先天性食管狭窄4例报告及诊治经验分析

目的探讨先天性食管狭窄的诊断及治疗方式。方法回顾性分析首都医科大学附属北京儿童医院2015年6月至2018年12月收治的4例先天性食管狭窄患儿的临床资料。4例患儿均为男性,入院年龄分别为5岁1个月、4岁2个月、10个月和3岁7个月。结果1例入院后诊断为贲门失迟缓症,在腹腔镜食管肌层切开过程中发现食管下段软骨异位,切除异位软骨后保留完整食管黏膜,随访1年进食顺利。1例先天性食管闭锁合并食管下段狭窄,多次影像学检查漏诊食管下段狭窄,胸腔镜下完成狭窄段切除再吻合,随访8个月进食顺利。1例球囊扩张食管4次,随访4个月进食顺利。1例先天性食管狭窄合并十二指肠梗阻,腹腔镜解除十二指肠梗阻7个月后行胸腔镜食管切除再吻合手术,随访2个月进食顺利。结论先天性食管狭窄常合并其它消化道畸形,容易漏诊,其治疗方式尚存在争议,腔镜手术具有较高可行性。     

先天性食管闭锁术后食管狭窄的诊治

目的 探讨本院9年先天性食管闭锁(esophageal atresia,EA)术后食管狭窄的诊治,期待提高EA患儿治愈率及生存质量.方法 随访1999年1月至2007年12月本院收治并手术的53例EA病例,总结术后食管狭窄的诊治情况.结果 手术的53例中29例(34.9%)全部经食管造影检查或胃镜直视下确诊为食管狭窄,其中27例(93.1%)扩张后症状缓解.1例(3.5%)放置镍钛合金自膨胀支架2周后治愈.1例(3.5%)出现食管穿孔.结论 球囊扩张是治疗EA术后食管狭窄的有效方法;早期诊断、积极有效地治疗食管狭窄能减少患病率,提高生存质量.     

先天性食管闭锁／食管气管瘘合并食管狭窄的治疗分析

目的探讨先天性食管狭窄并食管气管瘘／食管闭锁的临床特征、分型及治疗方法,以减少误诊误治。方法通过2例先天性食管狭窄并食管气管瘘／食管闭锁患儿的病例报告,分析影像学资料及临床分型、随访结果。结果1例患儿在食管闭锁手术中得到了确诊并切除了隔膜,术后接受了食管扩张术;1例患儿术后造影发现了食管狭窄,仅行保守治疗。2例患儿随访效果良好。结论食管闭锁手术中有必要对远端食管进行探查,排除合并食管狭窄畸形。     

先天性食管狭窄

先天性食管狭窄 (ｃｏｎｇｅｎｉｔａｌｅｓｏｐｈａｇｅａｌｓｔｅｎｏｓｉｓＣＥＳ)少见 ,病理类型及临床表现较复杂 ,尚无一致的治疗方法。 1975年至 1999年 ,我院手术治疗小儿先天性食管狭窄 16例 ,报告如下。临床资料本组 16例 ,男 10例 ,女 6例。年龄 :2个月～ 8岁。在母乳喂养期间症状不明显 ,偶有或时常有溢乳 ,增加辅食后症状逐渐明显 ,呕吐所进食物并吞咽困难 ,营养不良 ,4例有食物梗塞病史 ,2例表现为反复呼吸道感染 ,喘鸣。多数患儿存在生长发育滞后。术前均行Ｘ线钡餐检查 :发现食管上段狭窄 2例 ,食管中段狭窄 6例 ,下段狭窄 …     

Ⅲ型先天性食管闭锁的外科治疗

目的探讨Ш型食管闭锁的早期诊断与治疗方法。方法回顾性分析我院1995年01月￣2005年07月收治的26例Ш型食管闭锁患儿的临床资料。结果26例均行手术治疗,治愈24例(92.3%),死亡2例(7.7%);其中1例死于肺炎合并硬肿症,1例死于肺不张合并硬肿症;术后随访6个月￣3年,1例死于合并先天性心脏病(完全性大动脉转位),2例术后有食管吻合口狭窄,行球囊扩张好转,其余21例进食良好。结论早期诊断和及时的手术治疗有助于提高先天性食管闭锁及食管气管瘘患儿的手术存活率。     

