长段缺失型食管闭锁治疗中临床吞咽评估的应用

doi:10.12372/jcp.2023.22e1230

摘要/Abstract

摘要： 目的分析定期进行临床吞咽评估（CSE）对长段缺失型食管闭锁（LGEA）患儿24月龄内并发症及生长发育的影响。方法回顾性分析儿外科2016年1月—2022年1月进行LGEA手术患儿的临床资料。定期CSE随访的LGEA患儿纳入CSE组，未参与的纳入对照组，比较两组间并发症发生率以及24月龄内生长发育情况。结果最终纳入分析的LGEA患儿50例。CSE组患儿19例，男11例、女8例，I型16例（2例伴瘘）、Ⅱ型2例、Ⅲa型1例，产前诊断12例。对照组患儿31例，男16例、女15例，I型28例、Ⅱ型3例（2例伴瘘），产前诊断21例。CSE组平均出生体重低于对照组，食管盲端距离长于对照组，差异均有统计学意义（P<0.05）。CSE组术后到完全经口喂养的间隔天数为34.0（22.0~76.0）天，对照组为46.0（18.0~181.0）天，差异有统计学意义（Z=2.30，P=0.028）。与对照组相比，CSE组的肺部感染发生率更低，6月龄时CSE组的WAZ和LAZ更低，24月龄时CSE组的低体重和生长迟缓检出率低于对照组，差异均有统计学意义（P<0.05）。CSE组24月龄内LAZ增长值高于对照组，差异有统计学意义（P<0.05）。结论在LGEA患儿的长期治疗中定期进行CSE随访，可降低患儿24月龄内的肺部感染发生率，有利于术后早期完全经口喂养和体重身高的追赶。

关键词: 长段缺失型食管闭锁, 临床吞咽评估, 肺部感染, 营养状况

Abstract: Objective To analyze the effect of clinical swallow evaluation (CSE) on the complications and growth of children with long gap esophageal atresia (LGEA) within 24 months of age. Methods The clinical data of children who underwent LGEA surgery from January 2016 to January 2022 were retrospectively analyzed. Children with LGEA who had regular CSE follow-up were included in the CSE group and those who did not participate in CSE were included in the control group. The incidence of complications and the growth of children within 24 months were compared between the two groups. Results A total of 50 children with LGEA were included in the analysis. There were 19 children (11 boys and 8 girls) in the CSE group, including 16 cases of type Ⅰ congenital esophageal atresia (2 cases with fistula), 2 cases of type Ⅱ and 1 case of type Ⅲa. Twelve children received prenatal diagnosis. In the control group, there were 31 children (16 boys and 15 girls), including 28 cases of typeⅠand 3 cases of type Ⅱ (2 cases with fistula). Prenatal diagnosis was obtained in 21 cases. The birth weight of the CSE group was lower than that of the control group, the difference distance of the blind end of the esophagus was longer than that of the control group, and the difference was significant (P<0.05). The interval from postoperative to complete oral feeding was 34.0 (22.0-76.0) days in the CSE group and 46.0 (18.0-181.0) days in the control group, and the difference was statistically significant (Z=2.30, P=0.028). Compared with the control group, the CSE group had a lower incidence of lung infection, lower weight-for-age z score (WAZ) and lower length-for-age z score (LAZ) at 6 months. The detection rates of underweight and stunting in the CSE group at 24 months were lower than those in the control group, and the differences were statistically significant (P<0.05). The increment value of LAZ in the CSE group at 24 months was higher than that in the control group, and the difference was statistically significant (P<0.05).Conclusions Regular CSE follow-up in the long-term treatment of children with LGEA can reduce the incidence of lung infection within 24 months of age, and is conducive to early postoperative complete oral feeding and weight and height catch-up.

Key words: long-gap esophageal atresia, clinical swallow evaluation, pulmonary infection, nutritional status

王俊丽, 邬文杰, 唐春燕, 张宁, 王俊, 李斐. 长段缺失型食管闭锁治疗中临床吞咽评估的应用[J]. 临床儿科杂志, 2023, 41(1): 18-24.

WANG Junli, WU Wenjie, TANG Chunyan, ZHANG Ning, WANG Jun, LI Fei. Application of clinical swallowing evaluation in the treatment of long-gap esophageal atresia children[J]. Journal of Clinical Pediatrics, 2023, 41(1): 18-24.

