胸腔镜与开胸手术治疗先天性食管闭锁并食管气管瘘的对比研究

目的 比较胸腔镜手术与开胸手术治疗先天性食管闭锁并食管气管瘘的疗效差异.方法 回顾性分析50例Ⅲ型先天性食管闭锁并食管气管瘘的临床资料,其中25例为江西省儿童医院2012年12月至2014年1月收治,采用胸腔镜治疗;另25例为首都儿科研究所2008年6月至2014年4月收治,采用开胸治疗.男27例,女23例,术前均明确诊断并完成手术治疗.胸腔镜组采用3孔法,经胸行食管气管瘘结扎,食管吻合术.开胸组采用经胸膜外完成手术.结果 胸腔镜组25例均一期完成食管吻合术,无中转,术后2例死亡.开胸组25例中23例完成经胸膜外食管吻合术,2例因食管盲端距离过长行食管气管瘘结扎,胃造瘘术,术后放弃治疗.手术时间胸腔镜组平均为127min(110～160min),开放组平均133min(105～170min);呼吸机使用时间胸腔镜组平均为2.6 d(1～13 d),开放组平均2.3 d(1～11 d),两组对比差异均无统计学意义.胸腔镜组25例中2例吻合口漏(8％),7例狭窄(28％),2例食管气食管瘘复发(8％).开放组25例中2例吻合口漏(8％),4例狭窄(16％),无食管气管瘘复发,两组比较差异均无统计学意义.结论 胸腔镜手术治疗先天性食管闭锁并食管气管瘘是安全可行的,但要求术者具备熟练的微创手术技术和相关的手术技巧.     

先天性食管闭锁术后食管气管瘘复发诊治进展

复发性食管气管瘘是先天性食管闭锁术后常见且严重的并发症。瘘管修补术后再次复发仍是临床及护理工作中的重大挑战。随着微创和内镜技术的不断发展,近十年来不断涌现出更加精巧的治疗方式。本文基于既往研究报道,就先天性食管闭锁术后食管气管瘘复发进行综述。     

食管闭锁术后食管气管瘘复发的治疗进展

食管闭锁是一种常见的先天性消化系统畸形,手术治疗是唯一有效的治疗方式.但术后常发生一系列并发症,其中以食管气管瘘复发最为棘手.目前食管气管瘘复发的治疗以外科手术为主,然后围手术期的管理及二次手术的困难一直是小儿外科医师所面临的一项挑战.基于近年来国内外对于食管闭锁术后食管气管瘘复发的研究,本文介绍了食管气管瘘复发的围手术期管理技巧,简述了在外科手术方面提高食管气管瘘复发治愈率的要点及进展.同时也回顾了近年来内镜下治疗食管气管瘘复发的各种方法,分析了其优缺点及适应证.指出目前外科治疗治愈率已明显提高,内镜治疗也日益完善,并对将来的治疗研究方向进行展望.     

先天性双气管食管瘘的诊治一例并文献复习

目的:报道一例先天性双气管食管瘘（congenital double tracheoesophageal fistulas,CDTEFs）患儿并结合相关文献总结其临床特征、诊断方法及治疗方案。方法:收集1例CDTEFs患儿的临床资料及诊治方案,同时检索截至2020年8月PubMed、Ovid、Cochrane、万方、中...     

胸腔镜手术修补Ⅲ型食管闭锁术后食管肺瘘四例

目的探讨胸腔镜手术修补Ⅲ型食管闭锁术后食管肺瘘的可行性、手术经验及治疗效果。方法回顾性分析2017年1月至2019年12月就诊于首都医科大学附属北京儿童医院,行胸腔镜食管肺瘘修补手术的4例Ⅲ型食管闭锁术后食管肺瘘患儿的临床资料。4例患儿均为男孩,确诊年龄在1岁5个月至5岁1个月。4例患儿行上消化道造影检查均可见造影剂从食管溢出进入肺组织;CT检查均可见近端扩张食管与右侧肺组织关系密切,3例可见食管与肺组织有瘘道相通。4例行电子支气管镜检查,提示食管肺瘘2例。结果本组4例均在胸腔镜下完成食管肺瘘修补术,手术时间在2.5～3.0 h,平均2.7 h;术后均转入PICU,有创呼吸机使用时间1～5 d,平均3 d;术后平均住院时间14 d。1例患儿术后第2天胸腔引流管出现气泡,胸部X线片提示右侧胸腔少量气胸,考虑为肺部组织破损,后经保守治疗后痊愈。随访时间1～24个月,除1例患儿因食管狭窄目前在胃镜下球囊扩张治疗中外,余者均已完全经口喂养,生长发育良好。结论先天性食管闭锁术后食管肺瘘较为罕见,临床表现不具有特殊性,胸腔镜下行食管肺瘘修补术能取得良好的疗效。     

胸腔镜治疗先天性食管闭锁

目的 阐述胸腔镜治疗先天性食管闭锁的经验体会.方法 回顾性分析了2006年8月至2011年5月期间共进行11例胸腔镜下食管闭锁手术,采用Styker公司的胸腔镜器械,进行胸腔镜手术操作,患儿年龄为3 d～2个月,男7例,女4例,体重2.1～3.6kg.术前均作碘油造影及胸腹部摄片,证实为食管闭锁,1例1型,10例为Ⅲ型,其中8例伴有先天性心脏病.结果 3例转为开胸,其中2例因手术野影响,另1例为术中出血;7例均在胸腔镜下Ⅰ期完成手术;1例采用胸腔镜分期手术.术中出血少,术后恢复平稳,有2例发生吻合口漏,经保守治疗后恢复好.术后7例作食管扩张各一次.结论 胸腔镜下食管闭锁手术有一定的优越性,但需要掌握一定的适应证,同时要求手术者有较熟练的腔镜技术,患儿的选择和手术者的技术是保证手术成功的关键.     