胃镜直视下球囊扩张术治疗小儿食管狭窄

目的 探讨胃镜直视下球囊扩张治疗小儿食管狭窄的安全性和有效性.方法 12例食管狭窄患儿,其中食管闭锁术后吻合口狭窄7例、先天性食管狭窄3例、腐蚀性炎性狭窄2例,年龄5～59个月,在静脉复合麻醉和气管插管下,通过胃镜直视用控制辐射状扩张(CRE)三级扩张球囊行食管狭窄扩张.观察术后腹痛、黑便、呕吐的发生,同时随访术后3～12个月恢复饮食种类,狭窄口大小、营养情况.结果 12例共进行22次扩张,19次成功,3次术后出现并发症,扩张成功率为86%.12例中,3例扩张失败,9例扩张成功、症状改善,有效率为75%.扩张前狭窄口直径2～8 nun,3～12个月后复查胃镜和随访,狭窄口直径9～13mm,8例可进食固体食物、营养状况改善.结论 CRE三级食管球囊行食管狭窄扩张治疗,操作简单、效果确切,食道闭锁术后吻合口狭窄的扩张效果较好.     

儿童食管狭窄的病因及诊治进展

食管狭窄相关疾病包括:先天性食管狭窄、食管闭锁术后狭窄、胃食管反流伴发狭窄、食管化学烧灼伤引发狭窄、嗜酸性食管炎、放化疗后食管狭窄等。目前我国难治性食管狭窄多为食管化学烧灼伤后狭窄。食管连续扩张是治疗此类疾病的首选方法,疗效不佳时可配合使用激素、丝裂霉素等药物。食管替代术是该类疾病的最后防线。食管狭窄相关疾病诊治水平还需要多中心联合才能不断提高。     

胸腔镜技术治疗先天性食管闭锁术后食管狭窄的相关因素分析

目的：探讨胸腔镜技术治疗先天性食管闭锁术后食管狭窄的可能影响因素,以规避部分有害因素,降低食管狭窄的发生率。方法回顾性分析2008年10月至2013年4月本院经胸腔镜治疗的46例先天性食管闭锁患儿临床资料,其中18例术后诊断为食管狭窄;拟定可能影响因素包括：手术时体重、手术日龄、缝合方式、胸腔镜手术学习曲线、食管盲端距离、呼吸机使用时间、胸腔引流管的使用、术后GER、吻合口漏及术后进食时间;按各因素条件使用Excel表将46例患儿相关资料建立数据库,先行单因素检验,再将可能的危险因素纳入多因素非条件Logistic模型,筛选出影响术后食管狭窄的危险因素。结果手术日龄、手术体重及胸腔镜手术学习曲线在单因素分析中存在差异,而食管盲端距离、吻合口漏及术后GER在单、多因素分析中均有不同,差异有统计学意义（P＜0.05）。结论经胸腔镜治疗先天性食管闭锁术后食管狭窄主要与食管盲端距离、吻合口漏及GE R有关,预防措施主要是降低食管吻合口的紧张度,减少食管吻合口漏的发生和术后积极治疗GE R。     

