婴幼儿气道狭窄的诊疗现状与研究进展

婴幼儿气道狭窄是由先天性或后天性因素所造成的呼吸道管腔缩小,导致呼吸和发音功能障碍.近些年,随着纤维支气管镜在NICU与PICU应用的发展,先天性婴幼儿气道狭窄的诊断率明显提高;随着极早产、极低出生体重儿存活率的增高,气管插管相关性婴幼儿气道狭窄的发病率也在逐步升高;随着外科手术方式的进步以及纤维支气管镜诊疗应用的普及,过去诊疗困难、病死率极高的先天性气道畸形狭窄,在诊治与预后方面也有了巨大的提升.该文综述近年来婴幼儿气道狭窄的诊疗现状与新进展.     

先天性心脏病围手术期气管狭窄的综合治疗

目的 通过分析先天性心脏病围手术期气管狭窄患儿的治疗及转归,探讨不同原因导致气管狭窄的治疗方法.方法 回顾性分析2012年1月至2015年10月收治的60例气管狭窄合并先天性心脏病患儿的临床资料.其中,男42例,女18例;年龄1～144个月,平均4个月;体重(6.65±3.40) kg.先天性心脏病合并先天性气管狭窄39例,继发性气管狭窄21例.结果 先天性气管狭窄合并先天性心脏病39例,实施先天性心脏病矫治+气管狭窄旷置28例,先天性心脏病矫治+气管成形术5例,先天性心脏病矫治+气管支架置入1例;术后远期死亡共计4例,放弃手术治疗死亡4例,放弃治疗门诊随诊1例.继发性气管狭窄21例,实施心脏畸形矫治后气管软化狭窄减轻,不需手术治疗.结论 先天性心脏病合并先天性气管狭窄的主要致病原因在于其完全性软骨环导致气管内径增速缓慢,气道梗阻严重,即使实施心脏手术也不能完全改善其气管狭窄症状,必要时需同时实施气道成形术.继发性气管狭窄的主要致病原因在于气管临近大血管的压迫,缓解血管环畸形后气管狭窄即刻缓解,疗效满意,无需实施气管成形术.     

Congenital airway anomalies

Congenital airway anomalies (CAA) include a variety of conditions that cause respiratory distress in neonates and infants. These malformations occur at various anatomic levels and manifest in a wide spectrum of airway symptoms, with presentation significantly influenced by the level at which obstruction occurs as well as by the severity of obstruction. The prevalence of congenital airway malformations has been estimated to range between 0.2 and 1 in 10,000 live births. The most frequent CAA are laryngomalacia, bilateral vocal cord paralysis, subglottic stenosis, laryngeal webs, subglottic hemangioma, tracheomalacia, congenital tracheal stenosis, laryngotracheal cleft, and tracheal agenesis.     

Severe lower tracheal stenosis in infancy.

16 infants with severe distal tracheal stenosis (TS) seen from 1978-1988 are reviewed. Diagnosis was established by endoscopy and confirmed by radiographic methods, including magnetic resonance imaging (MRI) in three cases. Types of TS ranged from segmental stenosis to complex lesions involving the carina and bronchi. Associated vascular anomalies were found in nine patients (56%). All patients needed long-term intubation or a tracheostomy (seven cases) for stenting of the airway. Patients with congenital TS (CTS) were treated by tracheal resection (two survivors), dilatation (one survivor, two non-survivors), or observation (two non-survivors). Patients with pulmonary artery sling (PAS) were treated by division of the vascular sling (three survivors, one non-survivor), or combined vascular and tracheal surgery (one non-survivor). One patient with dilated pulmonary arteries compressing both main bronchi died in spite of oxygen therapy. Two cases of compression by an anomalous aorta were managed with dilatation (one survivor, one non-survivor). One patient with a severe stricture after a tracheal resection was successfully treated by dilatation. The overall mortality was 50%. We conclude that 1. endoscopic examination of the tracheobronchial tree and thorough evaluation of associated anomalies is mandatory in symptomatic patients; 2. if indicated surgical correction is the treatment of choice for tracheal stenosis; 3. dilatation and stenting of the stenosis are invaluable tools in the management of these infants.     

