颈椎前路手术并发食管瘘的原因及处理

 目的 探讨颈椎前路手术并发食管瘘的原因及处理对策。方法 回顾性分析2004年1月至2011年12月采用颈椎前路手术治疗2348例颈椎疾患患者资料，其中5例发生食管瘘，男3例，女2例；年龄14~48岁，平均34岁；颈椎外伤3例，颈椎病1例，颈椎结核1例。1例患者术中发现食管瘘，给予修补；另4例均为术后发现，行清创探查引流术，其中1例探查时发现食管瘘口遂给予修补，1例仅行清创探查术，1例清创探查术后二期行内固定取出术，1例清创探查术后二期行内固定取出及肌瓣填塞术。给予禁食、营养支持、伤口引流及抗生素治疗；定期吞服亚甲蓝，观察漏口情况。结果 经过9～61周治疗，所有患者食管瘘口愈合，恢复进食。随访6～48个月，无一例发生食管瘘复发、颈椎失稳及迟发感染；吞咽功能均良好；患者原有颈部疾患治疗效果均满意，颈椎外伤患者Frankel分级平均提高1级，颈椎病患者JOA评分由术前9分提高至术后15分。结论 采用食管瘘口修补、肌瓣填塞以及引流手术，并严格禁食禁水、营养支持，必要时取出内固定物，多数颈椎前路手术并发食管瘘的患者能获得满意的疗效。术中仔细轻柔操作是预防食管瘘发生的关键。

Management of esophageal fistula caused by anterior cervical spine surgery

Objective To evaluate cause, treatment and prevention of esophageal fistula caused by anterior cervical spine surgery. Methods Between January 2004 and December 2011, 2348 patients underwent anterior cervical spine surgery. Among them, 5 patients suffered from esophageal fistula owing to operation, including 3 males and 2 females, with an average age of 34 years (range, 14 to 48 years). The diagnosis of these patients included 3 cases of cervical injury, 1 case of cervical spondylosis and 1 case of cervical tuberculosis. There was 1 patient whose esophageal injury was founded during the surgery, and that was directly repaired. For another 4 patients, esophageal fistulas were founded after operation; one case underwent debridement and orificium fistulae repair; one case only underwent debridement; one case underwent debridement and second-stage removal of hardware; and one case underwent debridement and second-stage removal of hardware and esophageal repair with sternocleidomastoid flap. Postoperative treatment included esophageal rest, enteral nutrition, wound drainage, and antibiotic administration. Methylene blue was used to evaluate status of orificium fistulae. Results All patients with esophageal fistula were cured 9 to 61 weeks after treatment, and oral intake was achieved. They were followed up for 6-48 months. There was no recurrence of esophageal fistula, cervical instability and infectious spondylitis in any case. All patients were satisfied with swallowing function and outcome of cervical spine diseases. The Frankel grade was improved averagely one grade in patients with cervical injury, and the JOA score was improved from preoperative 9 points to postoperative 15 points in patients with cervical spondylosis. Conclusion Successful management of esophageal fistula caused by anterior cervical spinal surgery depends on primary closure of the perforation with or without muscle flaps, surgical drainage, esophageal rest and nutrition support, and removal of hardware if necessary. Prevention consists of the careful operation and gentle tissue handling.