肠折叠术在肠闭锁手术中的应用

目的 评价肠折叠术在肠闭锁手术中的应用效果.方法 回顾分析2005年4月至2009年4月南京医科大学附属南京儿童医院收治的68例肠闭锁患儿术前、术中和术后恢复过程的临床资料,比较手术方法、胎龄、出生体重、伴发疾病、手术年龄和时间、住院时间、全静脉营养持续时间、肠功能恢复时间(术后经口喂养时间、术后经口喂养达40ml/3 h的时间)、生长发育以及是否需再手术等方面的差异.结果 根据手术方法将患儿分为二组,38例在切除闭锁盲端肠吻合基础上加肠折叠术(折叠组),30例行扩张段斜行切除肠成形术(对照组);二组在胎龄、出生体重、伴发疾病、手术年龄上差异无统计学意义;折叠组手术时间(1.21±0.24)h、住院时间(12.2±2.5)d比对照组(1.77±0.31)h、(17.3±3.2)d显著减少(P＜0.05);折叠组术后经口喂养时间、术后经口喂养达40ml/3 h的时间和全静脉营养持续时间分别是(8±2.3)d、(13.1±1.9)d、(8.3±1.8)d,均比对照组(12.9±1.7)d、(18.7±1.1)d、(13.6±2.5)d显著缩短(P＜0.05);术后半年内折叠组有1例因粘连性肠梗阻需再次手术,对照组共有6例术后半年内再次手术,其中术后功能性肠梗阻3例、吻合口漏2例、粘连性肠梗阻1例,比折叠组显著增加.术后平均随访时间为2.7年(6个月至5年),二组生长发育达到正常标准,差异无统计学意义.结论 肠闭锁手术时在肠吻合基础上加肠折叠术,方法简单,创伤小,并发症少,有助于保留肠管吸收面积和促进肠功能恢复,可以作为预防肠闭锁扩张肠管功能性梗阻的一种有效选择方法.

Abstract：

Objective To evaluate the efficacy of bowel plication as a part the surgical treatment of intestinal atresia (IA) in childrea Methods Between April 2005 and April 2009,68 neonates with IA underwent surgical treatment in this center. According to the surgical procedures the patients underwent, the 68 neonates were divided into bowel plication group and control group. The 38 children underwent bowel plication after atretic segments resection and primary anastomosis. The 30 children of the control group underwent tapering enteroplasty after atretic segments resection. Data including operation procedures,ages,birth weight,concomitant diseases,age at surgery, length of hospital stay, length of total parenteral nutrition (TPN),postoperative intestinal function recovery (the time of the first oral feeding and the oral feeding volume reached 40 ml/kg/3h),growth and development,complications and reoperations were retrospectively analyzed. Results No differences of ages, birth weight, age at operation, and concomitant diseases were found between the two groups. The time of operation and hospital stay of the bowel plication group were significantly shorter than those of the control group [(1.21±0.24)h,(12.2±2.5)d vs. (1. 77 ± 0. 31)h, (17. 3 ± 3. 2)d,P＜0. 010]. The time of the first oral feeding, the time when oral feeding volume reached 40 ml/kg/3h,and TPN length of the bowel plication group were also shorter than those of control group [(8 ± 2. 3)d, (13. 1 ± 1. 9)d, (8. 3 ± 1.8)d vs (12. 9 ±1. 7)d,(18. 7 ± 1. l)d,(13. 6 ± 2. 5)d,P＜0. 05]. In the bowel plication group, 1 (2. 6%) underwent reoperation for adhesive intestinal obstruction half a year after the initial surgery. However,in the control group,6 (20%) included 3 underwent reoperation for intestinal obstruction,2 for anastomotic leakage and 1 for adhesive intestinal obstruction. The patients were followed up for an average period of 2. 7 years (6 months-5 years). All infants thrived. Conclusions The additional bowel plication after atretic segment resection and primary anastomosis improves the clinical outcomes for children with intestinal atresia.     