先天性气管食管瘘术后复发五例临床特点及文献复习

目的 回顾性分析先天性气管食管瘘(tracheoesophageal fistula,TEF)术后复发患儿的临床特点,提高对该病的认识和诊治水平.方法 回顾分析2015年9月至2016年7月在深圳市儿童医院呼吸科诊断的5例TEF复发患儿的临床资料,对临床特点、复发风险因素及诊断方法进行分析.结果 2例患儿于术后8年确诊,1例于术后1年确诊,2例于术后1~2个月确诊.3例表现为进食后反复呛咳、肺炎及生长发育落后;1例因呕吐、腹胀入院;1例无症状.3例术后有食管吻合口漏;4例术后有食管狭窄.2例伴有胃食管反流;5例伴有气管软化.2例行食管碘油造影怀疑TEF复发,2例结果阴性.1例经支气管镜检查可直接确诊,2例支气管镜检查发现可疑瘘口,2例支气管镜下仅发现手术疤痕,4例经美兰试验确诊.结论 尽管TEF复发以呼吸道症状和喂养困难为主要临床表现,但也可以无症状;TEF复发合并症多,临床表现相似,易漏诊;食管吻合口漏、食管狭窄是TEF复发的风险因素;支气管镜检查是诊断TEF复发的首选方法,美兰试验是确诊的金标准.开胸手术是TEF复发患儿的首选术式.     

先天性食管闭锁及气管食管瘘11例

目的探讨先天性食管闭锁及气管食管瘘的早期诊断和治疗方法。方法先天性食管闭锁患儿11例均在入院24h内行食管泛影葡胺或碘化油造影确诊,并经胸膜外入路行食管吻合术,分析总结其诊断和治疗。结果治愈9例(81.8%),死亡2例(18.2%)。1例术后有食管吻合口狭窄,行食管扩张术后治愈;1例术后吻合口瘘,经抗感染、营养支持、充分引流后瘘口愈合。结论早期诊断、及时手术、术后护理及并发症的防治对提高先天性食管闭锁患儿的存活率有重要作用。     

先天性食管狭窄15例诊疗体会

目的 总结先天性食管狭窄诊断和治疗体会,提出最佳的诊断、治疗方法.方法 回顾我院1990至2009收治的15例先天性食管狭窄临床资料,对临床表现(症状、体征、发病年龄等),诊断方法(UGI、胃镜等)进行分析.将患儿分为手术组与非手术组,比较两组治疗过程和预后情况(饮食状况、并发症等).结果 15例先天性食管狭窄患儿,男9例,女6例.发病年龄(10±5.5)个月(0～3岁9个月).主要临床表现为反复进食后呕吐.GI检查发现狭窄段位于食管下段者9例,位于中下段者6例.7例仅行胃镜辅助下食管扩张术,手术治疗8例,其中6例行狭窄段食管切除+端端吻合术,1例行狭窄段肌层切开+胃底折叠术,1例行狭窄段全层切开、纵切横缝+胃底折叠术.术后病理诊断2例为气管软骨异位型,1例为狭窄局部炎性假瘤形成,5例为肌层增厚型.术后4例出现吻合口狭窄,2例出现胃食管反流,1例伴发术侧膈膨升.结论 上消化道钡剂造影(UGI)是诊断首选方法,电子胃镜可作为诊断及辅助治疗的手段.治疗方法建议首选食管扩张术,对扩张2～3次以上无效者进行手术探查.下段狭窄者应行胃底折叠术避免术后并发胃食管反流.

Abstract：

Objective The aim of this study was to find an optimal procedure of diagnosis and treatment for congenital esophageal stenosis (CES). Methods From 1990 to 2009, 15 CES patients were treated in our hospital. Demographical, clinical, pathological and radiological data were collected retrospectively. Patients were further divided into surgery group and non-surgery group. Outcomes and complications were studied to identify the indication and timing for operation. Results The age of presentationof of these 15 patients (9 boys and 6 girls) were 10± 5. 5 months (1 day ～ 41months).Vomiting was the most significant and common symptomign. UGI were performed in all the 15 patients. 9 patients had stenosis in lower esophagus and 6 in mid-lower esophagus. In surgery group, 6patients underwent surgical resection; the remaining 2 patients underwent Heller myotomy esophagomyotomy and stricturoplasty, respectively. Tracheobronchial remnants were found in 2 patients and submucosal thickening were found in 5 patients. Inflammatory pseudotumor was found in the rest 1patient. The frequency of esophageal anastomotic stricture, gastroesophageal reflux and diaphragmatic erentration were 44.4 % (4/9), 22. 2 % (2/9) and 11.1% (1/9), repectively. Conclusions UGI is the first choice for the diagnosis of CES, while electronic gastroscope can play an alternative role. Esophageal dilatation could be the first therapy for CES, and operation is indicated when outcome dilatation fails.     

