胆道闭锁Kasai手术后自体肝生存时间小于2年的危险因素分析

目的探讨胆道闭锁(biliary atresia,BA)Kasai手术后自体肝生存(native liver survival,NLS)时间小于2年的危险因素。方法回顾性分析山西省儿童医院2009年1月至2017年6月行Kasai手术的BA患者临床资料及随访资料。根据术后NLS时间是否小于2年分为死亡组(n=78)和生存组(n=46)。将BA分型、性别、巨细胞病毒(cytomegalovirus,CMV)感染、手术年龄、术后使用抗生素方案、术后使用激素方案、是否合并早期胆管炎及术后黄疸是否消退作为自变量,采用Kaplan-Meier法绘制生存曲线并进行Log-rank检验,采用Cox比例风险模型(逐步前进法)筛选BA患者Kasai手术后NLS时间小于2年的危险因素。结果共纳入124例BA患者,其中生存组46例,死亡组78例,2年NLS率为37.1%。单因素分析结果显示合并早期胆管炎及术后黄疸消退是影响BA患者术后2年NLS率的因素(P<0.05)。Cox比例风险模型分析结果显示术后3个月内黄疸未消退为BA患者Kasai手术后NLS时间小于2年的独立危险因素,术后3个月内黄疸未消退组患者NLS时间小于2年的风险是黄疸消退患者的5.65(95%CI:2.45~13.04)倍。结论BA患者Kasai手术后3个月内黄疸未消退是NLS时间小于2年的危险因素。     

加速康复外科技术在肛门闭锁并直肠前庭瘘中的应用CSCD

Objective To explore the efficacy and safety of enhanced recovery after surgery (ERAS) in children with anal atresia and rectal vestibular fistula. Methods From January 2017 to October 2021, prospective review was conducted for 50 children with anal atresia and rectal vestibular fistula undergoing transanal analoplasty. They were randomized into two groups of ERAS and non-ERAS (n =25 each). ERAS group received enema once in the morning of operation day, oral 12.6% carbohydrate liquid 2 h pre-operation, intraoperative heat preservation, target-oriented rehydration ,no indwelling catheter post-operation, postoperative analgesia and other new measures; non-ERAS group had traditional perioperative treatment. Blood glucose at the beginning of anesthesia, blood glucose 24 h post-operation, white blood cell count ( WBC), C-reactive protein (CRP), time of initial exhaust and defecation post-operation, amount of intraoperative infusion, time of postoperative intravenous infusion ,time of postoperative hospitalization, expenditure of hospitalization incidence of complications and readmission rate at Day 30 post-discharge were compared between two groups. Results No significant inter-group differences existed in average age, weight, preoperative WBC, CRP, hemoglobin, albumin, prealbumin or blood glucose at admission. Blood glucose at the beginning of anesthesia in ERAS and non-ERAS groups was (4.92±0.50) and (4.53 ±0.42) mmol/L, blood glucose (5.03 ±0.66) and (5.96±41.18) mmol/L at 24 h post-operation. WBC at 24h post-operation (9.97 3.24) x 10°/L and (8.28 ±3.51) x 10°/L;CRP at 24 h post-operation (3.63±4.00) and (9.03±15.77) mg/L;initial postoperative exhaust and defecation time (12.1 ±6.4) and (14.0 ±9.3) h;intraoperative infusion volume (83.1 ±32.2) and (136. 1±68.4) mL;postoperative intravenous infusion time (4.68 ±1.25) and (6.6 ±1.68) days; postoperative hospital stay (7.12 ± 1.56) and (10.56 ±3.58) days; hospitalization expense (13 314. 34 ±2 856.86) and (16 088.69 ±3 282.34) CNY ;complications occurred (n =3,12%) and (n =6,24%) ;overall satisfaction was 88% and 60%. Both groups were cured and discharged and there was no re-admission within 30 days post-discharge. No inter-group differences existed in initial exhaust or defecation time, WBC and CRP at 24 h post-operation (P >0.05).In nonERASgroup, blood glucose declined at the beginning of anesthesia while postoperative blood glucose level rose with statistical difference (P <0. 05) ; overall satisfaction of ERAS group was higher than that of non-ERAS group with statistical difference (P lt; 0.05). Conclusion Conceptual application of ERAS is both safe and effective in children with anal atresia with rectovestibular fistula. It can effectively shorten the average time of hospital stay, curtain the length of postoperative hospitalization and lower hospitalization expenditure. A wider popularization is worthy. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

