目的 探讨胸腔镜下手术矫治Ⅲ型食管闭锁的疗效. 方法 回顾性分析我院2013年6月~2016年10月经胸腔镜手术治疗30例Ⅲ型食管闭锁的临床资料.手术年龄1~11 d,平均3.2 d;出生体重1700~3700 g,平均2827.5 g.术前造影检查提示食管近端盲端在T2水平15例,T3~T4水平15例.术前合并肺炎15例(其中4例需呼吸机辅助通气),先天性心脏病17例(其中肺动脉高压3例,永存左上腔静脉1例),肛门闭锁2例.均采用三孔法,在胸腔镜下完成气管食管瘘修补+食管端端吻合术. 结果 术中证实ⅢA型12例,ⅢB型18例.手术时间100~300 min,平均190 min,术中出血<5 ml,无中转开胸手术.29例顺利经胸腔镜一期完成手术;1例33周早产儿因重症肺炎一期仅行胸腔镜下气管食管瘘修补术,延期3周在胸腔镜下完成食管端端吻合术.术后2例放弃治疗死亡,余28例治愈出院.28例术后呼吸机使用时间2~14 d,平均4.2 d.术后住院时间7~30 d,平均15.8 d.28例中术后败血症5例,化脓性脑膜炎2例,均治愈.吻合口漏7例,保守治疗1~3周治愈.28例术后随访3~43个月,平均13.8月.吻合口狭窄11例,扩张2~6次缓解;气管食管瘘复发1例,再次手术修补成功;严重胃食管反流1例,再次腹腔镜下Nissen术. 结论 胸腔镜治疗Ⅲ型食管闭锁安全,有效,切口美观,能够达到微创效果.%Objective To discuss the efficacy of thoracoscopic surgical repair of type Ⅲ esophageal atresia (EA).Methods A retrospective review of 30 neonates undergoing thoracoscopic repair of type Ⅲ EA from June 2013 to October 2016 was performed in our institute.The average age was 3.2 d (range, 1-11 d) and the average weight was 2827.5 g (range, 1700-3700 g).Proximal esophageal blind sides were diagnosed at the T2 level by imaging examination preoperatively in 15 cases, and were at the T3-T4 level in remaining 15 cases.Before operation, 15 cases were diagnosed as having complication of pneumonia (4 severe cases need mechanical ventilation), 17 cases having congenital heart disease (including 3 cases of pulmonary arterial hypertension and 1 cases of persistent left superior vena cava), and 2 cases having anal atresia.All the patients were performed with three-pole method, and were given the repair of esophagotracheal fistula and esophageal end to end anastomosis.Results Confirmative diagnosis of type ⅢA was conducted during the operation in 12 cases, and type ⅢB in 18 cases.The average operation time was 190 min (range, 100-300 min).The amount of bleeding was < 5 ml.Twenty-nine patients underwent the one stage operation by thoracoscope successfully.One case of 33 weeks premature infant did not tolerate anesthesia due to severe pneumonia, so the repair of esophagotracheal fistula and the esophageal end to end anastomosis were performed at an interval of 3 weeks.Except for 2 patients who gave up treatment, the remaining 28 patients recovered successfully.The average time of mechanical ventilation was 4.2 d (range, 2-14 d), and average duration of hospital stay was 15.8 d (range, 7-30 d).Five patients with the complication of septicemia and 2 of purulent meningitis postoperatively were all cured.Anastomotic leakage occurred in 7 cases, and they were cured after 1-3 weeks of conservative treatment.A total of 28 cases were followed up postnatally for 3-43 months (mean,13.8 months).There were 11 cases of anastomotic stenosis which were given expansion 2-6 times until release and 1 case of esophagotracheal fistula relapse which fully recovered after surgical repair.Severe gastroesophageal reflux occurred in 1 case, and laparoscopic Nissen fundoplication was performed.Conclusion The thoracoscopic repair of type Ⅲ EA is a safe and feasible approach, which also has the advantages of reduced trauma, improved cosmetic results and fast recovery after operation.
展开▼