Congenital tracheal malformations

Congenital malformations of the trachea include a variety of conditions that cause respiratory distress in neonates and infants. A number of anomalies are self-limiting while others are life-threatening and require immediate therapy. The prevalence of congenital airway malformations has been estimated to range between 0.2 and 1 in 10,000 live births. The most frequent congenital tracheal malformations are: tracheomalacia, congenital tracheal stenosis, laryngotracheal cleft and tracheal agenesis. The management of congenital tracheal malformations is complex and requires an individualized approach delivered by a multidiscipilinary team within centralized units with the necessary expertise.     

Isolated congenital tracheal stenosis in a preterm newborn

Severe tracheal stenosis, resulting in functional atresia of the trachea is a rare congenital malformation with an estimated occurrence of two in 100,000 newborns. If no esophagotracheal fistula is present to allow for spontaneous breathing, this condition is usually fatal. We report on a male infant born at 32 weeks of gestation. The patient presented with respiratory distress immediately after delivery due to severe congenital tracheal stenosis resulting in functional atresia of the trachea. Endotracheal intubation failed and even emergency tracheotomy did not allow ventilation of the patient lungs. The patient finally succumbed to prolonged hypoxia due to functional tracheal atresia. The etiology of tracheal atresia and tracheal stenosis is still unclear, but both conditions are frequently combined with other anomalies of the VACTERL (vertebral anomalies, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, renal/radial anomalies and limb defects) and TACRD (tracheal agenesis, cardiac, renal and duodenal malformations) association. Conclusion Successful treatment of severe congenital tracheal stenosis and tracheal atresia depends on either prenatal diagnosis or recognition of this condition immediately after birth to perform tracheotomy without delay. Nevertheless, despite any efforts, the therapeutical results of severe tracheal stenosis and tracheal atresia are still unsatisfactory.     

先天性心脏病合并气道异常的临床分析

目的 探讨先天性心脏病（CHD）合并气道异常患儿的临床特征和预后。方法 回顾性分析重庆医科大学附属儿童医院2012年1~12月行胸部多排螺旋CT（MDCT）+气道重建和（或）纤维支气管镜（纤支镜）检查的住院CHD患儿的临床资料,按是否合并气道异常分为气道异常组和气道正常组,根据检查指征的不同,将气道异常组进一步分为心脏指征亚组和气道指征亚组。从病史中截取临床特征、CHD类型、气道异常类型、治疗和预后等资料,行气道正常组和异常组的比较。 结果 460例CHD病例进入分析。气道异常组195例（42.4%）,男113例,中位年龄6月龄（1 d至14.5岁）;气道正常组265例,男157例,中位年龄3.9月龄（1 d至15.4岁）。①166/195例存在1种气道异常,包括：单纯气道狭窄（125例,64.1%）、单纯气管性支气管（21例,7.2%）、单纯对称性支气管（8例,4.1%）和单纯气道软化（6例,3.1%）等,29例伴2种及以上气道异常;外源性压迫所致气道狭窄占80.9%（123/152）。②不同类型CHD合并气道异常的比例：血管环为84.2%,梗阻型为51.5%,发绀型为49.1%,左向右分流型为33.8%。气道指征亚组左向右分流型的比例高于心脏指征亚组（62.4% vs 20.3%）,发绀型比例低于心脏指征亚组（12.0% vs 51.4%）。③气道异常组喘息、既往肺炎≥3次的比例显著高于气道正常组（P＜0.05）。 ④气道异常组均未行外科治疗,随访复查MDCT+气道重建19例（轻度气道狭窄4例,中度气道狭窄15例）,其中气道狭窄消失6例（CHD术后均>1年）,减轻6例（CHD术后 <1年5例）,无明显变化5例（出院>1 年,CHD均未矫治）,加重者2例。气道异常组死亡22例。结论 儿童CHD合并气道异常的类型以气道狭窄最多见。对血管环和（或）反复呼吸道感染、喘息的CHD患儿应注意合并气道异常可能。大多数继发性轻中度气道狭窄在外源性压迫解除后1年以上,气道狭窄可能逐渐恢复正常。     