先天性食管闭锁和气管食管瘘疗效探讨

目的探讨先天性食管闭锁和气管食管瘘的治疗效果。方法对1994年1月-2006年12月治疗的107例先天性食管闭锁和气管食管瘘进行了回顾分析。结果成活85例,成活率为79.44%;放弃治疗13例,死亡9例,死亡率8.41%;术后发生吻合口瘘29例,吻合口狭窄4例。结论提高食管闭锁和气管食管瘘患儿成活率的关键是早期诊断,减少吻合口瘘的发生。     

胸腔镜联合3D打印生物可降解气管外支架治疗复发性气管食管瘘北大核心CSCD

目的探讨胸腔镜联合个体化3D打印生物可降解气管外支架治疗复杂的复发性气管食管瘘的可行性和安全性。方法收集2022年1月至2022年8月在西安交通大学第二附属医院小儿外科治疗的7例复发性气管食管瘘(recurrent tracheoesophageal fistula,rTEF)患儿的临床资料,其中女2例,男5例,年龄在4个月至10岁。依据术前胸部薄层CT(0.5 mm)进行气道三维重建并设计个体化支气管外支架,于西安交通大学机械制造系统工程国家重点实验室3D打印制作。所有患儿均接受胸腔镜气管食管瘘修补术联合3D打印生物可降解气管外支架置入术,支架于瘘管水平包绕气管并固定于气管软骨。结果7例患儿均成功完成胸腔镜气管食管瘘修补术及个体化3D打印生物可降解气管外支架置入术。手术时间为120~200 min,术后机械通气时间为5~11 d,监护病房住院日6~13 d,总住院日14~37 d。2例术后出现吻合口瘘,经保守治疗后痊愈。随访10~15个月时,7名患儿均未见气管食管瘘复发。结论胸腔镜气管食管瘘修补术联合3D打印可降解气管外支架可阻止rTEF黏膜管道的再通,可预防rTEF的复发,安全可行。     

食管闭锁术后食管气管瘘复发再手术的临床分析

目的：分析食管闭锁（EA）术后食管气管瘘复发（RTEF）再手术的临床资料,总结RTEF的原因、诊断方法及再手术的经验。方法回顾性分析2005年1月至2013年12月我们收治的10例EA术后RTEF患儿的临床资料,其中男7例,女3例,再手术平均年龄为19个月,平均体重为8.3kg,所有病例均为GrossⅢ型;10例中有9例曾接受经右胸食管气管瘘结扎＋食管端端吻合术。结果在初次手术中有4例（4/10）瘘管并未切断。9例（9/10）复发瘘管的食管端开口于原食管吻合口狭窄处或近端食管。8例（8/10）术后存在不同程度吻合口狭窄,1例合并吻合口瘘。再手术前所有患儿行食管欧乃派克造影检查,确诊和疑似RTEF分别为5例（5/10,50％）、4例（4/10,40％）。所有RTEF通过胃镜及支气管镜确诊（10/10,100％）。患儿均接受再次进胸手术,平均手术时间3.2h,平均术后住院时间为15.8d。术后均获随访3～96个月,食管造影提示所有病例均治愈,未再发生RTEF。结论 EA术后RTEF与初次手术瘘管处理不当、食管吻合口局部炎症反应等因素有关,需再次手术治疗,再手术的疗效及患儿预后良好。     

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula

Purpose  Recurrent tracheoesophageal fistula (RTF) complicates 5–11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences. Methods  From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF). Results  There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months–5 years) demonstrated no evidence of recurrences. Conclusion  Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences.     

Extrapleural thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Traditionally, open repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) required thoracotomy. Innovations in minimal access surgery have created a thoracoscopic technique resulting in violation of the pleural space. Most pediatric surgeons favor an extrapleural approach for open repair. We present a novel minimal access, extrapleural technique for repairing EA with TEF. A 2-day-old infant with EA and distal TEF underwent thoracoscopic extrapleural repair that utilized three ports. Initial creation of the extrapleural space was achieved through one of the port sites and was completed thoracoscopically. A thoracoscopic repair of EA with distal TEF was achieved within the extrapleural space. A small tear in the pleura was inadvertently created during the dissection. The child began feeding normally. At 1 year of age, the patient had dysphagia requiring a single esophageal dilatation. This is the first known report of an extrapleural thoracoscopic repair of EA with TEF. Although thoracoscopic repairs of EA/TEF have been previously reported, these were all done transpleurally. Many pediatric surgeons favor the extrapleural approach for two reasons: (1) containment of a potential leak within the extrapleural space, avoiding an empyema, and (2) easier transpleural access for future thoracic procedures.     