新生儿围产期肝脾出血的临床特点和预后分析

目的 总结新生儿围产期肝脾出血的临床特点、诊治方法 和预后.方法 回顾分析1992年6月1日至2009年6月1日南京医科大学附属南京儿童医院新生儿内、外科收治的围产期肝脾出血新生儿的临床资料,分析病因、临床表现、治疗及预后情况.结果 围产期肝脾出血新生儿共23例,其中巨大儿12例,早产儿6例.主要原因是异常分娩史(剖宫产、胎儿窘迫、产程延长、胎头吸引、急产等)和产伤,分别占65.2%(15/23)和47.8%(11/23).肝出血14例,脾出血6例,肝脾同时出血3例.早期主要临床表现包括反应差、嗜睡、拒乳者21例(91.3%),早期出现黄疸者18例(78.3%),苍白、贫血貌者17例(73.9%),腹胀者15例(65.2%),其他临床表现包括易激惹、呼吸困难、腹壁发紫、阴囊血肿等.保守治疗15例;手术治疗8例,其中死亡3例,病死率13.0%.结论 新生儿围产期肝脾出血与巨大儿、早产儿及异常分娩史有关,以产伤为主要原因,临床表现与出血量有关,早期表现具有非特异性,超声是最好的诊断手段.血流动力学稳定的患儿保守治疗成功率高,出血不止者应尽早手术.

Abstract：

Objective To summarize the clinical characteristics,diagnosis and management methods and prognosis of hepatorrhagia and splenorrhagia of newborns.Methods A retrospective review of clinical data of neonates with hepatorrhagia and splenorrhagia in perinatal period was performed from June 1,1992 to June 1,2009 in Nanjing Children's Hospital.Results There were twenty-three neonates suffered from hepatorrhagia and splenorrhagia in the perinatal period.There were 12 macrosomias and 6 preterm newborns.Abnormal birth history (65.2%,15/23),including caesarean section,fetal distress,application of vacuum extractor,prolonged labour and precipitate labor,were most commom reasons of hepatorrhagia and splenorrhagia,and birth injuries [47.8% (11/23)]was subsequent.In all cases,14 cases were hepatorrhagia,six were splenorrhagia,three were hepatorrhagia and splenorrhagia simultaneously.Primary early symtoms included low response,sleepiness (91.3%,21/23);jaundice 78.3% (18/23);pallor and anemia 73.9% (17/23);abdominal distension (65.2%,15/23) and so on.Ultrasonography and computed tomography may make a definite diagnosis.Fifteen newborns underwent non-operative treatment and 8 received hemostatic laparotomy.The general mortality was 13.0%(3/23).Conclusions Hepatorrhagia and splenorrhagia of neonates in perinatal period is associated with macrosomias,abnormal birth history and preterm birth,and birth injuries were the major etiological factors.Clinical presentations are nonspecific which maybe asociated with the degree of blood loss.Abdominal ultrasonography is an optimal diagnostic method.Nonoperative management may be successful in hemodynamically stable patients,while immediate intervention,such as laparotomy,is required to control persist bleeding.     

快速康复外科联合腹腔镜技术治疗婴儿先天性巨结肠

目的：评估快速康复外科（FTS）理念联合腹腔镜技术治疗婴儿先天性巨结肠的安全性及临床效果。方法回顾性分析南京医科大学附属南京儿童医院新生儿外科2010年6月至2013年6月接受择期手术治疗的72例年龄为2．5～5．0月的先天性巨结肠患儿的临床资料,根据家长意愿,其中33例予以快速康复外科理念指导下联合腹腔镜手术（FTS组）,39例予以单纯腹腔镜手术（对照组）,比较两组患儿手术以及术后肠功能恢复时间、总住院时间、住院费用和并发症发生率等情况。结果 FTS组与对照组患儿术中出血和手术时间比较,差异无统计学意义（均P＞0．05）。术后肠功能恢复时间FTS组（42±9） d,对照组（46±8） d;虽两组差异无统计学（P＝0．078）,但FTS组要快于对照组。FTS组总住院时间为（10±2） d,住院费用（15316±2273）元,明显低于对照组的（14±4） d和（18641±3082）元（P＜0．01）。随访4周,两组术后并发症发生率和术后恢复情况比较,差异均无统计学意义（P＞0．05）。结论快速康复外科理念联合腹腔镜技术治疗婴儿先天性巨结肠安全、有效。     