先天性气管支气管异常51例临床分析

目的分析经支气管镜检查诊断的先天性气管支气管异常患儿的临床特征。方法回顾分析了2003年1月至2007年11月在深圳市儿童医院接受诊断性支气管镜检查的135例患儿的结果,135例均采用异丙酚为主的静脉复合麻醉。结果共检出先天性气管支气管异常51例,检出率为37.8%(51/135),依次为气管、支气管软化32例,气管、支气管狭窄13例,气管性支气管11例,其中5例为2种或2种以上气道异常。21例患儿接受胸部CT检查,仅7例CT作出了正确诊断。对治疗反应不佳的喘息是先天性气管支气管异常最常见的症状,其他症状包括持续性局限性肺炎、肺不张或局限性肺气肿,气管插管困难,插管后拨管失败。18例(35.3%)合并其他部位畸形,分别为先天性心脏病、喉软化和气管食管瘘。结论先天性气管支气管异常在临床上并不少见,但其临床表现缺乏特异性,因此对可疑患儿应及时进行支气管镜检查以明确诊断。     

三维CT对支气管异物诊断价值的临床研究

目的 探讨三维CT在支气管异物诊断和鉴别诊断中的作用.方法 对37例可疑支气管异物的患儿行螺旋CT检查,并进行支气管三维CT重建,通过支气管镜检术、保守及手术治疗的结果 判断三维CT检查结果 的准确性.结果 37例可疑支气管异物的患儿中,X线胸部透视提示支气管异物8例(A组);X线胸部透视不提示支气管异物29例(B组).A组中,CT提示肺内感染5例、先天性肺发育异常-肺叶缺如2例、气管食管瘘1例.B组29例患儿中,CT提示支气管异物25例,经支气管镜检证实其中24例存在植物性异物,1例为气管内肿物;CT不提示支气管异物4例,证实为肺内感染、小儿急性喉炎各2例.手术证实存在植物性异物的24例中,CT显示气管支气管内异物影共14例次,不规则狭窄共6例次;阻塞性肺不张、肺气肿、肺炎共7例次;前两项为直接征象,占74%(20/27),后三项为间接征象,占26%(7/27).结论 三维CT检查对支气管异物的诊断及鉴别诊断有重要意义,有助于疑难病例的诊断和鉴别诊断.     

纤维支气管镜在大血管疾病合并气道狭窄中的诊断价值

目的 评价纤维支气管镜(简称纤支镜)在先天性大血管病变合并气道狭窄中的诊断价值及安全性.方法回顾性分析2005年10月至2009年6月NICU收治的经纤支镜检查确诊气道狭窄的先天性大血管病变患儿34例,其中血管环10例,主动脉梗阻性病变24例,年龄6 d～11个月,体重2.2～8.7 kg[(4.6±1.4)kg];记录纤支镜发现的气道狭窄情况、CT及手术所见确诊的心血管畸形及气道狭窄情况,总结分析纤支镜检查发现的气道狭窄与心血管畸形的关系、气道狭窄的处理及转归.结果 所有病例均在NICU或手术过程中顺利完成纤支镜检查.(1)34例气道狭窄的首发症状为气促、喘鸣、反复肺部感染和呼吸机依赖.(2)10例血管环患儿均先经纤支镜检查,发现气道外压性狭窄,提示血管环,气道狭窄以气管下段为主;9例经CT、1例经手术证实为血管环,其中7例伴先天性气管狭窄.(3)24例主动脉病变中5例为术前CT提示气管狭窄,其中1例纤支镜提示气道狭窄,余19例在主动脉梗阻性畸形矫治术中、术后经纤支镜发现气道压迫狭窄.24例主动脉病变中21例有左主支气管狭窄,2例有先天性气管狭窄.纤支镜检查与CT检查对气管狭窄的诊断基本吻合.(4)34例纤支镜检查过程中2例出现一过性血氧饱和度下降,5例出现一过性心动过速,其余患儿无不良反应.结论 纤支镜检查在大血管畸形伴气道狭窄的诊断中起重要作用,具有准确、安全、方便、快捷的优点,但对气管狭窄的情况、气管周围结构和血管畸形的了解需结合CT检查.     

