摘要
目的探讨颈椎前路手术后并发咽后壁及食管瘘的原因及诊治对策，并探索其防治策略。方法回顾性分析1999年3月至2010年6月收治17例颈椎前路手术后并发咽后壁及食管瘘患者的病历资料，男11例，女6例；年龄7-67岁，平均44．23岁。16例（94％）患者颈椎前路术后有切口处红肿、咽喉部疼痛，其中2例（11％）伴有高热，体温高达39．2℃，进食后切口有食物残渣及液体流出。17例均行钡餐食管造影且定期口服美蓝，其中7例（41％）患者口服美蓝后由切口流出；2例（11％）钡餐食管造影后有钡剂从瘘口溢出。14例（82％）瘘口明显者x线检查示椎前气体影。行钡餐食管造影或口服美蓝后由瘘口流出即可明确诊断；对于诊断不明但高度怀疑咽后壁及食管损伤者予禁食水、鼻饲或静脉营养、抗感染治疗1周后症状无改善者行手术探查确诊。结果17例患者均行手术治疗，术中见瘘口呈点状或小的不规形8例，长条状3例，瘘口边界不清、不规则2例，瘘口周围与颈椎前筋膜粘连、类似于撕裂口1例，有2处瘘口者1例，咽后壁及食管瘘口显露不清或不明原因2例（考虑瘘口可能不在切口同侧或较小已开始闭合）。3例探查术中发现咽后壁及食管瘘，立即给予缝合、放置引流管，7-14d后引流量〈30ml，连续3次引流液无细菌生长，拔出引流管；术后鼻饲2-3周改为流食，无不适，1个月后治愈。12例一期清创、瘘口缝合、放置冲洗及引流管，冲洗12-21d后连续3次引流液无细菌生长后先拔出冲洗管，2-3d后拔出引流管，2-3个月后痊愈。2例一期清创、瘘口缝合或部分缝合后切口敞开、呋南西林纱条填塞，逐步拔出填塞纱布、换药，残腔较大或引流脓性者，每日1次生理盐水冲洗伤口，逐步改为每周3次至每周1次，6-12个月伤口完全愈合。所有患者因发现咽后壁及食管瘘较及时，且积极给予手术治疗，术后无明显相关并发症。17例患者术后1-12个月均痊愈，恢复进食。结论颈椎前路手术后一旦发生咽后壁及食管瘘严重影响手术疗效甚至导致死亡，如果发生应及早确诊并积极干预治疗，可获得满意疗效。
Objective To investigate the diagnosis, treatment and prevention strategies of pharyngostoma and esophagostoma caused by anterior cervical spine surgery. Methods A retrospective analysis were performed in 17 cases of anterior cervical operation complicated with pharyngeal and esophageal fistula from 1999 March to 2010 June, including 11 male cases and 6 female cases, aged from 7 to 67 years with the mean age of 44.23 years. 16 cases （94%） got inflammation of anterior cervical surgery incision and throat pain. 2 cases （11%） accompanied by high fever, whose body temperature was as high as 39.2~ and incision particles or liquid flew after eating. 17 cases underwent upper gastrointestinal radiography, and regular oral methylene blue. Barium overflew from fistula in 2 cases （11%） after upper gastrointestinal tract barium meal angiography, while methylene blue overflew from incision in 7 cases （41%） after oral methylene blue. Through X-ray examination, gas fistula before vertebral was visible in 14 cases （82%）. A diagnosis can be made by outflow through fistula after barium esophagography or oral administration of methylene blue. For unknown but highly suspected pharyngeal and esophageal injury, operation can be confirmed if no improvement of symp- toms was found after fasting, nasogastric or parenteral nutrition, and ant-infection treatment for 1 week. Results All of 17 pa- tients underwent surgical treatment. During operation, fistula dot or small irregular shape can be seen in 8 cases; long stripe in 3 cases; boundary not clear or irregular in 2 cases; adhesion around the fistula of anterior cervical fascia, similar to tear in 1 case; two fistula in 1 case; fistula located in pharynx posterior wall or esophageal which was not clear or fistula of unknown reason in 2 cases （fascia might be not at the same side of incision or fascia was small and already closed）. Pharynx posterior wall and esophageal fistula was found in 3 cases during surgical exploration, which was immediate sutured and placed with drainage tube. After 7 to 14 days, if flow was less than 30 ml, and no bacterial growth was found in 3 consecutive drainage fluids, we pull out the tube. Patients who underwent nasal feeding for 2 to 3 weeks, and then took liquid diets complained nothing, and cured after 1 month. 12 cases underwent debridement, stitching fistula, irrigation and drainage tube placement instantly. The wash pipe was removed after 12 to 21 days and 3 consecutive drainage fluids showed no bacterial growth. Then 2 to 3 days later the drainage pipe was pull out. Two to three months later these patients healed. 2 cases firstly underwent debridement and suture or part suture, and then the incision was opened and filled with nitrofurazonium gauze tamponade. Gradually pull out the filling gauze and change the dressing of wound. If the residual cavity was large or the drainage was pus, flush the wound with physiological saline once a day, then three times a week, and finally once a week. These patients healed after 6 to 12 months. Pharyngostoma or esophagostoma of all patients was found timely, and active surgical treatment was performed, so no obvious complications was found postoperatively. All 17 patients recovered and resumed diet after 1 to 12 months postoperatively. Conclusion Pharyngeal and esophageal fistula is a rare but severe complication after anterior cervical surgery, which seriously affect the effect of operation and even lead to death. Early diagnosis and active intervention can obtain satisfactory curative effect.
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2016年第17期1085-1092,共8页
Chinese Journal of Orthopaedics
关键词
颈椎
减压术
外科
脊柱融合术
手术后并发症
食管瘘
Cervical vertebrae
Decompression, surgical
Spinal fusion
Postoperative complications
Esophageal fistula
