长段缺失型食管闭锁延迟吻合后顽固性吻合口狭窄的风险预测指标  

Risk predictors of refractory anastomotic stricture after delayed anastomosis of long-gap esophageal atresia

作　　者：张宁 邬文杰 汤笑妤 庄雨佳 王伟鹏 潘伟华 刘丰丽 王俊 Zhang Ning;Wu Wenjie;Tang Xiaoyu;Zhuang Yujia;Wang Weipeng;Pan Weihua;Liu Fengli;Wang Jun(Department of Neonatal Surgery,Affiliated Children's Hospital,Soochow University,Suzhou 215003,China;Department of Pediatric Surgery,Affiliated Xinhua Hospital,Shanghai Jiao Tong University,Shanghai 200092,China;Department of Neonatal Surgery,Affiliated Children's Hospital,Xuzhou Medical University,Xuzhou 221000,China)

机构地区：[1]苏州大学附属儿童医院新生儿外科,苏州215003 [2]上海交通大学附属新华医院儿普外科,上海200092 [3]徐州医科大学附属徐州儿童医院新生儿外科,徐州221000

出　　处：《中华小儿外科杂志》2023年第9期800-805,共6页Chinese Journal of Pediatric Surgery

基　　金：申康临床三年行动计划疑难疾病诊治攻关项目(SHDC2020CR2063B);上海市市级医院诊疗技术推广及优化管理项目(SHDC22022306);徐州医科大学附属徐州儿童医院2022年度科研立项项目(22040417);上海交通大学医学院儿科学院儿科专业"5+3"教学科研课题(EKJX2020002DGD)。

摘　　要：目的预测长段缺失型食管闭锁延迟吻合后顽固性吻合口狭窄的风险因素,以期改善患儿预后。方法回顾性分析2015年2月至2022年1月上海交通大学附属新华医院收治的长段缺失型食管闭锁的患儿资料57例,其中男32例,女25例;中位食管扩张次数为12(0~40)次;Ⅰ型食管闭锁53例,Ⅱ型4例,分非顽固性狭窄组(30例)和顽固性狭窄组(27例)。所有患儿均通过食管内应力延长后行食管延迟吻合,记录患儿术后1个月和2个月时吻合口近远端最宽处和狭窄处直径,计算近端狭窄指数和远端狭窄指数,并比较两组患儿的基本资料、食管重建时间、术中食管近远端距离、手术并发症等。单因素分析两组差异有统计学意义的相关因素,纳入多因素logistic回归,并用受试者操作特征(receiver operating characteristic,ROC)曲线评价其准确性。结果单因素分析显示,与顽固性狭窄相关因素为:食管重建时间、术中近远端距离、留置食道引流管时间、术后2个月近端狭窄指数及远端狭窄指数、胃食管反流。通过构建logistic回归方程发现独立危险因素为:食管重建时间(P=0.014)、术中近远端距离(P=0.017)、术后2个月远端狭窄指数(P=0.028)、胃食管反流(P=0.037)。ROC曲线显示食管重建时间的曲线下面积(area under the curve,AUC)为0.694,截断值为93.5 d,敏感度为81.5%,特异度为60%(P=0.012);术中近远端距离AUC为0.687,截断值为4.65 cm,敏感度为70.4%,特异度为60%(P=0.015);术后2个月远端狭窄指数AUC为0.710,截断值为61.04,敏感度为81.5%,特异度为53.3%(P=0.007);该4个独立因素联合诊断时AUC为0.891,敏感度为74.1%,特异度为93.3%(P<0.001)。结论食管重建时间、术中近远端距离、术后2个月远端狭窄指数和胃食管反流多因素联合对长段缺失型食管闭锁延迟吻合术后顽固性吻合口狭窄有良好的预测价值,为选择有效的临床治疗方案提供依据。Objective To predict the risk factors of refractory anastomotic stricture after delayed anastomosis of long-gap esophageal atresia(LGEA)to improve its prognosis.Methods The relevant clinical data were retrospectively reviewed for 57 children hospitalized with LGEA at Affiliated Xinhua Hospital from February 2015 to January 2022.There were 32 boys and 25 girls.The median number of esophageal dilation was 12(0-40)sessions.The clinical types wereⅠ(n=53)andⅡ(n=4).They were assigned into two groups of non-refractory stenosis(n=30)and refractory stenosis(n=27).Delayed esophageal anastomosis was performed after esophageal elongation by bougienage.The widest diameters at proximal and distal ends of anastomosis and stenosis diameter were recorded at Month 1/2 postoperatively and proximal/distal stenosis parameters calculated.Basic profiles,esophageal reconstruction time,intraoperative proximal/distal distance of esophagus and surgical complications were compared between two groups.Univariate analysis was performed for the statistically significant correlation factors between two groups.Multivariate Logistic regression was employed and receiver operating characteristic(ROC)curve utilized for evaluating its accuracy.Results Univariate analysis revealed that factors related to refractory stricture included esophageal reconstruction time,intraoperative proximal/distal distance,duration of indwelling esophageal drainage tube,proximal stricture index(upper pouch stricture index,U-SI)and distal stricture index(lower pouch stricture index,L-SI)at Month 2 postoperatively and gastroesophageal reflux.By constructing Logistic regression equation,independent risk factors included esophageal reconstruction time(P=0.014),proximal/distal distance during operation(P=0.017),L-SI at Month 2 postoperatively(P=0.028)and gastroesophageal reflux(P=0.037).ROC curve indicated that esophageal reconstruction time AUC was 0.694 with a cutoff value of 93.5 days,a sensitivity of 81.5%and a specificity of 60%,intraoperative proximal/distal distance

关 键 词：食管闭锁 吻合口 狭窄 风险因素 

分 类 号：R726.5[医药卫生—儿科]