复杂性食管异物的临床诊疗分析

Clinical diagnosis and treatment of foreign bodies in a complex esophagus

目的探讨复杂性食管异物伴发严重并发症的种类及特点,总结其临床诊断及治疗方法。方法对广东医科大学附属医院2015年1月至2018年1月住院治疗的244例食管异物中22例伴有严重并发症的患者资料进行回顾性分析,包括发患者群、就诊时间、异物类型及嵌顿位置、并发症类型及诊断治疗方式等。结果22例中除4例儿童外,其余患者均在发病后通过进食馒头、蔬菜、努力吞咽等方式,试图将异物强行推入胃中未果,从而出现严重并发症;从发病到就诊最长达32 d,平均5.9 d;误吞异物类型中17例(77.3%)为动物性骨头,以鱼骨和鸡骨为主;10例嵌顿于食管入口水平,5例嵌顿于T1-T2水平,3例嵌顿于T8-T9水平;严重并发症包括食管穿孔或合并食管局部炎症6例(27.3%),颈部及纵隔气肿、脓肿5例(22.7%),食管纵隔瘘4例(18.2%),游走于食管外异物3例(13.6%),咽后壁脓肿1例(4.5%),气胸1例(4.5%),气管食管瘘1例(4.5%),食管主动脉瘘1例(4.5%);14例于食管镜下取出异物,3例经颈侧切开探查取出异物,3例同时行颈部及纵隔脓肿切开引流术,1例行食管镜+胸腔镜探查,并行肺大泡切除术,1例行支气管镜异物取出术+气管食管瘘修补术;22例患者中治愈21例(95.5%),平均住院时间为6.2 d,死亡1例(4.5%)。结论复杂性食管异物多见于老年患者,多因发生异物嵌顿后患者错误的暴力吞咽方式、不及时就医等不恰当处理方法,导致了患者病情的延误。异物的类型、嵌顿位置及就医时间与并发症的产生及严重程度呈正相关,上消化道造影及CT检查是诊断食管异物及其并发症的最有效方法,能够清楚地显示出异物与周围重要组织器官的关系,多学科协助治疗是挽救严重并发症引起危重病情的重要方式。

Objective To investigate the types and characteristics of severe complications associated with complicated foreign bodies of the esophagus,and to summarize the clinical diagnosis and treatment.Methods From January 2015 to January 2018,244 cases with an esophageal foreign body were hospitalized in the affiliated Hospital of Guangdong Medical University,of which 22 were accompanied by severe complications.The clinical data of 22 patients were analyzed retrospectively.This data includes patients,the time of their visit,the types of foreign bodies,the location of the Kanton,types of complications,diagnosis,and treatment.Results Apart from 4 children,all patients had tried to force the foreign body into their stomach by eating steamed bread,vegetables and swallowing.This resulted in a number of serious complications.The longest time from onset to treatment was 32 days,with an average of 5.9 days.Seventeen(77.3%)of the foreign-body cases resulted from animal bones,mainly fish and chicken bones.Ten cases were at the esophageal entrance level,5 cases at the T1-T2 level and 3 cases at the T8-T9 level.In 6 cases(27.3%),severe complications included esophageal perforation or local inflammation emphysema in the neck and diaphragm,an abscess in 5 cases(22.7%)and an esophageal or phrenic fistula in 4 cases(18.2%).There were 3 cases(13.6%)of extraesophageal foreign bodies,1 case of a posterior pharyngeal abscess(4.5%),1 case of a pneumothorax(4.5%),1 case of an tracheoesophageal fistula(4.5%)and 1 case of an esophageal aortic fistula(4.5%).Foreign bodies were removed under esophagoscopy in 14 cases,foreign bodies in 3 cases by lateral cervical incision,incision and drainage of a cervical and mediastinal abscess in 3 cases,thoracoscopic exploration of the esophagus in 1 case,and pneumonectomy in 1 case.One patient underwent a tracheoesophageal fistula repair with a bronchoscopic foreign body removal.Of the 22 patients,21 were cured(95.5%),with an average hospital stay of 6.2 days.One patient passed away(4.5%).Conclusion Foreign body of the complex esophagus is more common in elderly patients.Patients who swallow foreign bodies by mistake generally start violently swallowing and do not seek medical treatment in enough time.This leads to the patients\condition worsening.A positive correlation was observed between the type of foreign body,the admitting hospital,and the time of medical treatment with the occurrence and severity of complications.An upper gastrointestinal angiography and computed tomography(CT)examination were the most effective in diagnosing an esophageal foreign body and its potential complications.These tools can clearly show the relationship between foreign bodies and the important tissues and organs around them.Multidisciplinary assistance therapy is important in reducing the occurrence of serious complications.