新生儿食管闭锁(Ⅲ型)术中气管食管瘘管对低氧血症的影响

目的通过回顾我院24例食管闭锁伴气管食管瘘患儿的麻醉管理,探讨此类患儿围术期低氧血症的预防和治疗措施。方法24例患儿,术前30min肌注阿托品0.02mg/kg。异丙酚3mg/kg,维库溴铵0.1mg/kg～0.15mg/kg静脉注射诱导气管插管。使用Drager麻醉机,行间歇正压通气穴IPPV雪,FiO2100%,术中根据患儿情况调整呼吸机参数。麻醉维持吸入1%～2%异氟醚,切皮前静注芬太尼1μg/kg～2μg/kg。根据手术时间必要时可单次追加维库溴铵0.05mg/kg熏芬太尼1μg/kg。记录术前、麻醉诱导后、瘘管结扎前5min、瘘管结扎后5min、手术结束时HR、SpO2、PETCO2和体温。结果瘘管结扎前5minSpO290.2%±3.3%、PETCO222.0±4.0mmHg与瘘管结扎后5minSpO295.1%±2.6%、PETCO238.2±5.8mmHg比较,P<0.05。结论气管食管瘘管的存在与术中低氧血症的发生发展密切相关;瘘管结扎后,低氧血症可有明显改善。     

Redo esophageal surgery: the diagnosis and management of recurrent tracheoesophageal fistula

This article presents a 30-year review of 38 recurrent tracheoesophageal fistulas. The initial 26 cases were presented in 2009 at the annual meeting of the British Association of Pediatric Surgeons and the European Association of Pediatric Surgeons Joint Conference and published in the Journal of Pediatric Surgery (Bruchet al. J Pediatr Surg 45:337–340, 2010). In the initial cohort of 26 patients, 18 had a leak after their primary operation and 22 had respiratory symptoms leading to the discovery of the recurrent fistula. The diagnosis was made by a contrast study in 24. The repairs entailed replacing a catheter through the fistula, separating the trachea and esophagus completely using sharp dissection and placing vascularized tissue, either pleura or pericardium between the suture lines. Postoperative complications included seven anastomotic leaks, four strictures and three recurrent fistulas. Long-term follow-up (median of 84 months) showed that 21 took all of their nutrition by mouth, three were tube fed and two required a combination of both. Of the 23 patients with growth chart data, 16 fell into the first quartile of the growth chart, whereas none fell between the 75th and 100th percentile. In conclusion, this initial series of 26 patients along with the updated additional series of 12 patients is the largest series thus far reported in the literature. All 38 patients represent the characteristics of recurrent tracheoesophageal fistulas, including techniques to make the diagnosis and to provide a secure closure of the fistula, and the long-term outcomes of these patients.     

Esophageal surgery in newborns,infants and children

The most common surgery on the esophagus by pediatric surgeons the world over is performed in the newborn period in babies with congenital esophageal atresia with tracheo-esophageal fistula. Post-operative complications like recurrent fistula, anastomotic stricture and some patients with gastroesophageal reflux would also require surgical intervention. Apart from esophageal dilatation, gastrostomy and feeding jejunostomy, children with strictures secondary to caustic ingestion, reflux or previous esophageal anastomosis may require esophageal substitution. This operation may also be required in babies with pure esophageal atresia as well as those with a long gap esophageal atresia with fistula. The entire stomach, stomach tubes, colon or jejunum are often used but techniques preserving as much of the original esophagus as possible are preferable and more physiological. Surgery is also required in children with congenital esophageal stenosis and duplication cyst.     

小儿先天性H型气管食管瘘的诊断与治疗

目的总结先天性H型气管食管瘘的诊治经验。方法收集本院近10年来收治的8例先天性H型气管食管瘘患儿临床资料,其中男性5例,女性3例,通过食管造影确诊5例,胸部CT±气道重建确诊1例,纤维支气管镜确诊1例,瘘管切断缝合术6例。结果 8例均手术治疗痊愈,1例术后第4天出现气胸、纵隔气肿,经保守治疗痊愈。随访3个月至9年,1例术后1个月复发,经再次手术治疗痊愈。结论先天性H型气管食管瘘诊断困难,对临床表现可疑者可通过多种检查方式获得诊断,瘘管切断缝合术可取得良好的治疗效果。     

Elective, postoperative ventilation in the management of esophageal atresia and tracheoesophageal fistula

The management of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) has undergone many changes. As a result of recent advances in neonatal intensive care and pediatric anesthesia, the survival of infants with EA and TEF has improved markedly, but the occurrence of anastomosic complications has remained constant. To overcome this problem, various techniques and suture materials have been used. This review of 20 consecutive cases of EA/TEF stresses the importance and influence of non-reversal of anesthesia, paralysis, and elective ventilation for protection of the esophageal anastomosis following repair of EA and TEF.