十二指肠有孔隔膜状狭窄手术方法探讨

目的：评价十二指肠隔膜切除术和菱行吻合术在各年龄段十二指肠有孔隔膜状狭窄患儿中的治疗效果。方法：将72例患儿分为3个年龄组,即新生儿组（〈30 d）、小婴儿组（30~60 d）和较大婴儿组（≥60 d）;将各年龄组按手术方法分别分为隔膜切除组和菱形吻合组,比较各年龄组中隔膜切除组和菱形吻合组的手术时间、术后肠功能恢复时间（术后胆汁样粪便排出时间）、术后达到完全肠内营养时间（经口喂养达80 mL/（kg·d）-1所需时间）、术后平均住院时间、术后2月及6月的体质量（仅新生儿组和小婴儿组）、术后梗阻性黄疸的发生率、术后再发生胆汁性呕吐的发生率。结果：新生儿组中,隔膜切除组手术时间、术后达到完全肠内营养所需时间及术后住院时间低于菱形吻合组（P均〈0.05）;小婴儿组中,隔膜切除组手术时间及术后2月体质量低于菱形吻合组,但肠功能恢复时间、术后达到完全肠内营养所需时间及术后住院时间高于菱形吻合组（P均〈0.05）;较大婴儿组中,隔膜切除组肠功能恢复时间、达到完全肠内营养所需时间、术后住院时间及术后胆汁性呕吐的发生率高于菱形吻合组（P均〈0.05）。结论：对于十二指肠有孔隔膜状狭窄的患儿,在新生儿期宜采用隔膜切除术,在≥60 d时宜采用十二指肠菱形吻合术。     

Sonic Hedgehog信号通路与先天性肛门直肠畸形

先天性肛门直肠畸形（congenital anorec tal malformation，CAM）是小儿外科最常见的畸形之一，关于该病的遗传学研究说法很多。最近国外学者认为Sonic Hedgehog（Shh）基因及其信号转导通路可能与无肛畸形的发生有关。本文就Shh信号通路构成、途径及其在肛门直肠畸形发生中的作用进行综述。     

肠折叠术在肠闭锁手术中的应用

Objective To evaluate the efficacy of bowel plication as a part the surgical treatment of intestinal atresia (IA) in childrea Methods Between April 2005 and April 2009,68 neonates with IA underwent surgical treatment in this center. According to the surgical procedures the patients underwent, the 68 neonates were divided into bowel plication group and control group. The 38 children underwent bowel plication after atretic segments resection and primary anastomosis. The 30 children of the control group underwent tapering enteroplasty after atretic segments resection. Data including operation procedures,ages,birth weight,concomitant diseases,age at surgery, length of hospital stay, length of total parenteral nutrition (TPN),postoperative intestinal function recovery (the time of the first oral feeding and the oral feeding volume reached 40 ml/kg/3h),growth and development,complications and reoperations were retrospectively analyzed. Results No differences of ages, birth weight, age at operation, and concomitant diseases were found between the two groups. The time of operation and hospital stay of the bowel plication group were significantly shorter than those of the control group [(1.21±0.24)h,(12.2±2.5)d vs. (1. 77 ± 0. 31)h, (17. 3 ± 3. 2)d,P＜0. 010]. The time of the first oral feeding, the time when oral feeding volume reached 40 ml/kg/3h,and TPN length of the bowel plication group were also shorter than those of control group [(8 ± 2. 3)d, (13. 1 ± 1. 9)d, (8. 3 ± 1.8)d vs (12. 9 ±1. 7)d,(18. 7 ± 1. l)d,(13. 6 ± 2. 5)d,P＜0. 05]. In the bowel plication group, 1 (2. 6%) underwent reoperation for adhesive intestinal obstruction half a year after the initial surgery. However,in the control group,6 (20%) included 3 underwent reoperation for intestinal obstruction,2 for anastomotic leakage and 1 for adhesive intestinal obstruction. The patients were followed up for an average period of 2. 7 years (6 months-5 years). All infants thrived. Conclusions The additional bowel plication after atretic segment resection and primary anastomosis improves the clinical outcomes for children with intestinal atresia.     

扩张皮瓣、肌皮瓣和黏膜瓣修复联体婴儿联体部巨大缺损二例

先天性联体畸形是一类复杂而少见的畸形,南京医科大学附属南京儿童医院2002至2012年收治2例,我们结合文献并对治疗中的有关问题进行探讨如下. 一、临床资料 (一).病例介绍 1.例1,一对患儿均为男性,剖腹产娩出,出生时体重5 900 g,出生后6h入院,面对面侧卧位,胸骨下部至脐部相连接,连接部约11.5 cm长. 2.例2,一对患儿均为女性,剖腹产娩出,出生时共重5 300 kg,出生后4h入院,为臀骶会阴部相连,两侧大阴唇后端相联,可见处女膜痕.两阴道中有一隔.无肛门,只有一漏口,开口异位于侧后方之两婴交界皮肤皱折处,距正中线8 cm,用力分开肛门可见中间有一中隔,距肛门口0.3 cm,联体部的直径9 cm,小体重儿有轻度脊柱侧弯.余器官完好(图1～3).     

