Ⅲ型先天性食管闭锁术后吻合口漏的相关营养评估研究

Nutritional evaluation of postoperative anastomotic leakage in children with type Ⅲ esophageal atresia

目的探讨营养因素对Ⅲ型先天性食管闭锁手术后吻合口漏的影响及保守治疗过程中营养状态评估,为更有效地治疗吻合口漏提供指导。方法回顾性分析2016年1月1日至2020年1月31日浙江大学医学院附属儿童医院收治的102例Ⅲ型先天性食管闭锁患儿的临床资料。所有患儿行Ⅰ期食管气管瘘缝扎、食管端端吻合重建术,26例于术后5~7 d出现吻合口漏。分析吻合口漏的发生与患儿胎龄、体重、闭锁类型、术前白蛋白、前白蛋白、年龄别体重Z评分(weight-for-age,WAZ)及炎症水平的关系。观察经保守治疗自愈的患儿在愈合过程中血清白蛋白、前白蛋白及WAZ的变化情况,评估患儿围手术期营养状态。结果术后发生吻合口漏26例,无吻合口漏76例,两组患儿的胎龄、性别、体重、合并畸形、手术方式、前白蛋白、WAZ值及超敏C反应蛋白(hypersensitive C-reactive protein,CRP)差异无统计学意义(P>0.05)。但吻合口漏患儿术前白蛋白水平明显低于无吻合口漏患儿,差异有统计学意义(P=0.015)。Ⅲa型食管闭锁患儿术后发生吻合口漏的风险明显高于Ⅲb型患儿,差异有统计学意义(P=0.038)。通过多因素Logistic回归模型分析发现食管远近端距离长(Ⅲa型)(OR:0.29,95%CI:0.10~0.83)和术前白蛋白水平低(OR:0.85,95%CI:0.73~0.99)是发生吻合口漏的独立危险因素。在26例吻合口漏的病例中22例通过保守治疗自愈,平均自愈时间为(23.90±11.81)d,愈合时间延长组患儿术前白蛋白水平及WAZ值明显低于愈合时间正常组患儿(P=0.007和P=0.019)。保守治疗患儿围手术期营养曲线未出现明显波动。结论术前营养状态是影响吻合口漏发生和自愈的因素,包括有效的全肠外营养在内的综合治疗能维持患儿保守治疗期间营养水平的稳定。

Objective To explore the correlated factors and postoperative nutritional status with conservative treatment after surgical anastomotic leakage(AL)for typeⅢesophageal atresia.Methods From January 1,2016 to January 31,2020,clinical data were collected from 102 children with typeⅢesophageal atresia undergoing 1-stage tracheoesophageal fistula ligation and single-layer end-to-end esophageal anastomosis.They were divided into AL(n=26)and non-AL(n=76)groups according to the occurrence of postoperative complications.The correlated factors of AL were reviewed.Meanwhile,the outcome of conservative management for AL was evaluated.Results No significant differences existed in gestational age,gender,weight,comorbidity,procedure,prealbumin,weight-for-age(WAZ)or hypersensitive C-reactive protein(CRP)(P>0.05).A significant inter-group difference existed in preoperative albumin level(P=0.015).TypeⅢa had a higher risk of AL than typeⅢb(P=0.038).Multivariable logistic regression analysis demonstrated that long esophageal atresia(typeⅢa)and low preoperative albumin level were the independent risk factors for AL.Twenty-two recovered after conservative measures and the average duration of recovery was(23.90±11.81)days.The preoperative albumin level and WAZ value of children with prolonged healing time were significantly lower than those with normal healing time(P=0.007&P=0.019).No significant difference existed in serum prealbumin or WAZ value during perioperative period.Conclusion Preoperative nutritional status is one of risk factors of AL and affects self-healing time.AL in children with typeⅢesophageal atresia may recover after conservative measures.Effective total parenteral nutrition therapy maintains normal nutritional level during conservative management.