双镜联合治疗胸段食管异物的临床研究

Thoracoscope-gastroscope dual-scope method in the treatment of thoracic esophageal foreign bodies：a clinical feasibility trial

摘要:

目的：探讨双镜联合方法在治疗胸段食管异物中的可行性。方法：73例患者分成34例经典手术组（经典组）和39例双镜联合手术组（双镜组）。经典组做20 cm长皮肤切口，经第5肋间进胸，游离、切开食管取出异物；双镜组经右胸做4个肋间小切口，经口放置胃镜，在胃镜光源引导下游离、切开食管，取出异物。出现主动脉食管瘘患者，在经典组先行主动脉腔内隔绝术（thoracic endovascular aortic repair，TEVAR），再开胸行食管异物清除、食管修补和动脉止血，而在双镜组用胃镜取出异物同时行TEVAR，再在电视胸腔镜辅助（video-assisted thoracoscopic surgery，VATS）下行食管修补。结果：CT诊断食管异物的准确率为100%，诊断食管肌层损伤准确率为90.41%。经典组手术时间100（90，135） min，术中出血量200（150，300） mL；双镜组手术时间90（90，110）min，术中出血量200（150，300） mL，2组间手术时间和术中出血量比较差异无统计学意义。经典组术后发生食管瘘11例，肺炎6例；双镜组发生食管瘘1例，肺炎4例，2组间发生食管瘘并发症比较差异有统计学意义，发生肺炎并发症比较差异无统计学意义。3例患者出现主动脉食管瘘（经典组1例，双镜组2例），经典组患者经TEVAR后死亡，而双镜组患者经胃镜清除异物和同时行TEVAR术后顺利康复出院。对发生食管瘘的高危因素进行logistic回归分析，发现手术方法、病程、年龄是发生食管瘘的高危因素，回归系数分别为-92.538、11.973、1.783。结论：双镜联合手术可减少清除食管异物手术的并发症。【关键词】食管异物；双镜联合；主动脉腔内隔绝术

Abstract:

Objective：To investigate the feasibility of a dual-scope method in the treatment of thoracic esophageal foreign bodies. Methods：73 patients were divided to a traditional surgery group（n=34） and a dual-scope surgery group（n=39）. In the traditional group，a 20cm skin incision was made above the 5th intercostal space，through which the researcher entered the chest，dissociated and cut open the esophagus，and then removed the esophageal foreign body. Four intercostal incisions were made in the dual-scope group. Light from the orally-inserted gastroscope was used to help the researcher dislocate and cut open the esophagus and then remove the esophageal foreign body. In the traditional group，patients with aorto-esophageal fistula were treated with thoracic endovascular aortic repair（TEVAR） first，and esophageal foreign body clearance，esophageal repair，and arterial hemostasis were performed afterwards. In the dual-scope group，TEVAR was performed simultaneously with esophageal foreign body clearance，while esophageal repair was performed later via video-assisted thoracoscopic surgery. Results：Accuracy rate of CT for diagnosis of thoracic esophageal foreign body and esophageal muscle injury was 100% and 90.41%，respectively. In traditional group operation time was 100（90，135） min，bleeding volume during operation was 200（150，300） mL. In dual-scope surgery group operation time was 90（90，110） min，bleeding volume during operation was 200（150，300） mL. There was no significant difference in operation time and bleeding volume during operation between the two groups. In the traditional group，11 cases had esophageal fistula and 6 cases had pneumonia. There were 1 case of esophageal fistula in the double-mirror group and 4 cases of pneumonia. There was a statistically significant difference in the incidence of esophageal fistula between the two groups；that of pneumonia was statistically insignificant. Aorto-esophageal fistula developed in 3 patients（1 patient in traditional group，2 patients in dual-scope group）. The patient in traditional group died after TEVAR，but the patients in the dual-scope group recovered and discharged successfully after TEVAR was performed si－multaneously with esophageal foreign body clearance. High risk factors of esophageal fistula in the thoracic esophageal foreign body patients include operation method，age，the course of disease as per results of logistic regression analysis；regression coefficients were -92.538，11.973 and 1.783，respectively. Conclusion：The dual-scope method can reduce the complications of thoracic esophageal foreign body surgery.