Subglottic Ductal Cysts Associated with Complete Tracheal Ring Deformity: Coexistence of Two Rare Airway Abnormalities with Fatal Outcome

Subglottic cysts are rare and may cause airway obstruction. Most cases are acquired secondary to endotracheal intubation, even short-term, particularly in the premature neonate. Complete tracheal rings are rare anomalies associated with tracheal stenosis. To our knowledge, the two have not been reported coexisting. A 16-month-old ex-premature boy was found unresponsive, with his tracheostomy tube dislodged. Tracheomalacia, subglottic stenosis, and a laryngeal cyst had been diagnosed shortly after birth, and the cyst was surgically treated at that time. At autopsy, a complete tracheal ring was noted in the subglottic region, above the tracheostomy site, and the tracheal diameter was markedly decreased in this area. In addition, multiloculated cysts were present at that level, arising from both anterolateral tracheal walls. These completely occluded the airway. To our knowledge, this is the first case of a combination of tracheal ring anomaly and subglottic cysts. Pediatric pathologists must be aware of iatrogenic lesions associated with care of the premature neonate, particularly as the age of viability continues to decrease.     

电子支气管镜在儿童上气道梗阻性疾病中的诊断价值

目的 评价电子支气管镜在儿童上气道梗阻性疾病中的诊断价值及安全性.方法 对91例上气道梗阻患儿行电子支气管镜检查,总结分析病因.结果 (1) 儿童上气道梗阻病因依次为先天性喉气管软化合并感染(45例)、声门下异物(13例)、喉气管占位性病变(9例)、声门区水肿(6例)、气管狭窄(5例)、喉咽腔病变(咽后脓肿3例、肿物2例)、声门区增生(3例)、声门下狭窄(2例)、声带麻痹(2例)、喉蹼(1例);(2) 不同年龄段病因不同:新生儿期依次为声带麻痹、喉气管软化;~6个月依次为先天性喉气管软化、会厌囊肿,其他少见病因如气管狭窄、咽后脓肿、喉蹼等疾病;~1岁依次为喉气管软化、气管狭窄、声门下异物等;~3岁依次为声门下异物、声门区水肿、喉气管软化等;>3岁儿童1例为喉乳头状瘤.(3) 疾病好发的年龄段不同:先天性喉气管软化好发于6个月以下婴儿,气管异物好发于1~3岁幼儿,先天性会厌囊肿多见于3个月以下婴儿.(4) 并发症:16例有一过性血氧饱和度下降,11例出现气管支气管痉挛,术后8例有一过性发热,6例有短期喉鸣加重.结论 电子支气管镜在儿童上气道梗阻性疾病的诊断中起重要作用,可迅速、直观地判断病变部位和性质,避免误诊,有助于指导治疗.

Abstract：

Objective To investigate the diagnostic value and safety of bronchovideoscope in the pediatric upper airway obstruction.Methods Bronchovideoscope was performed in 91 pediatric patients with upper airway obstruction.The etiology was analyzed and summarized.Results (1) Our study showed that the etiology of pediatric upper airway obstruction were as follow in turn:congenital laryngo-trachemalacia (45 cases),subglottic foreign body (13 cases),laryngotracheal occupying lesion (9 cases),vocal area edema (6 cases),tracheal stenosis (5 cases),laryngopharyngeal lesion (3 cases of retropharyngeal abscess,2 cases of tumor),vocal area hyperplasia (3 cases),subglottic stenosis (2 cases),glottic paralysis (2 cases),laryngeal web (1 case).(2) The common etiology of pediatric upper airway obstruction was different with age.Neonatal period:glottic paralysis,laryngomalacia in turn;1~6 month:laryngo-trachemalacia,tracheal stenosis,subglottic foreign body in turn;1~3 year:subglottic foreign body,vocal area edema,laryngo-trachemalacia in turn,>3 year:laryngeal papilloma.(3) Specific disease had predominant age:laryngo-trachemalacia predominated in infants less than 6 month;tracheal foreign body was most common in child aged 1~3 years old;epiglottic cyst was most common in infant less than 3 month.(4) Complication:during procedure,16 patients had transient decrease of saturation of blood oxygen and 11 patients had tracheobronchial spasm.After procedure,8 patients had transient fever and 6 patients had transient aggravation of laryngeal stridor.Conclusion Bronchovideoscope plays an important role in the diagnosis of pediatric upper airway obstruction.It can directly identify position and nature of disease,and then guide treatment.     