Congenital esophageal stenosis associated with esophageal atresia: new concepts

Congenital esophageal stenosis (CES) is suspected by a fixed intrinsic narrowing of the esophagus that affects the normal swallowing mechanism. The diagnosis is only confirmed by histopathologic picture, which may show fibromuscular disease (FMD) or tracheobronchial remnants (TBR). The latter involves ciliated pseudo stratified columnar epithelium, seromucous glands or cartilage each alone or in combination. The aim of this study is to document the usefulness of histologic picture of surgical specimens obtained from the lower esophageal pouch (LEP) during primary repair in detecting cases of CES associated with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). Over an 8-year period, 57 consecutive cases operated upon for EA with or without TEF were subjected for histologic examination of surgical specimens obtained from the tip of the LEP. Cases that histologically showed FMD or TBR were included. The usefulness of this histologic picture as a diagnostic and therapeutic aid is assessed. Methods of treatment and outcome were also reviewed. Eight patients out of 57 (14%) had a histologic picture suggestive of CES, two with FMD, four with TBR without cartilage and two with cartilage. Out of 57 patients, 23 developed strictures, six of them had positive biopsies suggestive of CES. One patient with TBR without cartilage did not have stricture. Another case of pure atresia had LEP resection and gastric pull up showed cartilage involving the whole lower esophagus. Excluding the case of pure EA with gastric pull up, all patients suffered from feeding problems and recurrent aspiration. Fluoroscopic barium studies showed late onset minor dysmotility in five patients and late onset major dysmotility in two. All cases studied showed significant gastro-esophageal reflux (GER). Stricture was seen at the anastomotic site extending distally in the two fibromuscular cases and one case with cartilage, at the anastomotic site in three cases with TBR without cartilage. Anti reflux surgical procedures were performed in four patients without benefit in two patients with major dysmotility. Dilatation was successful in the three patients with TBR without cartilage. One patient with cartilage had resection of the anastomotic site and required frequent dilatations and is now doing well. A case of FMD did not improve after frequent dilatations and myotomy together with Nissen’s fundoplication and required resection while the other case of FMD responded partially to dilatations. Cartilage in cases of CES requires surgical resection. Those with TBR without cartilage may not develop stricture. If stricture develops, it responds well to dilatation and patients have good clinical outcomes. Unlike isolated CES, GER is a significant feature in CES with EA. Anti reflux procedures should be avoided before definitive surgery for the stricture and if necessary a partial wrap with gastrostomy is recommended. CES should be considered in the etiology of anastomotic stricture. Taking a surgical specimen routinely from the tip of the LEP during primary esophageal repair for histologic studies is highly recommended.     

Congenital esophageal stenosis

A series of 20 patients with congenital esophageal stenoses (CES), including 4 with tracheobronchial remnants, 6 with membranous diaphragm, and 10 with fibromuscular stenosis, is presented. The experience acquired by treating these patients is compared to 95 cases from the literature and a definition of CES is proposed. The 35% association of CES woth other anomalies, especially esophageal atresia, is analyzed and some difficulties in the treatment of this rare anomaly are discussed. Offprint requests to: C. Nihoul-Fékété     

婴幼儿食管瘢痕狭窄的外科治疗

目的：回顾性分析婴幼儿食管良性狭窄30例外科治疗结果。探讨外科治疗各种方法的优劣。方法：30例中男20例，女10例。年龄1岁5个月-5岁，平均29个月。体重5-20kg。除1例为农药烧伤外，余均为误服强酸、碱烧伤。颈段食管完全闭塞3例，基本闭塞5例，余食管造影均见钡剂在食管全长呈不规则线样通过、其中5例伤后曾有时间不等声嘶及吸气性呼吸困难，6例在外院行胃造瘘，全部病例采用保留结肠左动脉升支供血，经胸骨后径路顺蠕动吻合横结肠代食管结肠颈部吻合或结肠咽吻合。结果：手术后颈部吻合口瘘1例，吻合口狭窄1例。术后气管切开1例，经治疗后顺利进食，无手术死亡。经4-20余年随访，患儿发育正常。结论：主张对的食管瘢痕狭窄应积极采取食管重建术。食管替代物中以横结肠为最佳。同期食管瘢痕切除食管的危险性大，手术应以食管旷置为佳。重建平面需在颈部或咽部，不主张任何形式的胸内吻合。     

