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Article(id=1199688713778332383, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199688705905623579, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.0426.2023.0731, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1679414400000, receivedDateStr=2023-03-22, revisedDate=null, revisedDateStr=null, acceptedDate=1683302400000, acceptedDateStr=2023-05-06, onlineDate=1763957678503, onlineDateStr=2025-11-24, pubDate=1703692800000, pubDateStr=2023-12-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763957678503, onlineIssueDateStr=2025-11-24, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763957678503, creator=13701087609, updateTime=1763957678503, updator=13701087609, issue=Issue{id=1199688705905623579, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='12', pageStart='1359', pageEnd='1491', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763957676626, creator=13701087609, updateTime=1763958367038, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1199691601774739748, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199688705905623579, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1199691601774739749, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199688705905623579, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1473, endPage=1477, ext={EN=ArticleExt(id=1199688714206151416, articleId=1199688713778332383, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Progress in clinical diagnosis and treatment of tracheoesophageal fistulas, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Tracheoesophageal fistulas (TEF) is a kind of pathological fistula between trachea or bronchus and esophagus, including tracheoesophageal fistula and bronchoesophageal fistula. In clinical practice, tracheoesophageal-fistula is more often seen. There are many pathogenesis of TEF, which could cause serious complications. It is a disease which has serious impact on the quality of life, difficult to treat and high mortality. There are many methods to treat TEF, but the therapeutic effect is poor. There is an urgent need for new treatment methods to TEF. The detection of nasogastric tube retention by chest and abdominal X-ray is the gold standard for diagnosis. The main treatment methods include surgical treatment, stent implantation, local biological glue blocking, stem cell therapy and so on. In order to provide reference for relevant clinical diagnosis and treatment of TEF, this article reviews the main research progress in the diagnosis and treatment of TEF in recent years.

, correspAuthors=Sheng-Bo Yang, authorNote=null, correspAuthorsNote=
E-mail:
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气管食管瘘是指气管或支气管与食管之间的病理性瘘道，包括气管-食管瘘和支气管-食管瘘，临床以气管-食管瘘较多见。气管食管瘘致病原因较多，可引起严重的并发症，影响生活质量，是一种治疗困难、病死率较高的疾病。气管食管瘘目前治疗方式较多，但多数疗效欠佳，对新兴治疗手段的需求迫切。胸腹部 X 线摄影检出鼻胃管滞留是气管食管瘘诊断的金标准，其主要治疗方法包括外科手术治疗、支架置入、局部生物胶水封闭、干细胞治疗等。本文综述近年气管食管瘘诊断与治疗的主要研究进展，旨在为该病的临床诊治提供参考。

, correspAuthors=杨胜波, authorNote=null, correspAuthorsNote=
杨胜波，E-mail：
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吴彤，医学硕士，主要从事线粒体动力学方面的研究

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吴彤，医学硕士，主要从事线粒体动力学方面的研究

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吴彤，医学硕士，主要从事线粒体动力学方面的研究

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气管食管瘘临床诊疗研究进展
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吴彤 1 , 周云芝 2 , 徐淑凤 3 , 杨胜波 1, *
解放军医学杂志 | 综述 2023,48(12): 1473-1477
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解放军医学杂志 | 综述 2023, 48(12): 1473-1477
气管食管瘘临床诊疗研究进展
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吴彤1, 周云芝2, 徐淑凤3, 杨胜波1, *
作者信息
  • 1遵义医科大学人体解剖学教研室，贵州遵义 563003
  • 2北京市应急总医院呼吸内科，北京 100028
  • 3秦皇岛市第一医院呼吸与危重症医学科，河北秦皇岛 066000

    • 吴彤，医学硕士，主要从事线粒体动力学方面的研究

通讯作者:

