congenital esophageal atresia
Introduction
Introduction to congenital esophageal atresia Congenital esophageal atresia and esophageal tracheal fistula (tracheoesophagealfistula) are not uncommon in the neonatal period. According to domestic statistics, the incidence rate is 1 in 2000 to 4500 newborns, similar to the foreign incidence rate (2500 to 3000 newborns). There is one case), which is the third place in the digestive tract developmental malformation, second only to anorectal malformation and congenital megacolon. The incidence of boys is slightly higher than that of girls. In the past, children with this disease died more than a few days after birth. In recent years, due to the development of pediatric surgery, the success rate of surgical treatment has increased. basic knowledge The proportion of illness: 0.002% Susceptible population: newborn Mode of infection: non-infectious Complications: pneumonia, pneumothorax, esophageal perforation, pleural effusion, intestinal fistula
Cause
Congenital esophageal atresia
Cause (45%):
The esophagus and trachea in the early stage of the embryo are all produced by the original foregut. The two are in common. At 5-6 weeks, the mesoderm grows in a mediastinum. The esophageal trachea is separated, the ventral side is the trachea, the dorsal side is the esophagus, and the esophagus passes through a tube. In the consolidation stage, the epithelial cells in the tube proliferate and proliferate, so that the esophagus is occluded, and then there are vacuoles in the tube, which fuse with each other, and the esophagus is re-conducted into a hollow tube. If the embryo develops abnormally in the first 8 weeks, separation and cavitation may be incomplete. Caused by different types of malformations, some people think that it is related to vascular abnormalities, the supply of foregut blood flow is reduced, can cause atresia, older mothers, low birth weight children are prone to occur, and 1/3 are premature infants.
Pathogenesis (15%) :
Esophageal atresia often coincides with esophageal tracheal fistula, accounting for about 90%. In rare cases, there are no fistulas, which can be divided into five types.
1. Type I: the upper and lower esophagus are not connected, each is blinded, the distance between the two segments varies, the same with the trachea, no esophageal tracheal fistula, can occur in any part of the esophagus, the upper part of the esophagus is often located T3 ~ T4 level, the lower part of the blind end is more on the sputum, this type is less common, accounting for 4% to 8%.
2. Type II: The upper part of the esophagus communicates with the trachea, forming an esophageal tracheal fistula, the lower part is a blind end, and the two sections are far apart. This type is less common, accounting for 0.5% to 1%.
3. Type III: The upper part of the esophagus is a blind tube, and the lower part is connected with the trachea. The point of communication is generally at the bifurcation of the trachea or slightly above it. The distance between the two sections is more than 2cm, and the type is called A type. Type, this type is the most common, accounting for 85% to 90% or more.
4. Type IV: The upper and lower segments of the esophagus are connected to the trachea respectively, which is also a rare type, accounting for 1%.
5.V type: no esophageal atresia, but there is a sputum and tracheal communication, also known as H-type, for simple esophageal tracheal fistula, accounting for 2% to 5%.
Due to the above different pathological conditions, pediatric oral secretions or emulsions accumulate in the upper pocket of the esophagus, can be returned to the pharynx, inhaled into the respiratory tract, esophagus and trachea can be directly into the trachea, the lower esophagus and the trachea can communicate, gastric juice can be Inverse flow into the trachea, and finally can cause aspiration pneumonia, esophageal atresia is also combined with other malformations, accounting for about 50%, the first type is most likely to occur, to congenital heart disease (19% to 35%), intestinal atresia, anus Atresia (20% to 40%) is the most common, followed by genitourinary system (10% to 15%), musculoskeletal system, facial (rabbit, cleft palate), central nervous system malformation, and some of the above malformations are life-threatening or urgent. Surgery.
Prevention
Congenital esophageal atresia prevention
The treatment of this disease is a fundamental measure. In prevention, it is mainly to achieve early detection, early diagnosis, early treatment, pregnant women with excessive amniotic fluid should be alert to the possibility of congenital malformation, amniocentesis and amniotic fluid alpha-fetoprotein The simultaneous increase of acetylcholinesterase is helpful for prenatal diagnosis. If you see too much saliva in the newborn, you should always be attracted. You should be highly alert to the possibility of this disease. At this time, you should avoid the so-called "diagnostic feeding", but you should take the esophagus intubation. Check to avoid pneumonia and confirm the diagnosis as soon as possible.
In the esophagography, the use of tincture should not be used to avoid silicosis. Generally, water-soluble iodine can be used. The amount of the agent should be low. The developer should be slowly injected into the blind end by the catheter. The developer should be absorbed immediately after the film to prevent pneumonia.
Complication
Congenital esophageal atresia Complications pneumonitis, pneumothorax, perforation, pleural effusion, intestinal fistula
Early prevention, early diagnosis and careful treatment are prerequisites for reducing postoperative complications. Complications are mainly anastomotic leakage, stenosis, recurrence of hernia, especially attention should be paid to the prevention and treatment of anastomotic leakage, which is the most common and dangerous after operation. Complications, common complications:
1. Pneumonia.
2. Pneumothorax.
3. Esophageal perforation, often due to esophageal anastomosis infection ulceration perforation.
4. Pleural effusion or suppurative pleurisy requires closed drainage.
5. Esophageal anastomosis and stomach, intestinal fistula.
6. Recurrence of esophageal tracheal fistula, the following symptoms should be suspected of recurrence of sputum: cough after eating, suffocation and cyanosis, increased saliva; dysphagia with abdominal distension, recurrent pneumonia, general condition worse, weight does not increase.