小儿急性肠梗阻肠黏膜免疫屏障损伤及细菌移位的研究

目的 探讨小儿急性肠梗阻细菌移位及机制.方法 收集山西省儿童医院普外科2009年9月至2010年8月急性肠梗阻患儿共43例,依治疗方法分三组:肠切除肠吻合组(吻合组)22例,未切除肠管组14例,保守治疗组7例.另选择17例正常肠管及健康儿童10例分别作正常肠管、血清对照组.应用聚合酶链反应(PCR)定性检测细菌共有的16SrRNA和大肠杆菌特异性半乳糖苷酶基因BG;肠系膜淋巴结细菌培养;免疫组织化学方法检测肠黏膜固有层T细胞亚群、浆细胞计数;酶联免疫吸附试验(ELISA)定量检测血清TGF-β1浓度.结果 吻合组16SrRNA、BG阳性率分别为86.4%、72.7%,淋巴结培养阳性率77.3%;未切除肠管组16SrRNA、BG阳性率分别为64.3%、42.8%,淋巴结培养阳性率57.1%;保守治疗组16SrRNA、BG阳性率分别为57.1%、28.5%,正常肠管血清对照组16SrRNA、BG均未检出;吻合组肠黏膜固有层T细胞亚群、浆细胞数量均低于正常对照组;吻合组、未切除肠管组术前血清TGF-β1浓度均高于保守治疗组与对照组,术后7 d各组血清TGF-β1浓度与对照组比较无差异.结论 急性肠梗阻患儿肠黏膜固有层T细胞亚群、浆细胞均降低,引起肠黏膜免疫屏障破坏,同时TGF-β1水平升高,参与机体免疫抑制,免疫功能紊乱,加重黏膜免疫屏障破坏,增加机体易感性,促进了细菌移位.

Abstract：

Objective To investigate the mechanism of intestinal mucosal barrier damage and bacterial translocation in children with acute intestinal obstruction. Methods From September 2009 to August 2010, 43 patients with acute intestinal obstruction were treated at this center and recruited in this study. According to the treatment they underwent, they were divided into 3 groups: Group1 included 22 patients who were performed bowel resection and anastomosis. Group 2 had 14 patients who underwent surgeries but without bowel resection. Group 3 had 7 patients who were cured without surgery. The other 17 healthy bowels and 10 healthy children's serum were selected as normal controls.Polymerase chain reaction (PCR) was performed to examine β-lactosidase gene (BG) of E. coli and 16SrRNA gene. Bacteria in mesenteric lymph nodes were cultured. Immunohistochemical staining was used to indentify the T cell subsets and plasma cells in the lamina propria of mucosa. TGF-β1 in serum was quantified using enzyme-linked immunoabsorbent assay (ELISA). Results In group 1, 16SrRNA and BG were positive in 86. 4% and 72. 7% of the patients, respectively. Positive culture rate of E coli in mesenteric lymph nodes was 77. 3%. In group 2, 16SrRNA and BG positive rates were 64. 3% and 42. 8%, respectively. Positive culture rate of E coli in mesenteric lymph nodes was 57.1 %. In group 3,16SrRNA and BG positive rates were 57. 1 % and 28. 5%, respectively. 16SrRNA and BG were not detectable in normal control patients' serum and bowel. In the removed bowel, T cell subsets and plasma cells' population were significantly decreased compared with the control bowel. The serum TGF-β1 level of the patients underwent surgery was significantly higher than that of the healthy controls or the patients without surgery. But the difference was not significant between these 2 groups since 7 days after surgery. Conclusions In the children with acute intestinal obstruction, the reduction of T cell subsets and plasma cells in the lamina propria, increasing TGF-β1 in the serum are observed.These changes may be related to the damaged intestinal barrier and bacterial translocation.     

小儿急性肠梗阻细菌移位及血清IL-10变化的临床意义

目的应用PCR技术检测小儿急性肠梗阻细菌移位,探讨血清白细胞介素-10（IL-10）变化及临床意义。方法应用聚合酶链反应（PCR）定性检测小儿急性肠梗阻各组及对照组全血细菌DNA;应用酶联免疫吸附试验（ELISA）检测小儿急性肠梗阻组术前、术后及对照组血清中IL-10浓度。结果肠切除肠吻合手术组16SrRNA、大肠杆菌（BG）阳性率分别为86.4%、72.7%;未切除肠管手术组16SrRNA、BG阳性率分别为64.3%、42.8%;保守治疗组16SrRNA、BG阳性率分别为57.1%、28.5%,正常血清对照组16SrRNA、BG均未检出;肠梗阻各组术前血清IL-10浓度高于对照组（P〈0.01）;各组间术前血清IL-10浓度比较有差异（P〈0.05）;肠梗阻各组术前与术后比较有差异（P〈0.01）。结论急性肠梗阻患儿发生细菌移位,随病情加重发生细菌移位机会增加,检测IL-10对小儿急性肠梗阻细菌移位的发生机制及判断愈后有着重要意义。