杨胜波，E-mail：
Progress in clinical diagnosis and treatment of tracheoesophageal fistulas
Tong Wu1, Yun-Zhi Zhou2, Shu-Feng Xu3, Sheng-Bo Yang1, *
Affiliations
  • 1Department of Human Anatomy, Zunyi Medical University, Zunyi, Guizhou 563003, China
  • 2Department of Respiratory Medicine, Beijing Emergency General Hospital, Beijing 100028, China
  • 3Department of Respiratory and Critical Care Medicine, the First Hospital of Qinhuangdao, Qinhuangdao, Hebei 066000, China
出版时间: 2023-12-28 doi: 10.11855/j.issn.0577-7402.0426.2023.0731
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摘要
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气管食管瘘是指气管或支气管与食管之间的病理性瘘道，包括气管-食管瘘和支气管-食管瘘，临床以气管-食管瘘较多见。气管食管瘘致病原因较多，可引起严重的并发症，影响生活质量，是一种治疗困难、病死率较高的疾病。气管食管瘘目前治疗方式较多，但多数疗效欠佳，对新兴治疗手段的需求迫切。胸腹部 X 线摄影检出鼻胃管滞留是气管食管瘘诊断的金标准，其主要治疗方法包括外科手术治疗、支架置入、局部生物胶水封闭、干细胞治疗等。本文综述近年气管食管瘘诊断与治疗的主要研究进展，旨在为该病的临床诊治提供参考。

气管食管瘘  /  支架  /  生物蛋白胶  /  干细胞  /  再生医学

Tracheoesophageal fistulas (TEF) is a kind of pathological fistula between trachea or bronchus and esophagus, including tracheoesophageal fistula and bronchoesophageal fistula. In clinical practice, tracheoesophageal-fistula is more often seen. There are many pathogenesis of TEF, which could cause serious complications. It is a disease which has serious impact on the quality of life, difficult to treat and high mortality. There are many methods to treat TEF, but the therapeutic effect is poor. There is an urgent need for new treatment methods to TEF. The detection of nasogastric tube retention by chest and abdominal X-ray is the gold standard for diagnosis. The main treatment methods include surgical treatment, stent implantation, local biological glue blocking, stem cell therapy and so on. In order to provide reference for relevant clinical diagnosis and treatment of TEF, this article reviews the main research progress in the diagnosis and treatment of TEF in recent years.