Tracheal agenesis: approach towards this severe diagnosis. Case report and review of the literature

Tracheal agenesis (TA) is a severe congenital disorder with often an unexpected emergency presentation. There is complete or partial absence of the trachea below the larynx, with presence or absence of a tracheoesophageal fistula (TOF). A neonate with TA is described, and another 48 cases found in literature are reviewed. Due to absence of a TOF, five cases were diagnosed prenatally because of congenital high airway obstruction syndrome (CHAOS). When a TOF is present, polyhydramnion and several other congenital malformations seen on the ultrasound examination should alert clinicians of potential tracheal problems. Prenatal magnetic resonance imaging (MRI) may provide a definitive diagnosis. Postnatal diagnosis is based on recognition of specific clinical signs in the newborn with TA: respiratory distress with breathing movement without appropriate air entry, no audible cry, and failed endotracheal intubation. Despite progress in surgical interventions, mortality remains high. Prenatal diagnosis of TA is possible, but only if a TOF is absent resulting in CHAOS. Prenatal diagnosis of polyhydramnion and other congenital malformation should alert clinicians of potential tracheal problems. Prenatal MRI may provide a definitive diagnosis.     

Three-Dimensional Computed Tomographic Findings of Bilateral Tracheal Bronchus

A newborn male was admitted with cyanosis and respiratory distress. Echocardiography showed a right heart isomerism associated with a single right ventricle, a double-outlet right ventricle, and pulmonary atresia. Chest X-ray demonstrated severe left upper lobe emphysema and a shift of the mediastinal structures to the right. Two-dimensional computed tomography (CT) exhibited left upper lobe emphysema and right upper lobe atelectasis. Three-dimensional (3D) spiral CT angiography showed a bilateral tracheal bronchus. The left tracheal bronchus branch was compressed between the descending aorta and the ductus arteriosus. After a right arteriopulmonary shunt operation, the patient’s respiratory condition improved dramatically, with spontaneous closure of the ductus arteriosus. Subsequently, 3D-CT clearly exhibited the disappearance of tracheal compression. This combination of bilateral tracheal bronchus and congenital heart anomaly is extremely rare. The 3D-CT is a powerful noninvasive means for dynamically demonstrating the special relationships of arterial and tracheal anomalies.     

Management of laryngotracheal stenosis in infants and children: the role of re-do surgery in cases of severe subglottic stenosis

Although many advances have improved the treatment of congenital and acquired laryngotracheal stenosis in children over the past two decades, the therapeutic decision-making process remains challenging for pediatric surgeons and otolaryngologists. Severe subglottic stenosis is a complex laryngeal injury that necessitates multiple airway procedures, and the approach depends on the exact nature of the cicatricial lesion and its effect on the vocal cord mobility. Therefore, it is imperative that the pediatric surgeons and otolaryngologists dealing with this situation should be well trained in endoscopy and laser treatment, in addition to open surgical intervention. Open re-do surgery remains the best choice in cases of severe congenital stenosis, glottic immobility, or after two to three endoscopic procedures have been performed without any significant improvement.     

Pulmonary sling: Morphological findings. Pre- and postoperative course

Pulmonary sling (PS) is a congenital condition in which the left pulmonary artery (LPA) arises from the right pulmonary artery (RPA), forming a sling around the trachea causing tracheal compression. The incidence is not so rare as initially thought. Symptoms of severe airway obstruction often begin in the newborn or young infant. Echo-colour-Doppler may reveal the PS but emphysema can mask the typical findings. Deviation of fluid-filled lungs may be detected prenatally. Chest radiographs show unusual air distribution, deviation of heart and mediastinum and altered tracheobronchial angles. Bronchography and bronchoscopy demonstrate the high incidence of associated tracheal anomalies such as cartilagenous rings and long tracheal stenosis. Anterior oesophageal indentation is not always seen in the oesophogram. Magnetic resonance imaging (MRI) and computed tomography (CT) reveal the PS, but cautious interpretation is necessary because of different levels of the anomalous LPA. PS and associated cardiovascular malformations can be clearly detected by angiography. Associated extrathoracic anomalies are common. Early diagnosis and therapy of PS is mandatory and consists of reimplantation of the LPA into the pulmonary trunk and division of the ligamentum arteriosum. The postoperative course may be cumbersome necessitating bronchological interventions. Tracheal resection may be necessary but restenosis is frequent. A one-stage repair has been proposed in such cases and was successfully done in a few reported cases. Relief of respiratory obstruction is often complete when there are no associated tracheobronchial anomalies. Late postoperative course is favourable but respiratory obstructive attacks may occur with decreasing incidence over time and tracheal growth.     

