia for early diagnosis and removal of foreign bodies.