tracheoesophageal fistulas  /  stent  /  fibrin glue  /  stem cell  /  regenerative medicine
吴彤, 周云芝, 徐淑凤, 杨胜波. 气管食管瘘临床诊疗研究进展. 解放军医学杂志, 2023 , 48 (12) : 1473 -1477 . DOI: 10.11855/j.issn.0577-7402.0426.2023.0731
Tong Wu, Yun-Zhi Zhou, Shu-Feng Xu, Sheng-Bo Yang. Progress in clinical diagnosis and treatment of tracheoesophageal fistulas[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (12) : 1473 -1477 . DOI: 10.11855/j.issn.0577-7402.0426.2023.0731
正文
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气管食管瘘(tracheoesophageal fistula，TEF)是指气管或支气管与食管之间的病理性瘘道，包括气管-食管瘘和支气管-食管瘘(bronchoesophageal fistula，BEF)，临床以气管-食管瘘较多见。TEF致病原因较多，临床并不罕见，治疗困难且病死率较高。该病可引起严重的并发症，恶性TEF患者病情进展迅速，如治疗不及时可在短期(6~12周)内死亡[1]。既往研究显示，TEF未及时治疗者预后很差，即使成功接受治疗的患者，病死率仍高达12%[2]。目前针对TEF的治疗方式较多，但多数疗效不佳，因此，探索新的治疗手段的需求尤为迫切[3]。本文综述近年来TEF诊断、治疗及策略选择的相关研究进展，以期为TEF的临床诊疗提供参考。
1 病因及分类
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TEF可分为先天性和获得性两大类。先天性TEF主要发生于患儿的胚胎发育时期，常与食管闭锁同时出现，因此合并称为食管闭锁-气管食管瘘[4]。获得性TEF可在病理学上进一步分为非恶性与恶性TEF。获得性非恶性TEF(non-malignant TEF，NMTEF)主要与医源性损伤包括机械性通气的并发症、气管食管相关手术并发症、肉芽肿性纵隔感染、外伤、腐蚀性损伤、异物、结核分枝杆菌等病原微生物感染或支气管局部炎症等相关[4]。获得性恶性TEF(malignant TEF，MTEF)是由食管癌、肺癌或甲状腺癌等恶性肿瘤进展侵犯引起，也可由肿瘤相关的治疗措施导致，如颈胸部食管肿瘤切除重建后吻合口漏、食管/气管恶性肿瘤致食管/气管狭窄的扩张手术和支架置入术、气管食管肿瘤的放化疗或食管/气管的侵入性治疗等，导致气管、支气管等呼吸道与食管的病理性瘘口。
2 诊断
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TEF早期由于瘘口较小不易被发现，一旦瘘口形成往往在较短时间内迅速扩大甚至危及生命，增加了治疗难度。因此，TEF的早期识别和诊断尤为重要。先天性TEF的临床征象包括流涎、进食后呛咳、发绀、呼吸窘迫等[5]。近期文献报道的TEF 1例具有类似“猫鸣”的症状，也可视为先天性TEF的一种表现[6]。胸腹部 X 线摄影检出鼻胃管滞留是TEF诊断的金标准[7]。
非先天性患者当出现气管分泌物突然增多，吞咽后阵发性呛咳，咳出食物残渣时，有必要排除TEF。影像学检查包括食管造影、X线胸片、胸部增强 CT和内镜检查[8]等。即使单一检查能够明确诊断，也有必要进行胸部影像学和内镜联合检查(如果可能，同时进行软性支气管镜和上消化道内镜检查)。支气管镜和消化道内镜检查可直视瘘口，有助于瘘口位置和大小的确定。当黏膜壁呈现红肿症状时，非常小的瘘容易被忽视；而应用气管镜观察气管时，可口服或通过食管镜注入亚甲蓝或空气，如在气管内看到蓝色泡沫或吸痰时吸出蓝染痰液，可间接反映TEF的存在。支气管镜检查可评估气管损伤的程度，精确定位瘘的位置及其距离声带、隆突等的距离。虽然没有正式的指南，但多数专家认为食管造影和内镜检查对疾病的诊断和术前准备是必要的。食管造影优先选用钡剂，较石蜡油具有更好的生理耐受性，后者因高渗性与肺水肿关系密切[9]。
