不修补瘘口手术方法治疗92例消化道胸内瘘的经验

The experience of surgical methods without repairing the fistula for 92 cases with gastrointestinal intrathoracic fistula

目的总结不修补瘘口手术方法治疗92例消化道胸内瘘的经验。方法不修补瘘口手术方法均通过VATS、VATS辅助小切口或开胸进行,手术的重点在于促进肺膨胀、消灭残腔、胸腔引流管有效引流。进入患侧胸腔后,遵循"有菌变无菌"的理念,间断碘伏灭菌,大量温等渗冲洗液冲洗,使脓腔尽可能干净,易清除和剥离肺脏层胸膜纤维素或纤维板,恢复肺的完全复张,消除胸腔残腔,使瘘口被肺支撑、紧贴覆盖和局限。术毕于胸腔及瘘口旁放置多根T管引流,实现术后有效引流。结果不修补瘘口手术92例,治愈85例,治愈率92.4%(85/92),死亡7例,病死率7.61%(7/92),其中食管胃吻合口瘘5例,含主动脉食管瘘3例、胸胃气管瘘1例、肺部感染并呼吸衰竭1例;食管破裂1例,感染性休克死亡;食管异物穿孔1例,肺部感染并呼吸衰竭死亡。结论不修补瘘口手术治疗消化道胸内瘘可在VATS或VATS辅助小切口下完成,安全、有效。

Objective To summarize the experience of surgical methods without repairing the fistula for 92 cases with gastrointestinal intrathoracic fistula.Methods The surgical methods without repairing the fistula were performed through VATS,small incision assisted with VATS or thoracotomy.The focus of the surgery was to promote lung expansion,eliminate the residual cavity of chest cavity and keep effective drainage.After entering the chest cavity from the affected side,wash chest cavity with a large amount of warm normal saline and sterilize intermittently with iodophor to ensure the sterile environment in the pus cavity.Then completely remove the pleural cellulose or fiberboard on visceral pleura to promote lung expansion,eliminate the residual cavity of the chest cavity.The fistula was covered tightly and supported firmly by the visceral pleura on the lung.Multiple T-tubes were placed in thoracic cavity and fistula to keep effective postoperative drainage.Results Among 92 cases,85 cases were cured and the cure rate was 92.4%(85/92).7 cases died and the mortality rate was 7.61%(7/92).The 7 dead cases include 5 cases with esophagogastric anastomotic fistula(the death of 3 cases was cause by aortic esophagogastric fistula,the death of 1 case was cause by thoracic gastric tracheal fistula and 1 case was dead because of pulmonary infection and respiratory failure),1 case with esophageal rupture(the cause of death was septic shock),and 1 case with esophageal perforation(the cause of death was pulmonary infection and respiratory failure).Conclusion Most of the surgeries without repairing gastrointestinal intrathoracic fistula are conducted simply through VATS or small incision assisted with VATS.,which is safe and effective.