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食管异物及合并主动脉食管瘘的诊断与治疗

目的探讨食管异物所致主动脉食管瘘的诊断及治疗方法。 方法回顾性分析2004年1月至2012年12月南昌大学第二附属医院32例异物性食管损伤患者的诊断和治疗经验。其中男21例、女11例，年龄18～78岁。采用多层螺旋CT（MSCT）及其影像后处理对食管异物病理变化进行准确分级；对主动脉食管瘘的患者采用包括杂交技术（覆膜支架腔内隔绝术＋胸腔镜纵隔引流术）为主的治疗方案，总结MSCT和杂交技术在异物性主动脉食管瘘诊疗中的应用价值。 结果平扫影像诊断与临床诊断符合率为75%（24/32），影像后处理诊断与临床诊断符合率为100%（17/17）。MSCT分级所有Ⅰ级、Ⅱ级和Ⅲ级患者均治愈出院，4例Ⅳ级患者采用杂交技术治疗；7例Ⅳ级主动脉食管瘘患者中有5例痊愈出院，2例死亡，因开胸行主动脉修补术中死亡1例，开胸行主动脉置换术后24 h内死亡1例。30例痊愈出院患者随访6个月，除1例Ⅳ级患者有轻微背痛以外，其他患者无不适。 结论MSCT对食管异物性损伤的准确分级和治疗方式选择均有重要的价值，杂交技术治疗异物性主动脉食管瘘具有重要的临床意义。

新生儿先天性食管闭锁/气管食管瘘麻醉策略的改进

应用带膜镍钛记忆合金支架治疗晚期食管癌

目的总结应用带膜镍钛记忆合金支架治疗晚期食管癌的临床经验。方法53例晚期食管癌患者在食管X线钡餐透视下采用介入法、内镜法或术中植入法在食管内放置带膜镍钛记忆合金支架。术后进食困难程度用Neuhaus分级评估，并随访观察所有患者近期和远期疗效。结果所有患者支架均一次放置成功，无操作引起的严重并发症，术后患者吞咽困难症状明显改善，置入支架后患者吞咽困难分级较置入支架前明显降低（P〈0．01），能顺利进半流质或普通食物。狭窄食管段直径由2～4mm扩张至16～20mm。随访49例（92．5%），随访时间3～24个月。术后近期并发症主要为胸骨后异物感、疼痛、恶心和少量消化道出血，发生率为96．2％（51／5a）。26例患者（53．1％，26／49）于术后3～15个月内死亡，平均生存7．8个月，死亡原因多为肿瘤转移、全身衰竭。结论食管内放置带膜镍钛记忆合金支架治疗晚期食管癌患者的食管狭窄、食管瘘简单易行、损伤小，近期疗效明显，是一种有效的姑息性非手术治疗方法。

胸食管异物损伤的临床诊断与治疗

目的　探讨提高胸食管异物损伤诊断及治疗效果的方法。　方法　回顾性分析九江学院附属医院2004年5月至2011年10月26例胸食管异物损伤患者的临床资料，其中男18例，女8例；年龄41.2 （18～70）岁。通过多层螺旋CT （MSCT）成像结合临床特征判断其病理类型，采用胃镜异物取出11例，全身麻醉下胃镜异物取出5例，行开胸手术8例，主动脉覆膜支架腔内隔绝2例。　结果　Ⅰ类损伤10例，Ⅱ类损伤5例，Ⅲ类损伤6例，Ⅳ类损伤5例。20例有异物，6例无异物；24例治愈，2例死亡， 分别因血管置换术中出血及血管修补术后再出血死亡。　结论　依据MSCT成像结合临床特征及病史，明确胸食管异物损伤的诊断及病理类型，采取多学科合作的合理治疗方法，能明显提高胸食管异物损伤的诊疗效果。

支气管胸膜瘘、气管食管瘘一例

临床资料 患者男性, 88 岁。因“咳嗽、咳痰、喘憋40余年, 加重伴发热3 d”入院。住院前3 d 因受凉感冒, 有痰不易咳出, 出现意识不清, 血氧、血压下降给予紧急气管插管和呼吸机辅助呼吸, 由急诊收入重症监护室。既往高血压病史, 血压控制不良。入院查体: T 36. 8 ℃, R 25 次/min, P 87 次/min, BP90/60 mmHg( 1 mmHg = 0. 133 kPa) 。神清,精神弱, 双肺呼吸音粗, 双肺可闻及少许干湿啰音, 心律齐,腹软, 双下肢无水肿。

