發(fā)布時(shí)間：2018-05-11 06:16

  本文選題：先天性食管閉鎖 + 手術(shù)治療��； 參考：《上海交通大學(xué)》2014年博士論文

【摘要】：先天性食管閉鎖是一種嚴(yán)重的消化道發(fā)育畸型，也是新生兒期具有代表性需要緊急處理的外科疾病之一，國(guó)外統(tǒng)計(jì)發(fā)病率1/3000-1/4000。我國(guó)在其診治、圍手術(shù)期支持、術(shù)后并發(fā)癥處理以及預(yù)后隨訪等方面仍存在很多問題,與發(fā)達(dá)國(guó)家仍然存在差距。即使是大中城市的兒童醫(yī)療中心，仍缺乏規(guī)范化模式。如何提高治愈率，將創(chuàng)傷降到最小，以及將并發(fā)癥發(fā)生率降到最低，是目前國(guó)內(nèi)外小兒外科醫(yī)生共同努力的方向。 隨著早期診斷率的提高，新生兒麻醉和手術(shù)方式的改進(jìn)，圍手術(shù)期監(jiān)護(hù)和營(yíng)養(yǎng)支持的加強(qiáng)，近年來我國(guó)先天性食管閉鎖治愈率有所上升，但對(duì)于合并其他復(fù)雜畸形、長(zhǎng)段型、低體重兒等病例，在治療上仍存在困難與爭(zhēng)議，且相關(guān)的臨床研究往往因樣本量小、病例異質(zhì)性大而很難深入。本研究擬回顧整理自1995年10月至2013年10月我科收治的93例先天性食管閉鎖病例資料，從術(shù)前一般情況分析、手術(shù)術(shù)式探討、營(yíng)養(yǎng)支持選擇以及術(shù)后隨訪等各個(gè)方面進(jìn)行分析和討論，總結(jié)在處理先天性食管閉鎖方面的臨床問題時(shí)的重點(diǎn)、要點(diǎn)和難點(diǎn)。 研究結(jié)果如下： 一、術(shù)前一般情況與預(yù)后 1.總存活率89%（83/93）。男女存活率為91.8%VS84.4%；早產(chǎn)兒存活率為91.7%（VS足月兒88.9%）；低體重兒存活率為92.3%（VS正常出生體重組88.8%）；畸形伴發(fā)率為53.8%，伴其他畸形組存活率為84%（VS無伴其他畸形組95.3%）；術(shù)前并發(fā)肺炎組存活率為80.4%（VS術(shù)前無肺炎組97.9%）；Ⅰ、ⅢA、ⅢB的存活率分別為94%、91%、90%，2例Ⅴ型均死亡。 2.對(duì)于符合標(biāo)準(zhǔn)的21例Ⅲb型先天性食管閉鎖病例，進(jìn)行術(shù)前等待時(shí)間與術(shù)后住院天數(shù)相關(guān)性分析，得出兩者具有顯著性正相關(guān)。 二、手術(shù)治療 1.共對(duì)71例患兒實(shí)施了手術(shù)治療。我院明確診斷并完成根治術(shù)的59例患兒中，5例患兒術(shù)后死亡。外院術(shù)后來我院就診并再次行手術(shù)治療的12例患兒中，10例診斷為食管氣管瘺復(fù)發(fā)，其中10例行食管重建術(shù)，2例僅行瘺管結(jié)扎術(shù)，均存活。 2.對(duì)于超長(zhǎng)段型食管閉鎖，均采用食管替代術(shù)，存活率100%。通過對(duì)胃代食管術(shù)組、結(jié)腸代食管術(shù)組和舌狀瓣翻轉(zhuǎn)代食管術(shù)組的比較，可知術(shù)后結(jié)腸代食管組呼吸機(jī)輔助通氣時(shí)間明顯少于其他兩組，而舌狀瓣翻轉(zhuǎn)代食管組在術(shù)后胸腔引流留置、胃管留置、空腸營(yíng)養(yǎng)及住院天數(shù)等明顯高于其他兩組，預(yù)后隨訪可見胃代食管組胃食管返流發(fā)生率高于其他兩組。 三、營(yíng)養(yǎng)支持 1.將22例IIIA型先天性食管閉鎖病例，排除行分期手術(shù)5例、低體重出生兒1例、死亡2例后分成兩組：實(shí)驗(yàn)組（NFT：Nasointestinalfeedingtube，術(shù)中即放置鼻空腸營(yíng)養(yǎng)管）和對(duì)照組（Control未放置），比較術(shù)后兩周的直接膽紅素時(shí)，可以發(fā)現(xiàn)兩組數(shù)值具有顯著性差異。 2.采用DSA輔助技術(shù)放置營(yíng)養(yǎng)管，平均手術(shù)時(shí)間為1.14小時(shí)，成功率100%，平均放置時(shí)間為2.63月。 四、并發(fā)癥 1.71例術(shù)后患兒中，41例即伴有不同程度的肺炎及胸腔感染，發(fā)生率為57.7%（41/71）。術(shù)后吻合口漏13例，發(fā)生率為18.3%（13/71）。對(duì)存活且出院的患兒進(jìn)行常規(guī)3個(gè)月、6個(gè)月、1年隨訪，隨訪率92.4%（61/66），進(jìn)奶好，無嘔吐，每個(gè)月增加體重350-550g。在中遠(yuǎn)期并發(fā)癥方面，6例食管氣管瘺復(fù)發(fā)，21例食道狹窄（其中吻合口狹窄18例），3例食道憩室，5例胃食管返流，1例出現(xiàn)腸梗阻，1例反復(fù)肺炎，1例重度營(yíng)養(yǎng)不良，均得到有效治療。60.6%的患兒（40/66）定期于我院行食管造影檢查追蹤預(yù)后。 2.31例先天性食管閉鎖術(shù)后食管狹窄患兒行食管球囊擴(kuò)張術(shù)共計(jì)86次，78次成功，擴(kuò)張成功率為90.7%。86次擴(kuò)張中有8次擴(kuò)張失敗。