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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。

新生儿先天性食管闭锁/气管食管瘘麻醉策略的改进

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.

重症烧伤并呼吸道吸入性损伤作气管切开致气管食管瘘一例

The application value of spiral CT postprocessing technique in airway stenting technique

Objective To investigate the application value of spiral CT postprocessing technique in the airway stent implantation technology. Methods Twenty-three patients with malignant airway stenosis or malignant tracheoesophageal fistula who needed the treatment of airway stent implantation from May 2012 to April 2016 were collected, including 19 males and 4 females with an average age of (61.6±10.0) years. Bronchoscopy and spiral CT with three-dimensional airway reconstruction were proceeded for the same patients before and after stent implantation, and the relevant data about narrow airway was measured by volume rendering, multiplanar reformation (MPR) and CT virtual endoscopy (CTVE) in a variety of ways, to confirm the location and size of narrow airway and fistulas, the degree and length of airway stenosis, as well as the distal end of the situation, and evaluate the patency of airway, the position and shape of stents, adjacent airway and complications after stenting. The positive forecast outcomes of the two inspections wascompared. Results Airway stents were placed successfully according to the data from the spiral CT airway three-dimensional reconstruction. Thirty stents were implantated in the 23 patients, including 21 column-type stents, 3 L-type stents, and 6 Y-type stents. All stents stayed in situ, with patency and no deformation.The fistulas were closed and the airways were reopened. Symptoms of cough after eating and drinking and dyspnea were relieved. The positive rates of bronchoscopy and CT examination on diagnosis of airway stenosis were both 100% (23/23). Complications: MRP showed tumor growth leading to stenosis again in 3 patients, and CTVE displayed mucous congestion in 2 patients. Conclusions The technique of 64-layer spiral CT postprocessing technique can measure the relate data of airway stricture or fistulas as a kind of convenient, quick, accurate, and noninvasive method in patients with malignant airway stenosis or tracheoesophageal fistula who need the treatment of airway stenting. It is of high reference value both to airway stent implanting and postoperative observation, and is worthy of application.

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.

Pedicled latissimus dorsi myocutaneous flap for treatment of acquired tracheo-esophageal fistula combined with tracheocutaneous fistula: A case report

We reported a patient intubated for more than 30 d following brain injury, transferred to our department with tracheocutaneous fistula and a 2 cm fistula between the trachea and the esophagus. We performed tracheal resection and esophageal closure with a latissimus dorsi myocutaneous flap interposed between suture lines. The patient continued mechanical ventilation after surgery and the tracheotomy was achieved 14 d after the beginning of surgical treatment. The patient was started oral feeding and discharged on the 10 d after tracheotomy and referred to a neuromotor recovery clinic for treatment of post-traumatic sequelae.

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。

自膨式金属支架对恶性气道疾病的疗效及影响术后生存的因素分析

目的 探讨自膨式金属支架（self-expandable metallic stent，SEMS）治疗恶性气道疾病的疗效及影响支架置入术后生存的因素。方法 2020年2月—2022年6月在广安市人民医院住院治疗的恶性气道疾病患者，根据CSCO指南对患者进行抗肿瘤治疗的基础上，行SEMS置入治疗，收集患者的临床资料。数据用SPSS 23.0进行分析。P<0.05具有统计学意义。结果 共纳入54例患者，其中恶性中央气道狭窄（malignant central airway obstruction，MCAO）40例和恶性气管食管瘘（malignant tracheoesophageal fistula，MTEF）14例；咳嗽和呼吸困难为主要的临床表现；最常见的原发疾病为食管鳞状细胞癌、其次为肺鳞状细胞癌；合并肺炎的患者占87%，痰培养中最常见的病原菌为革兰阴性杆菌，其次为真菌。共置入支架58枚，其中直筒支架42枚、Y型支架16枚；支架置入后，气道狭窄程度较支架置入前明显改善，气促分级明显低于支架置入前，第一秒用力呼气容积明显高于支架置入前（P<0.05）；SEMS置入后症状改善率为94.4%；3个月后总生存率为70.4%。多因素分析显示C反应蛋白浓度［OR=1.011，95%CI（1.001～1.020），P=0.016］为SEMS置入3个月后恶性气道疾病死亡的独立危险因素，白蛋白水平［OR=0.883，95%CI（0.781～0.997），P=0.045］为保护性因素。结论 SEMS在恶性气道疾病姑息性治疗中起着重要作用；支架置入前感染的有效控制、营养状况的改善对术后生存有利。