纤维支气管镜下带囊支架置入术治疗儿童气管狭窄2例

目的:通过纤维支气管镜下带囊支架置入术治疗儿童气管狭窄,观察近期疗效和并发症。方法:例1,女,4月龄,因“发现心脏杂音3个月余,咳嗽10 d渐加重,伴发热、喘息3 d”入院,诊断为膜周部+肌部室间隔缺损,房间隔缺损（继发孔型）,肺动脉高压,主气道下段及左右主支气管变形狭窄。行肺动脉环缩术,房间隔、室间隔缺损修补术+主动脉悬吊术成功后,术后2个月内3次撤离呼吸机均未成功。例2,女,1岁10个月,因“咳嗽1个月余”入院,诊断为左主支气管狭窄,EBV相关性噬血细胞淋巴组织细胞增生症。左侧支气管狭窄致使排痰困难,肺部反复感染,左肺气肿。2例患儿家长在充分了解纤维支气管镜下带囊支架置入术可能的风险后签署知情同意书。采用“边麻边进”方法行气道黏膜表面麻醉,例1和例2 选择带囊支架长度分别为24和29 mm,直径均为4 mm（均经雷帕霉素处理）,由支架导入器送入纤维支气管镜,在纤维支气管镜直视下释放带囊支架,然后退出支架导入器。结果:2例患儿置入带囊支架后狭窄段气管扩张良好,带囊支架放置2~3个月随访,未见肉芽组织增生等并发症。结论:纤维支气管镜下带囊支架置入术治疗气管狭窄近期疗效较好,远期疗效尚待观察。     

新生儿食管闭锁的外科治疗

目的 总结新生儿食管闭锁的诊断和治疗经验.方法 回顾性分析我院2002年6月至2010年6月收治的新生儿食管闭锁61例,男34例,女27例.手术年龄18 h～7 d,平均(2.5±0.6)d,体重1 500～4 000 g,其中低体重儿(＜2 500g)16例.61例中按Gross病理解剖分类:Ⅰ型2例,Ⅲa型32例,Ⅲb型27例,Ⅲa型中有1例远端食管有局限狭窄,开口约0.2 cm;合并畸形:先天性心脏病15例,肠道畸形4例,泌尿系畸形3例.结果 61例中2例Ⅰ型食管闭锁先行近端食管引流、胃造瘘,2周后行结肠代食管手术,59例Ⅲ型均Ⅰ期食管气管瘘切断缝扎、食管端端吻合术,Ⅲa型中远端食管有1例局限性狭窄,行纵切横缝解除狭窄.术后并发单侧或双侧严重肺炎42例,硬肿症3例,近期吻合口狭窄24例,吻合口瘘3例.除1例术后2d合并肠穿孔死亡,3例放弃治疗(均为早期病例:1例为术后1周出现核黄疸,2例术后合并严重肺部感染不能脱离呼吸机),余57例均痊愈出院.术后随访3个月～8年,轻度胃食管反流3例,余均进食良好,生长发育正常.结论 尽早诊断、及时手术,积极预防和治疗并发症,新生儿食管闭锁可取得良好的效果.