擴(kuò)張失敗主要原因是球囊擴(kuò)張過程中，氣道受壓造成患兒呼吸困難，而停止擴(kuò)張(共5次)。另1次為狹窄處球囊固定不佳，，造成擴(kuò)張中球囊多次滑脫而失敗，1次為食管破裂。3-6個(gè)月隨訪中，26例患兒治療有效，總有效率為84%。年齡小于6月的患兒所需擴(kuò)張次數(shù)比大于6月的患兒少。利用DSA輔助技術(shù)時(shí)，平均手術(shù)時(shí)間顯著少于利用傳統(tǒng)方式進(jìn)行食管擴(kuò)張，但兩種方式下擴(kuò)張成功率并無區(qū)別。 以上結(jié)果提示： 1.先天性食管閉鎖患兒的預(yù)后與性別、胎齡、出生體重?zé)o關(guān)。危險(xiǎn)因素包括伴發(fā)畸形、合并肺炎以及分型。采用Montreal法評(píng)估危險(xiǎn)分級(jí)簡(jiǎn)單而實(shí)用。 2.明確診斷為Ⅲb型食管閉鎖的且術(shù)前評(píng)估可耐受手術(shù)，建議盡早行手術(shù)治療，可有效縮短住院天數(shù)，加快術(shù)后恢復(fù)。合并其他需手術(shù)處理的畸形時(shí)，應(yīng)個(gè)體化治療。針對(duì)I型超長(zhǎng)段型食管閉鎖，建議采用舌狀瓣翻轉(zhuǎn)代食管術(shù)。結(jié)腸代食管術(shù)后對(duì)呼吸道影響較小。胃代食管術(shù)后胃食管返流發(fā)生率較高。 3.對(duì)Ⅲa型先天性食管閉鎖患兒術(shù)后應(yīng)用鼻空腸營(yíng)養(yǎng)管，能夠早期開放腸內(nèi)營(yíng)養(yǎng)，減少膽汁淤積的發(fā)生率。 4.食管閉鎖術(shù)后并發(fā)癥較多且復(fù)雜，發(fā)生率高，需要各科室協(xié)作并密切隨訪，必要時(shí)需行食管造影術(shù)明確診斷。應(yīng)用DSA技術(shù)輔助球囊擴(kuò)張可以降低操作難度，縮短手術(shù)時(shí)間。
[Abstract]:Congenital esophageal atresia is a serious malformation of digestive tract development, and it is also one of the surgical diseases with representative needs for emergency treatment in the newborn period. The statistical incidence rate of foreign statistics 1/3000-1/4000. in China is still a lot of problems in its diagnosis and treatment, perioperative support, postoperative complications treatment and prognosis. There is a gap. Even the children's Medical Center in large and medium-sized cities still lacks a standardized model. How to improve the cure rate, minimize the trauma and minimize the incidence of complications is the direction of the joint efforts of pediatric surgeons at home and abroad.
With the improvement of early diagnosis rate, improvement of neonatal anesthesia and operation mode, perioperative monitoring and strengthening of nutritional support, the cure rate of congenital esophageal atresia in our country has increased in recent years, but there are still difficulties and disputes in the treatment of other complicated malformations, long segment type and low weight infants, and the related clinical studies are still found. In this study, 93 cases of congenital esophageal atresia admitted from October 1995 to October 2013 were reviewed and analyzed from the general situation analysis, surgical approach, nutritional support selection and postoperative follow-up. The key points, key points and difficulties in clinical problems of congenital esophageal atresia.