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措施		目标
评估喂养表现	照顾者访谈：喂养史和当前喂养状态	确定影响标准喂养进展和期望的问题及障碍：弄清楚喂养困难的开始时间，是持续性还是急性；提供当前有关用餐时间安排、地点、具体策略、经口和肠内摄入的信息
评估喂养表现	直接评估：口腔外周检查，口腔喂养技能，治疗试验	确定吞咽的结构和功能是否存在问题，识别技能病因；提供用餐时间有关技能贡献、障碍和亲子互动的信息
筛查/识别潜在危险	①吞咽 ②呼吸 ③胃肠道/营养 ④神经系统 ⑤其他医疗 ⑥发育	确定仪器评估的必要性；确定喂养困难的潜在危险因素
咨询、推荐和治疗计划		就病因、预后、饮食和治疗需求为照顾人员提供咨询/教育；制定喂养计划（儿童安全有效地饮食）；制定治疗计划（提高饮食和技能的推荐目标和策略）；进行转诊（仪器性吞咽评估或其他医疗转诊）

项目	CSE组(n=19)	对照组(n=31)	统计量	P
男性[n(%)]	11(57.9)	16(51.6)	χ²=0.19	0.665
胎龄(x±s)/周	37.3±1.0	37.6±1.9	t=0.50	0.772
早产儿[n(%)]	9(47.4)	15(48.4)	χ²=0.01	0.944
出生体重(x±s)/g	2 337.1±390.2	2 686.1±490.7	t=2.63	0.011
产前诊断[n(%)]	12(63.2)	21(67.7)	χ²=0.11	0.740
合并症[n(%)]
心脏畸形	4(21.1)	5(16.1)	χ²=0.19	0.660
肛门闭锁	2(10.5)	2(6.5)	χ²=0.00	1.000
胃肠道畸形	2(10.5)	1(3.2)	χ²=0.20	0.659
泌尿系统缺陷	1(21.1)	3(9.7)	χ²=0.00	0.983
骨骼肌肉畸形	2(11.1)	3(9.7)	χ²=0.00	1.000
腭裂	1(5.3)	0(0)	-	0.380³⁾
甲减	1(5.3)	0(0)	-	0.380³⁾
胃造瘘¹⁾[n(%)]	18(94.7)	31(100)	-	0.380³⁾
根治术时食管盲端距离²⁾(x±s)/cm	5.4±1.0	4.6±1.3	t=2.09	0.042
食管吻合术入路为胸腔镜[n(%)]	17(89.5)	31(100)	-	0.140³⁾
手术日龄(x±s)/d	127.0±93.3	135.0±76.6	t=0.33	0.720
住院天数[M(P₂₅~P₇₅)]	89.0(67.0~111.0)	71.0(55.0~93.0)	Z=1.95	0.051

并发症	CSE组(n=19)	对照组(n=31)	χ²值	P
肺部感染	4(21.1)	17(54.8)	5.53	0.019
吻合口狭窄	14(73.7)	20(64.5)	0.46	0.500
胃食管反流	12(63.2)	13(41.9)	2.12	0.145
食管裂孔疝	5(26.3)	6(19.4)	0.05	0.822
吻合口瘘	2(10.5)	3(9.7)	0.00	1.000
食管气管瘘	1(5.3)	4(12.9)	0.15	0.698
气管狭窄	1(5.3)	2(6.5)	0.00	1.000

项目	CSE组(n=19)	对照组(n=31)	统计量	P
6月龄
WAZ	-3.3(-3.9 ~ -1.6)	-1.5(-3.2 ~ -0.6)	Z=2.10	0.036
LAZ	-2.8(-4.2 ~ -1.4)	-1.9(-3.0 ~ 0.0)	Z=1.98	0.048
低体重	13(68.4)	14(45.2)	χ²=2.57	0.109
生长迟缓	14(73.7)	15(48.4)	χ²=3.10	0.079
24月龄
WAZ	-1.1(-1.6 ~ -0.6)	-1.2(-2.3 ~ -0.2)	Z=0.10	0.923
LAZ	-1.3(-1.9 ~ -0.2)	-1.2(-2.1 ~ -0.3)	Z=0.12	0.901
低体重	1(5.3)	9(29.0)	χ²=4.16	0.041
生长迟缓	2(10.5)	13(41.9)	χ²=5.53	0.019
24月龄WAZ增长值	2.4(0.6~2.7)	0.8(-0.7~2.6)	Z=1.48	0.140
24月龄LAZ增长值	1.3(0.3~3.7)	0.0(-1.2~1.6)	Z=2.16	0.031