支气管镜联合消化内镜成功治疗食管癌术后气管食管瘘和胃底胸膜瘘一例

目的 探索气管食管瘘及胃底胸膜瘘的临床救治方法。方法 回顾分析我院呼吸与危重症医学科经支气管镜联合消化内镜成功治疗食管癌术后气管食管瘘和胃底胸膜瘘1例。结果 患者男，64岁，因“进食后胸痛3周余”于2021年6月21日入胸外科，23日胃镜示食管中段新生物，病理为中分化鳞癌，25日行胸腔镜下右胸腹两切口食道癌根治术。术后第4天患者出现胸痛伴发热，7月5日胸部CT示左侧液气胸，胸腔镜探查术置管引流后脱机困难，10日转入呼吸与危重症医学科，数字减影血管造影下介入和气管镜检查明确诊断气管食管瘘和胃底胸膜瘘，保守治疗1个月效果不佳，经多学科讨论后先行气管镜引导下气道Y型覆膜支架植入封堵术，后行胃镜下氩离子束凝固术烧灼+气管食管瘘和胃底胸膜瘘钛夹夹闭术。患者术后痰量减少，无发热，复查CT两肺感染和胸腔积液明显吸收，消化道造影未见钡餐外溢现象，患者顺利脱机堵管，拔除气切套管后康复出院，门诊随访病情稳定。结论 食管癌术后短期内同时出现气管食管瘘和胃底胸膜瘘，实属罕见，救治难度较大。该患者的成功救治说明支气管镜联合消化内镜是治疗气管食管瘘和胃底胸膜瘘的有效方法，值得借鉴和推广。

Surgical Intervention of Iatrogenic Tracheobronchoesophageal Fistula

Abstract： Objective To investigate the cause and treatment of iatrogenic tracheobronchoesophageal fistula and provide experiences for clinic treatment. Methods Between January 1995 to December 2008, 21 patients with tracheobronchoesophageal fistula were treated in Shanghai Chest Hospital and Shanghai 6th Hospital. Among them, iatrogenic fistula happened in 12 patients including 8 males and 4 females whose age ranged from 35 to 74 years old with an average age of 47. Fistula developed 21 d to 5 years after the treatment of the primary diseases which were mainly tumors. Two of them developed tracheoesophageal fistula, 10 bronchoesophageal fistula; 6 right bronchoesophageal fistula, and 4 left bronchoesophageal fistula. Fistula excision and surgical repair of the tracheobronchoesophageal fistula were performed on 2 patients; Lung lobectomy and repair of the esophageal fistula were performed on 5 patients; Tracheal fistula repair and pneumonectomy with reconstruction of the digestive tract were done on the rest 5 patients. Results No operative death occurred. Postoperative complications in 2 cases were cured without recurrence. In the 1year followup to all the 12 patients, no recurrence of fistula occurred. Conclusion Iatrogenic tracheobronchoesophageal fistula is a complex and severe disease for which surgery is the only best treatment.

Clinical efficacy of stapler technique for repair of cervical tracheoesophageal fistula

Objective To evaluate the clinical efficacy of fistula repair by stapler technique in patients with cervical tracheoesophageal fistula. Methods Retrospective analysis of 8 patients with cervical tracheoesophageal fistula who accepted operative treatment in the Department of Thoracic Surgery, Lanzhou University Second Hospital from October 2014 to October 2016 was conducted. There were 5 males and 3 females at a mean age of 46.4±13.9 years ranging from 23 to 67 years. The fistula was induced by tracheal intubation in 4 patients, by esophageal foreign bodies in 2, by tracheal stent in 1 and by esophageal diverticulum in 1. The fistula was closed by stapler technique. The surgical effects were evaluated through Karnofsky performance score (KPS), image assessment, patient satisfaction score and assessment of improvement in feeding-induced bucking. Results The operations were performed successfully with time of 117.5±6.6 min and intraoperative blood loss of 60.0±7.0 ml. After the operations, the patients did not suffer incision bleeding and infection, hoarseness, dyspnea, drinking-induced bucking, fistula relapse, tracheoesophageal stenosis or any other complications, and no death occurred during the perioperative period. The chest X-ray test was performed 1 week later showed that the pulmonary infection disappeared, and only 1 patient suffered from esophageal stenosis 1 year later. The postoperative KPS score was 90.0±7.0 points, which significantly improved in contrast to preoperation (P<0.01). Postoperative pulmonary infection area reduced significantly (P<0.05), tracheoesophageal fistula disappeared, postoperative patients satisfaction rate was 90%, and assessment of feeding-induced bucking was excellent. Conclusion Using stapler technique to repair cervical tracheoesophageal fistula is safe, easy and useful, with less operation time and postoperative complications.

Research progress of endoscopic vacuum-assisted closure therapy for esophageal fistulas

How to effectively repair esophageal fistulas, caused by esophageal perforation, rupture and anastomotic leakage after esophagectomy has always been a key problem for the digestive surgeon. Although there are many clinical treatment methods, the therapeutic effect is still completely unsatisfactory, especially when severe mediastinal purulent cavity infection is associated with the esophageal fistula. In recent years, foreign centers have promoted a new minimally invasive endoscopic treatment technology to repair the esophageal fistula, endoscopic vacuum-assisted closure therapy, with significantly curative effect. In this article, we will review the specific operation, advantages and disadvantages, as well as the clinical efficacy of endoscopic vacuum-assisted closure therapy in treating the esophageal fistulas, to provide a new therapeutic technique for esophageal fistulas and expand the new field of minimally invasive endoscopic therapy.

体外膜肺氧合支持下修补严重气管食管瘘一例