The results of the study are as follows:
First, preoperation general situation and prognosis
The 1. total survival rate was 89% (83/93), the survival rate of male and female was 91.8%VS84.4%, the survival rate of premature infants was 91.7% (VS 88.9%), the survival rate of low weight infants was 92.3% (VS normal birth weight group 88.8%), the abnormal accompanying rate was 53.8%, and the survival rate of other malformed groups was 84% (VS without other malformed group 95.3%), and the survival rate of pneumonia group was 80.4% (VS) before operation. There was no pneumonia in group 97.9% before operation. The survival rates of type I, III, A and III B were 94%, 91%, 90%, respectively, and 2 cases died of type V.
2. for 21 cases of type III B congenital esophageal atresia, the correlation between the pre operation waiting time and the number of postoperative hospital days was analyzed.
Two, surgical treatment
1. a total of 71 children were treated with surgical treatment. Of the 59 children with definitive diagnosis and complete radical surgery, 5 children died after operation. Of the 12 children who had been treated in our hospital and retreated again in our hospital, 10 cases were diagnosed as the recurrence of esophageal tracheal fistula, including 10 cases of esophagus reconstruction and 2 cases of fistula ligation.
2. for the super long segment esophageal atresia, esophageal replacement was used. The survival rate of 100%. was compared to the group of gastroesophagoesophagus, colonic replacement esophagus and tongue flap transposition, and the time of ventilator ventilation was obviously less than that of the other two groups. Indwelling, gastric tube indwelling, jejunum nutrition and the number of days in hospital were obviously higher than those of the other two groups. The prognosis of gastroesophageal reflux in the gastric esophagus group was higher than that of the other two groups.
Three, nutritional support
1. 22 cases of type IIIA congenital esophageal atresia were excluded, 5 cases of staging operation, 1 cases of low birth weight infants and 2 cases of death were divided into two groups: the experimental group (NFT:Nasointestinalfeedingtube, the nasal jejunum nutrient tube in the operation) and the control group (Control unplaced), and compared with the direct bilirubin of two weeks after the operation, two groups of numerical values could be found. Significant differences.
2. the DSA assisted technique was used to place the nutrient tube. The average operation time was 1.14 hours, the success rate was 100%, and the average placement time was 2.63 months.
Four, complications
Of 1.71 cases, 41 cases were associated with different degrees of pneumonia and thoracic infection, the incidence was 57.7% (41/71). Postoperative anastomotic leakage was 13 cases, the incidence was 18.3% (13/71). The patients who survived and discharged were followed up for 3 months, 6 months, 1 years follow-up, the follow-up rate was 92.4% (61/ 66), the milk was good, no vomiting, and the weight of 350-550g. was increased in medium and long term each month. In the case of complications, 6 cases had recurrent esophageal tracheal fistula, 21 cases of esophagus stenosis (18 cases of anastomotic stenosis), 3 cases of esophageal diverticulum, 5 cases of gastroesophageal reflux, 1 cases of intestinal obstruction, 1 cases of repeated pneumonia and 1 cases of severe dystrophy, all of which were effectively treated with.60.6% in our hospital (40/66) to follow up the prognosis of esophagography in our hospital.
2.31 cases of children with esophageal stricture after congenital esophageal atresia underwent esophageal balloon dilatation in total 86 times, 78 successful and 8 dilatation failures in 90.7%.86 expansion. The main reason for the failure of the dilatation was due to the balloon dilatation, the airway pressure caused the children's dyspnea, and the expansion was 5 times. The other 1 was the narrowing of the balloon. In the 1 month follow-up of the 1 months of esophageal rupture, 26 cases were treated effectively, and the total effective rate of children with 84%. age less than June was less than those in June. The average operation time was significantly less than the traditional way of esophageal dilatation when the DSA assisted technique was used. There is no difference in the rate of success in the two ways.
The above results suggest that:
1. the prognosis of children with congenital esophageal atresia is not related to sex, gestational age and birth weight. Risk factors include concomitant malformation, pneumonia and classification. The risk classification is simple and practical using Montreal method.
2. a definite diagnosis of type III B esophagus atresia and preoperative assessment can be tolerated. It is suggested that early operation should be performed to shorten the days of hospitalization and accelerate postoperative recovery. Individualized treatment should be taken when other surgical malformations need to be treated. For I type super long esophagus atresia, it is suggested that the tongue flap turn over esophagectomy and colon esophagectomy is recommended. It has little effect on the respiratory tract. The incidence of gastroesophageal reflux after gastric esophagectomy is high.
3. the application of nasojejunal feeding tube for children with type III congenital esophageal atresia after operation can open enteral nutrition early and reduce the incidence of cholestasis.
The complications of 4. esophagus atresia are more complicated and complicated and the incidence is high. It is necessary to cooperate with each department and follow up closely. It is necessary to make a clear diagnosis of esophagography when necessary. The application of DSA technique to assist the balloon dilatation can reduce the difficulty of operation and shorten the operation time.

【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R726.5

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本文編號(hào)：1872763