Congenital esophageal stenosis: a case report and review of the literature.

A child with congenital esophageal stenosis (CES) demonstrates the need for accuracy in the diagnosis and management of this rare problem. Other etiologies of dysphagia must be looked into, but when the expected results are not realized CES should be considered. A range of diagnoses and diagnostic studies may help to get children with dysphagia the treatment that they need to resolve their symptoms.     

Current characteristics and management of congenital esophageal stenosis: 40 consecutive cases from a multicenter study in the Kyushu area of Japan

Purpose

Congenital esophageal stenosis (CES) is rare, and the available clinical data are limited. We explored the current diagnosis, treatment and outcomes of CES.

Methods

A questionnaire survey was performed using medical records at pediatric surgical centers in the Kyushu area.

Results

Over 10 years, 40 patients (24 males) had CES. The incidence of associated anomalies was 52.5% (21/40), and that of esophageal atresia was 20.0% (8/40). The mean age at the diagnosis was 12.0 months (range, 1 day–8.8 years). Seven (17.5%) patients were diagnosed in the neonatal period. Ten (25.0%) developed CES due to tracheobronchial remnants, 27 (67.5%) due to fibromuscular stenosis (FMS) and 1 (2.5%) due to membranous stenosis + FMS. Thirty-six (90.0%) were treated by balloon dilatation (mean, 3 times; range, 1-20). Perforation at dilatation occurred in 7 (17.5%) patients, and all were diagnosed with FMS. Eighteen (45.0%) patients underwent radical operation (3 primary, 15 secondary to dilatation).

Conclusions

Our study clarified the characteristics and outcomes of CES, including neonatal diagnoses. CES occurred in 1 in every 33,000 births in the Kyushu area. Careful attention should be paid, even in cases of dilatation for FMS. CES requires long-term follow-up for symptom persistence after adequate and repeated treatment.

     

Esophagocoloplasty for caustic stricture of the esophagus: changing concepts

A review of 520 patients with caustic esophageal strictures who underwent esophageal replacement over a 15-year period in our institution is presented. Their ages at the time of esophagocoloplasty varied from 9 months to 18 years (mean 3.4 years). Simple colon bypass of the strictured esophagus was performed in 455 patients utilizing the retrosternal route. Transhiatal esophagectomy with simultaneous colon interposition was performed in 65 successive patients. The overall mortality was 4.42%; 296 patients were available from between 1 and 15 years for follow-up. The isoperistaltic left colon is the best substitute for a strictured esophagus in our experience. A pre-reconstruction feeding catheter gastrostomy was of utmost importance in most cases. Technical measures to reduce colonic graft redundancy, gastrocolic reflux, and esophagocolic anastomotic leak and stenosis were associated with satisfactory long-term functional results.     

腹腔镜联合食管支架治疗合并食管下端狭窄的小儿胃食管反流

目的探讨腹腔镜胃底折叠联合食管支架治疗合并食管下段狭窄的小儿胃食管反流的初步疗效。方法对6例胃食管反流并食管下段狭窄患儿采取腹腔镜胃镜下联合手术治疗，总结其手术情况及术后短期随访情况。结果除1例二次手术者中转开腹手术外，其余均顺利完成手术。术后1例出现轻度吞咽困难，1例支架异位。随访中3例取出支架，3例仍保留支架者未出现术后狭窄。结论腹腔镜胃底折叠联合食管支架置入治疗合并食管下段狭窄的小儿胃食管反流短期疗效良好。