新生儿皮下脂肪坏死1例

患儿女性,26天,发现头颈部多发包块半月于2009年1月3日入院.2008年12月20日因左头颈部皮肤红肿及头皮包块入院.体检:表面皮肤红,触之哭闹,诊断为新生儿皮肤感染,予以抗感染治疗1周,皮肤红肿好转出院.出院后头颈部包块未消失,数量增多,再次入院.     

HepG2细胞胰岛素抵抗模型中脂代谢的改变

目的:探讨胰岛素抵抗(insulin resistance,IR)对肝细胞脂代谢酶的影响?方法:用不同浓度胰岛素刺激HepG2细胞,建立肝细胞IR模型;用油红O染色观察细胞形态及胞内脂滴形成;应用甘油三酯(triglyceride,TG)检测试剂盒检测细胞中TG含量;Real-time PCR检测乙酰辅酶a羧化酶(acetyl-CoA carboxylase,ACC)?肝型脂肪酸结合蛋白(liver-type fatty acid-binding protein,L-FABP)?脂蛋白脂酶(lipoprotein lipase,LPL)?肉碱棕榈酰转移酶(carnitine palmitoyltransferase 1,CPT1)?微粒体甘油三酯转移蛋白(microsomal triglyceride transfer protein,MTP)等脂代谢相关因子及转录因子胆固醇调节元件结合蛋白-1c(sterol regulatory element-binding protein-1c,SREBP-1c)?过氧化物酶体增生物激活受体α(peroxisome proliferator activated receptor α,PPARα)的mRNA表达水平?结果:用浓度1×10-4 mol/L的胰岛素刺激细胞36 h后形成IR?IR细胞内脂滴增多,TG含量增加;IR细胞内脂合成相关的ACC?SREBP-1c的mRNA水平较对照组升高;LPL?CPT1?MTP?PPARα的mRNA水平较对照组降低;L-FABP mRNA水平与对照组相比无差异?结论:IR通过提高肝细胞脂合成?降低脂氧化过程,导致肝细胞内脂质异常堆积?     

不同类型致痛性操作对新生儿疼痛的影响

目的 评估不同致痛性操作对新生儿疼痛评分和生理指标的影响. 方法 2009年3月1日至5月31日入住南京医科大学附属南京儿童医院新生儿医疗中心的新生儿108例,其中早产儿46例,足月儿62例.通过实时床边观察和数码录像收集新生儿从入院到出院期间所有诊疗需要所致的疼痛性操作过程,应用新生儿面部编码系统(Neonatal Facial Coding System,NFCS)、新生儿疼痛评估量表(Neonatal Infant Pain Scale,NIPS)及早产儿疼痛量表(Premature Infant Pain Profile,PIPP)评估新生儿的疼痛反应,同时记录操作前后患儿心率和血氧饱和度变化.采用Student-t检验、x2检验和重复测量方差分析比较不同致痛性操作对新生儿疼痛评分和生理指标的影响. 结果 早产儿共接受不同类型致痛性操作6966例次,经历最多的前3种致痛性操作分别为气管内吸引(23.6％,1645/6966)、口鼻腔吸引(18.3％,1278/6966)和外周静脉穿刺置管(17.2％,1195/6966),而足月儿经历最多的前3种致痛性操作分别为外周静脉穿刺置管(27.0％,989/3667)、拔除留置针(20.5％,751/3667)和去除胶布(18.4％,675/3667).早产儿致痛性操作疼痛评分较高的前3种分别是气管插管[NFCS(7.00±1.66)分,PIPP(14.08±3.54)分]、股静脉穿刺[NFCS(6.52±1.66)分,PIPP(12.15±3.11)分]和腋静脉穿刺[NFCS(5.75±1.89)分,PIPP(11.75±4.19)分]；足月儿致痛性操作疼痛评分较高的前3种分别是股静脉穿刺[NFCS(6.68±1.34)分,NIPS(5.58±1.32)分]、去除胶布[NFCS(6.00±1.41)分,NIPS(5.67±0.58)分]及腹壁静脉穿刺[NFCS(6.00±0.00)分,NIPS(5.50±0.71)分].不同类型的致痛性操作引起的足月儿心率(F=0.186,P=0.836)及血氧饱和度(F=1.672,P=0.198)变化差异无统计学意义. 结论 住院新生儿经历反复多次的致痛性操作,其中气管插管和股静脉穿刺可引起重度操作性疼痛,应加强新生儿的疼痛管理.