食管异物导致主动脉食管瘘的外科治疗

Surgical management of aortic esophageal fistula caused by foreign body

目的探讨食管异物导致主动脉食管瘘(AEF)的外科治疗方法和预后,以提高对该疾病的认识。方法选取2006年7月—2020年3月复旦大学附属中山医院收治的食管异物导致AEF患者12例。回顾性分析其外科治疗的过程和随访结果。分期手术方法为一期手术切除病变主动脉并置换人工血管或行主动脉腔内覆膜支架置入,同时彻底进行外科清创,包括切除胸段食管,充分冲洗胸腔,清除纵隔和胸腔感染灶;二期手术重建消化道。或者仅置入主动脉覆膜支架封堵主动脉瘘口。结果12例患者均由食管骨性异物导致AEF。所有患者胃镜检查均发现食管溃疡穿孔;5例增强CT示主动脉弓降部或胸主动脉假性动脉瘤-食管瘘合并纵隔脓肿,7例增强CT示AEF合并纵隔感染。3例患者于外院诊断为AEF,行主动脉覆膜支架腔内隔绝术失败转至本院手术。10例患者接受分期手术,其中8例行一期主动脉人工血管置换术,2例一期行主动脉覆膜支架置入术,同期切除食管;二期行消化道重建。2例患者仅行主动脉覆膜支架置入术。10例患者,分期手术均顺利完成,痊愈出院,随访1个月~13年,所有患者均生存。2例仅置入覆膜支架封堵主动脉瘘口的患者均于术后1个月左右,因再次大出血抢救无效死亡。结论食管异物导致AEF的患者应该尽早诊断,及时手术干预;伴有感染时,分期手术治疗安全有效。

Objective To explore the surgical treatment and prognosis of aortic esophageal fistula(AEF)caused by foreign body,and to improve the understanding of this disease.Methods Twelve patients with AEF caused by foreign body,who were admitted to Zhongshan Hospital of Fudan University from July 2006 to March 2020,were enrolled in this study.The course of surgical treatment and follow-up results were retrospectively analyzed.The staging surgery contained phaseⅠ(aortic prosthesis or stent implantation,and simultaneous debridement)and phaseⅡ(digestive tract reconstruction).Results Enhanced CT showed pseudoaneurysm-esophageal fistula in the descending aorta or thoracic aorta in combination with mediastinal abscess in 5 cases,and AEF combined with mediastinal infection in 7 cases.Three patients were diagnosed as AEF in other hospitals,and were transferred to our hospital for surgery after failure of aortic stent endovascular isolation.Ten patients underwent staging surgery.In phaseⅠ,8 patients were implanted with aortic prosthesis and 2 patients underwent aortic stent implantation.At the same time,we also removed the esophagus and cleared the mediastinal and chest infections.In phaseⅡ,the digestive tract was reconstructed.The ten patients completed the operation successfully,and were cured before discharge.The follow-up ranged from 1 month to 13 years,and all survived.Two patients who were only treated with coated stent died of massive hematemesis again about one month after the operation.Conclusion AEF caused by foreign body should be diagnosed as soon as possible and treated with timely surgical intervention.Staging operation is safe and effective in the condition of infection.