3 治疗方法与处理策略
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TEF的病因较多，其治疗策略需要个体化，包括外科治疗(如瘘道切除术和修补术等)、气管或食管支架置入、局部生物胶水封闭，近年更有干细胞治疗等方法显示出良好的应用前景。
3.1 一般处理原则
TEF较严重的并发症是呼吸道污染、肺炎，甚至导致肺源性败血症而危及生命。先天性TEF主要治疗由解剖畸形引起的并发症，获得性TEF需处理瘘道形成的致病因素。用H2受体拮抗剂或质子泵抑制剂进行抑酸治疗，以降低胃酸的酸度和体积。卧床患者需抬高床头至45°，严格限制经口进食，应用抗反流药物，加强口腔吸引，并予祛痰药和吸痰等对症治疗。对于有创机械通气的患者，可将气管内插管向前推进，将气囊置于瘘口远端，以防止呼吸道污染。
3.2 外科手术
TEF的外科治疗包括气管食管瘘切除术、气管食管瘘口分别修补术[10-11]、切除气管/食管病变端端吻合[12]及通过胸腔镜修复[13]等，视具体情况可进行上述术式的单选或组合。切除受累的气管并直接缝合食管缺损是治疗插管后TEF的金标准[1]。对难以实施上述彻底性手术者，可实施姑息性手术，如气管食管瘘旷置、颈段/胸段食管外置、胃及空肠造瘘等。Dario等[14]报道了过颈椎前路手术修复TEF 1例。横断气管切开并远端残端回缩后，直接闭合食管缺损[15]，用合成生物可吸收补片修复膜性气管缺损[16]，然后在缝合线间置入肌肉瓣[17-18]，重建气管。对于不适合行气管切除和吻合术的患者，这种替代气管成形术可治疗较大的TEF，患者术后无气管狭窄或环周气管缺损，疗效明确。Koch等[19]对21例TEF进行外科瘘口缝合，成功率为95.5%，其中52.4%的患者接受了二次手术，但TEF的最终闭合率达91.5%。需要指出的是，单纯外科瘘口手术操作复杂，患者自身的各种高危因素可能对治疗结果造成不良影响，且多数患者身体状态可能难以耐受手术治疗。在恶性瘘道存在的情况下行手术切除更加困难，尽管可联合食管旷置等其他外科手段，但预后不良，病死率较高[20]。近期Kennedy等[21]报道，与其他技术比较，滑片气管成形术(slide tracheoplasty)是治疗复杂先天性和获得性TEF的有效外科术式，且并发症发生率较低。
3.3 气管或食管支架
对于因恶性或良性肺、食管疾病引起的气管阻塞及瘘管，置入多种不同材料制成的气管或食管支架是一种重要的治疗方法。目前，气管支架置入术已成为应用广泛且流行的技术。支架置入术一般包括气管支架置入术、食管支架置入术、食管与气管同步双支架置入术等。
3.3.1 气管支架
单气管支架的理想指征是存在气管狭窄相关的潜在因素或TEF发生于近端气管，且食管支架的放置在技术上具有挑战性。这是由于 TEF 的位置近端处于食管狭窄或肿瘤引起的食管腔阻塞处，使得扩张或支架置入具有挑战性，故考虑气管支架置入。气管支架的位置必须完全覆盖瘘口，理想的是超过瘘口半径20 mm[22]。从理论上说，这种方式可保证支架置入后不会出现瘘道纵向扩张。然而，由于瘘口位置的不确定性，20 mm的安全范围可能难以实现。
目前主要有两种材料制作的气管支架——金属支架和硅酮支架；此外还有混合型支架(金属支架覆硅酮膜、聚丙烯膜或其他膜)和在研的其他多种支架(生物降解支架、药物洗脱支架、生物工程支架、3D 打印支架等)，有不同的尺寸、形状和直径可供选择。直型支架适用于近端气管，“L”或“Y”型支架用于远端气管，气管支架外径应大于瘘口处气管内径的10%~20%。自膨式金属支架(self-expandable metallic stent，SEMS)易于置入放置，成为TEF临床应用的首选，且能够更好地贴壁于气管黏膜。与硅酮支架相比，SEMS可使用导丝或直接在支气管镜下可视化放置。此外，SEMS与气管壁的贴壁位置较好，有利于降低支架的迁移率[23]。然而，SEMS的耐久性较差，易发生金属疲劳和支架断裂。在用于MTEF时，SEMS的耐久性不足并非突出问题，因为这些患者很少存活超过几个月。Wang等[24]认为，在MTEF的治疗中倾向于选择SEMS，术后完全闭合率可达71%。因耐久性不足，SEME在NMTEF 中的应用受到限制。
硅胶支架外表面有螺柱，旨在防止迁移和减少黏膜缺血[25]。然而，这些螺柱可能会阻止支架与气管腔完全贴壁，从而降低支架的密封效果。在NMTEF的管理中，硅胶支架比SEMS的耐久性更好，因此临床应用更为广泛。