7. Anastomotic stenosis, prevention method can start dilating esophagus or local injection of hormone in the early postoperative period (10-14 days).
8. Long-term comorbidities, such as tracheal softening, gastroesophageal reflux disease, bronchitis and mental retardation, chest deformity and breast asymmetry are all related to developmental malformations, and the incidence of pulmonary dysfunction is higher, secondary to Repeated gastroesophageal reflux caused by Filler (1976) and Schuartz (1980) were aortic fixation, which was to suture the horizontal part of the aortic arch to the sternum to treat tracheal softening and dyspnea after surgery. Most of the cases reported so far have been successful.
Symptom
Congenital esophageal atresia symptoms Common symptoms Decreased esophageal atresia dehydration frequent vomiting white foam cough bloating dyspnea breathing suffocation mouth spit white foam amniotic fluid
Because the esophageal atresia can not swallow amniotic fluid, the mother often has a history of polyhydramnios, accounting for 19% to 90%. After the birth of the child, saliva increases, constantly overflowing from the mouth, frequent foaming, because the pharynx is full of sticky secretions, breathing When the pharynx can have a snoring sound, breathing is not good, often in the first feeding or feeding water, swallowing a few mouthfuls will start vomiting, because the esophagus and the stomach are not connected, mostly non-spray, because the milk is inhaled and filled with blindness The bag, which flows back into the trachea through the throat, causes cough and bruising, and even suffocation, and the breathing stops. However, the symptoms disappear after the vomit is quickly cleared. After that, the same symptoms occur every time the breastfeeds, and the abdomen without a trachea is a boat. Patients with tracheal fistula enter the stomach due to a large amount of air, and the abdominal distension is more obvious. In the first few days, the fetus will be discharged, but only the intestinal secretion will be discharged later, and dehydration and weight loss will occur soon. It is easy to have secondary aspiration pneumonia, often invading the right upper lobe. There may be symptoms such as fever, shortness of breath, and difficulty in breathing. If early diagnosis and treatment are not available, most cases will die within 3 to 5 days .
Examine
Congenital esophageal atresia
1. X-ray and endoscopy X-ray examination is simple and accurate, and has a decisive diagnostic significance for the disease. It should be routinely seen or photographed in the chest and abdomen. If there is no gas in the abdomen, it is characterized by esophageal atresia; if there is esophageal fistula There may be gas accumulation in the stomach and intestine. Therefore, gas in the abdominal cavity cannot completely exclude esophageal atresia. If neonates develop pneumonia complicated with atelectasis, especially the right upper lobe atelectasis, most of them are type III esophageal atresia. There may be a large amount of gas in the gastrointestinal tract. The chest anterior piece shows the proximal end of the inflated body. When inserted into the stomach tube, it is blocked and folded back. The lateral piece shows the inflated blind end and forms a shallow arc-shaped impression on the trachea. Oil angiography may cause inhalation of pneumonia, and it is often unnecessary. Barium meal inspection should be contraindicated.
2. Some scholars use endoscopy to diagnose the disease. In order to facilitate the discovery of the fistula, a small amount of blueberry is dripped from the trachea, and then the blue part is observed from the esophagoscope; or a little blue is swallowed first, then the fiberoptic bronchoscope is used. Finding the blue appearing site from the tracheobronchial to determine the fistula and its location, Cudmore (1990) reported that it is quite safe to use an autoclaved micronized methylcellulose suspension of methylcellulose (0.5 ml) for imaging. Active fluorescent imaging can also be used to diagnose primary or recurrent tracheoesophageal fistula, umbilical angiography to confirm the diagnosis of right aortic arch and CT, etc. It is worth noting that the mucus in the blind end should be exhausted before the examination, and ready to be prepared. Give oxygen, suck "" and keep warm.
Diagnosis
Diagnosis and diagnosis of congenital esophageal atresia
In the diagnosis, it is important to identify different types of esophageal atresia. Congenital esophageal atresia can be divided into five types according to the position of the esophageal atresia and whether there is an esophageal fistula.
1. The proximal part of the esophagus is a blind end, and the distal part opens into the posterior wall of the trachea to form an esophageal tracheal fistula. According to Holder statistics, this type is the most common, accounting for 86.5%.
2. The proximal part of the esophagus enters the posterior wall of the trachea, forming an esophageal tracheal fistula, and the distal end is a blind end. This type is rare, accounting for about 0.8%.
3. The proximal and distal esophagus are blind ends, no airway, no esophageal tracheal fistula. This type accounts for 7.7%.
4. The proximal and distal segments of the esophagus are respectively introduced into the posterior wall of the trachea to form two tracheal esophageal fistulas. This type is also rare, accounting for 0.7%.
5. The esophageal lumen is unobstructed and there is no occlusion, but the anterior wall of the esophagus communicates with the posterior wall of the trachea, forming an esophageal tracheal fistula, accounting for 4.2%.
