多学科合作模式在食管闭锁手术后食管气管瘘复发规范化诊疗中的应用研究

Multidisciplinary framework for standardized management of recurrent tracheoesophageal fistula after operations for esophageal atresia

目的食管气管瘘复发(recurrent tracheoesophageal fistula,rTEF)是食管闭锁手术后的复杂并发症,其治疗通常需要多学科共同干预。上海交通大学医学院附属新华医院近年来采取多学科合作模式(multidisciplinary team,MDT)对rTEF展开治疗。本研究旨在总结本院MDT模式下rTEF的治疗经验,并评估其预后情况。方法回顾性收集2012年9月至2020年12月本院诊治的164例rTEF患者临床资料以及随访结果。MDT团队包括小儿外科、放射介入科、小儿消化营养科、小儿呼吸科、小儿重症医学科、耳鼻咽喉头颈外科及儿童保健科医生,多学科协作针对术前评估、围手术期处理及术后随访环节,制定规范化诊治方案。结果164例rTEF患者中,115例首次手术采用胸腔镜术式,49例首次手术为开胸手术。术前有33例存在气管软化,21例存在声带麻痹,6例存在喉软化。术后吻合口瘘的发生率为27.4%;吻合口狭窄的发生率为21.3%;9.1%的患者出现rTEF;6例死亡,病死率为3.7%。19例术后撤离呼吸机困难,包括气管软化9例,喉软化3例,气管内赘生物7例;10例经保守治疗缓解,1例气管软化患者经气管切开术痊愈,1例喉软化患者经声门上成形术痊愈,7例气管内赘生物经内镜下治疗获痊愈。本院MDT模式治疗先天性食管闭锁(esophageal atresia,EA)术后rTEF并发症发生率、平均呼吸机使用时长、平均ICU停留时长以及平均住院时长呈逐年下降趋势。手术后平均随访33.6个月,29例存在病理性胃食管反流,其中6例接受抗反流手术,其余患者经保守治疗得以缓解。结论针对rTEF采取MDT模式下的规范化治疗有助于提高rTEF的疗效,减少手术后并发症,改善患者预后。

Objective As one complex complication after repairing esophageal atresia,recurrent tracheoesophageal fistula(rTEF)requires therapeutic interventions with multiple specialized professionals.A multidisciplinary team(MDT)has been formed for managing rTEF children in recent years.The goal of this study was to summarize clinical experiences and evaluate prognostic outcomes of rTEF management at our center.Methods Retrospective review was conducted for clinical data and postoperative follow-up results of 164 rTEF inpatients from September 2012 to December 2020.MDT members included professionals from general pediatric surgery,pediatric respiratory medicine,pediatric intensive care unit,ear-nose-throat(ENT),interventional radiology and pediatric healthcare.Standardized treatment protocols were formulated for preoperative evaluations,perioperative interventions and postoperative follow-ups.Results The initial surgery for esophageal atresia was thoracoscopic repair(n=115,70.1%).Preoperative examinations revealed asymptomatic tracheomalacia(n=33),vocal fold immobility(n=21)and laryngomalacia(n=6).A total of 191 operations were performed.The incidence of postoperative anastomotic leak,anastomotic stricture and recurrence was 27.4%,21.3%and 9.1%respectively.The overall mortality rate was 3.7%.Nineteen survivals experienced difficult postoperative weaning from mechanical ventilation.Among 9 cases of tracheomalacia,8 children were cured by conservative measures.Otolaryngology revealed laryngomalacia(n=3).One child was cured by supraglottoplasty while another two were relieved after conservative measures.Granulation formation in airway was identified under laryngoscopy(n=7)and all were cured by endoscopy.An obvious declining tendency in postoperative complications,duration of stay,duration of stay in pediatric intensive care unit and total stay of hospitalization were recorded.Mid-term follow-ups(a median of 33.6 months)hinted at pathological gastroesophageal reflux(n=29)and 6 recovered after fundoplication.None of the survivors had any severe respiratory complication.Conclusion MDT approach may foster a proper coordination of various specialties to offer benefits to the management of rTEF,lower postoperative comorbidities and improve patient prognoses.