3.3.2 食管支架
食管支架置入是封堵食管中段和远端瘘口的良好选择，尤其是对无气管狭窄的患者。此外，食管壁柔韧性好，可更好地贴合支架。SEMS是大多数恶性病例理想的食管支架，这是由于其在各种恶性食管疾病中所展示出的持久性、适用性和良好的疗效。当将覆膜与未覆膜的 SEMS 进行比较时，覆膜的支架展现出抗肿瘤生长的特性，但其发生移位的概率更高[25]。对于良性食管疾病，由于自膨胀塑料支架易于取出的特性，所以在临床治疗中常被应用[2-3]。但是近年来，针对良性食管疾病，如穿孔、瘘管或狭窄等的治疗，也有使用完全覆膜的SEMS进行治疗的报道[26]。对于瘘口直径的测量，可在食管中使用球囊导管来估计近似的直径，有助于支架的定制选择。食管支架置入术已知的并发症包括外源性气管压迫、出血、食管穿孔及新的TEF形成等[26]。对于食管支架置入的外压可能导致气管阻塞的高风险患者，在特定情况下可考虑同时使用气管和食管“双重”支架。
3.3.3 食管与气管双支架
当TEF患者食管和气管均存在中重度狭窄，或者单独使用食管或气管支架封闭瘘口不能实现时，可采用食管和气管支架联合置入的治疗方式。此时由于解剖学结构的原因，单独置入食管支架可能造成支气管压迫而导致窒息。因此，双支架的应用是必要的[27]。首先放置的应该是气管支架，然后再置入食管支架，应避免食管支架对气管的压迫而加重气管狭窄，加剧患者的呼吸困难甚至威胁生命。
日本学者Nakagomi等[28]在2020年报道11例患者(其中合并食管气管狭窄8例，合并有瘘3例) 成功接受了双支架置入术，患者的呼吸和吞咽困难均得到满意的恢复；且除呼吸机依赖的1例外，其他患者的瘘口均成功封闭；患者症状缓解维持了较长时间 (>3个月2例，2~3个月3例，1~2个月5例)。一项对112例患者生存影响的前瞻性评估显示，使用气管支架的患者(n=65)的平均生存期为219.1 d [95% 置信区间 (CI) 197.3~240.9 d] ，使用食管支架的患者(n=37)为 262.8 d(95% CI 244.4~281.3 d)，接受双支架置入的患者(n=10)为252.9 d(95% CI 192.9~312.9 d)[29]。尽管仅基于生存时间还不能确定哪种形式的支架置入方法更好，但仍可预测接受单一支气管支架置入的部分患者会因为食管支架的置入而进一步获益。
3.4 超视距内镜吻合夹(over the scope clip，OTSC)技术
自2007年Kirschniak等[30]报道OTSC作为新技术进行的胃肠道缺损吻合案例后，OTSC开始应用于TEF。OTSC由高弹性的钛镍记忆合金制成，夹子可将病灶钳夹和夹闭，适用于早期食管1~2 cm的瘘口。OTSC的夹子在宽度和闭合力及发射方式方面均超过了传统的内夹，对患者吞咽食物的影响较小[31]。
3.5 医用生物蛋白胶
生物蛋白胶是从动物血液中提取的相关成分，由主体和催化剂两部分组成，主体含纤维蛋白原、凝血酶原􀃼因子，催化剂主要含凝血酶、氯化钙溶液。医用生物蛋白胶具有局部刺激少，固化迅速、胶接强度大和显著的抗菌性等特点，适合瘘口吻合粘接。经胃镜应用医用生物蛋白胶封堵术是一种有效的治疗手段，值得临床选择使用。其对小瘘口(<5 mm)在内镜下成功治疗的可能性相对较大，而对大瘘口(>8 mm)，如果胶水流入气管，则会对支气管造成致命损伤[32]。而且其黏稠性可使气管镜/胃镜之前端镜体黏着封堵，影响进一步操作，是其难以规避的缺点。
3.6 双盘封堵器(Amplatzer)
起初设计是用于经导管闭合心脏缺损，现已成功地用于治疗TEF和与非恶性原因有关的支气管食管瘘[33-34]。但有报道使用Amplatzer装置可能会出现严重的气管并发症，如黏膜粘连和肉芽组织形成引起气管阻塞，与装置本身有关的糜烂性改变引起新的TEF等。此外，与气管支架不同，Amplatzer减少了气管横截面积。因此，这种装置难以应用于TEF的处理[35]。
3.7 再生医学方法