Abstract：

Objective To summarize the diagnosis and treatment for congenital esophageal atresia (CEA) in neonates. Methods From June 2002 to June 2010, 61 neonates with congenital esophageal atresia underwent surgery at this center. Of these patients, 34 were boys and 27 were girls. Their age ranged from 18 hours to 7 days (mean, 2. 5 ±0. 6 days). Their weight ranged from 1500 grams to 4000 grams. Sixteen patients were very low-birth-weight infants (＜1500 g). According to the anomalies of CEA, 2 were diagnosed with type Ⅰ CEA, and the other 59 were type Ⅲ CEA (32 type Ⅲa and 27 type Ⅲb). The most common associated anomalies were cardiac anomalies (16, 26%), followed by intestinal anomalies (5, 8%) and renal anomalies (3, 5%). Results The 2 cases with type Ⅰ CEA underwent proximal drainage of esophagus and gastrostomy to stabilize their conditions. Two weeks later, they underwent the second stage surgery to replace esophagus with colon. The 59 patients with type Ⅲ CEA underwent fistulectomy and end-to-end esophagus anastomosis via thoracic approach. A stenosis in the medial-distal esophagus was found on 1 type Ⅲa CEA patients, and was repair with longitudinal incision and transverse suture. Postoperative complications included pneumonia on 42 patients (68. 8%), scleredema on 3 patients (4. 9%), mild anastomosis orifice stenosis on 24 patients (39. 3%), and anastomosis orifice fistula on 3 patients (4. 9%). One patient died of intestinal perforation 2 days after surgery. Three patients were given up including 1 developed kernicterus 1week after surgery, and the other 2 had serious pulmonary infection and couldn't be withdrawn from mechanical ventilation. The other 57 cases were discharged from hospital. The patients were followed up for 3 months to 8 years. Three patients had mild gastroesophageal reflux. The others ate and drank normally during follow-up. Conclusions Early diagnosis and carefully management of postoperative complications are important to improve clinical outcomes and prognosis of congenital esophageal atresia in neonates.     

Tracheobronchial rupture due to blunt trauma in children: report of two cases.

Tracheobronchial tree injuries occur in a small number of patients after blunt chest trauma, and their occurrence is uncommon in the pediatric trauma population. The authors report two male children, one with a tracheal rupture, and the other with disruption of the main right bronchus. Mediastinal and subcutaneous emphysema resulting in airway obstruction were noted in Case 1 and soft-tissue emphysema, pneumomediastinum and tension pneumothorax were evident in Case 2 at the time of presentation. In the child with bronchial disruption, a major airway injury was suspected early on, because of a massive air leak despite two properly placed chest tubes. The definitive diagnosis was established bronchoscopically, and thoracotomy and primary repair were performed. The child with rupture of the posterior tracheal wall was diagnosed at an early stage by bronchoscopy and he was successfully managed without surgery.     

婴幼儿肺动脉吊带24例临床特征及诊治分析

目的 分析婴幼儿肺动脉吊带（PAS）的临床特征、诊断及治疗。方法 回顾性分析2009年9月至2014年7月在重庆医科大学附属儿童医院诊断为PAS的病例,分析其一般情况、临床特征、影像学检查、诊断、治疗和预后。结果 29例PAS患儿进入分析,男16例,女13例,诊断PAS时年龄2月龄至3.5岁,中位年龄为7月龄。25例有反复喘息症状,26例入院时肺部听诊可闻及哮鸣音。15例为单纯PAS,确诊PAS中位年龄为6月龄;余14例伴有其他心血管病变,确诊PAS的中位年龄为8月龄,与单纯PAS患儿比较差异无统计学意义（P>0.05）。26例患儿行增强CT心血管重建+气道重建明确PAS及合并先天性心脏畸形诊断,余3例心脏超声提示PAS,增强CT仅行气道重建检查;29例CT检查均提示气道狭窄,合并支气管桥7例。25例行心脏彩超检查,其中13例检查时间早于增强CT心血管重建,5例确诊为PAS。13例行纤维支气管镜检查均发现气管狭窄,其中6例存在气管软骨环。16例行手术治疗,其中12例手术成功,4例死亡。单因素分析显示,有机械通气时间>72 h、手术时年龄≤5月龄或体外循环时间>100 min等因素的PAS患儿病死率高（P< 0.05）。结论 对反复喘息发作内科治疗效果不佳的婴幼儿,需警惕PAS的可能,合并心血管畸形并不能帮助早期发现PAS。增强CT心血管重建+气道重建检查可发现PAS及伴随气道畸形,有呼吸道症状者应尽早手术治疗,多数患儿的气道畸形不需手术处理。机械通气时间>72 h、手术时年龄≤5月龄或体外循环时间>100 min与PAS患儿病死率相关。