近年来基于间充质干细胞 (mesenchymal stromal/stem cells，MSC)的再生医学方法治疗TEF受到广泛关注[36]。骨髓、脂肪组织和脐带血是临床试验中常用的MSC来源。MSC是一种多能细胞，被认为是源于中胚层的非造血成体干细胞的子集，具有成纤维细胞样形态和多向分化潜能[37-39]。MSC的治疗效果涉及复杂的机制，如移植后的MSC整合到宿主受损组织中促进细胞存活、增殖、旁分泌的作用，以及干细胞对机体先天和获得性免疫系统的调节等[40]。MSC被启动后根据损伤部位环境的生物学信息，可分泌多种细胞保护性旁分泌因子，以增强损伤组织的修复再生[41]。MSC 可产生多种生长因子，如肝细胞生长因子(hepatocyte growth factor，HGF)、血管内皮生长因子(vascular endothelial growth factor，VEGF)、碱性成纤维细胞生长因子(basic fibroblast growth factor，bFGF)、胰岛素样生长因子1 (insulin-like growth factor-1，IGF-1)、表皮生长因子 (epidermal growth factor，EGF)、血小板源性生长因子(platelet-derived growth factor，PDGF)，以及转化生长因子β(transformation growth factor-β，TGF-β)、前列腺素E2(prostaglandin E2，PGE2)和基质细胞衍生因子-1(stromal cell-derived factor-1，SDF-1)等[42]。这些因子可抑制炎症反应，触发血管生成过程，增强成纤维细胞活性，促进祖细胞在原位组织中的分化和增殖等[43]。据文献报道，1例先天性TEF的55岁男性患者接受了加压注射器定点自体脂肪干细胞注射2次后获得成功，且其保持长期完全愈合、无症状超过10年[44]。但干细胞治疗TEF的机制、效果和可行性尚需进一步深入研究。
4 总结与展望
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随着各种医源性操作的增加，以及食管癌、支气管肺癌和甲状腺癌等恶性肿瘤发病率的上升，使获得性的良恶性TEF越来越多，其治疗困难，病死率高，严重危害患者的生活质量甚至生命。对TEF的治疗，目前临床上比较成熟的治疗方法为外科手术治疗、气管镜或消化内镜下支架置入术等，但疗效不如人意。在对TEF治疗的探索进程中，以干细胞为基础的再生医学方法治疗TEF成为富有前景的治疗手段。尽管干细胞引导的再生医学治疗TEF还需要大量的基础和临床研究验证，但其仍有可能成为疗效更确切、创伤更小的成熟治疗手段，并为更多医师与患者所接受。
基金
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  • 国家自然科学基金(32260217)
  • 河北省自然科学基金(H2021107002)
文献
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参考文献 引证文献
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2023年第48卷第12期
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doi: 10.11855/j.issn.0577-7402.0426.2023.0731
  • 接收时间：2023-03-22
  • 首发时间：2025-11-24
  • 出版时间：2023-12-28
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  • 收稿日期：2023-03-22
  • 录用日期：2023-05-06
基金
National Natural Science Foundation of China(32260217)
国家自然科学基金(32260217)
Natural Science Foundation of Hebei Province(H2021107002)
河北省自然科学基金(H2021107002)
作者信息
    1遵义医科大学人体解剖学教研室，贵州遵义 563003
    2北京市应急总医院呼吸内科，北京 100028
    3秦皇岛市第一医院呼吸与危重症医学科，河北秦皇岛 066000

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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