新生儿胃穿孔的临床特点及影响预后的因素

目的探讨新生儿胃穿孔的临床特点及影响预后的相关因素。方法本研究为回顾性研究。研究对象为山西省儿童医院新生儿外科2008年1月至2017年12月手术治疗的49例新生儿胃穿孔病例。分析这些患儿的临床表现、辅助检查、手术情况及预后等临床资料。根据预后将患儿分为存活组和死亡组,探讨影响患儿预后的相关因素。采用独立样本t检验或连续性校正χ^2检验(或Fisher精确概率法)分析数据。结果(1)49例患儿中,男29例(59.2%),女20例(40.8%);早产儿30例(61.2%),足月儿19例(38.8%);体重(2450±700)g,范围为1010~5000 g。29例(59.2%)为低出生体重儿。11例(22.4%)有围产期不良事件;17例(34.7%)术前合并感染性休克;6例(12.2%)合并其他消化道畸形。2例(4.1%)有生后窒息复苏史,2例(4.1%)合并呼吸窘迫综合征行机械通气,12例(24.5%)有留置胃管或洗胃史。(2)49例患儿的发病时间为(3.8±2.0)d,47例(95.9%)于生后1周内发病,其中36例于生后≤4 d发病;25例(51.0%)发病到手术时间≤12 h。(3)首发症状以单纯腹胀最常见69.4%(34/49)],12例(24.5%)腹胀伴呕吐,39例(79.6%)患儿术前腹部立位X射线片可见膈下大量游离气体,肝脏受压下移,胃泡影减小或消失。(4)所有患儿入院后均急诊行开腹探查、胃壁一期修补术。术中见27例(55.1%)穿孔位于胃大弯,5例(10.2%)位于胃小弯,14例(28.6%)位于胃前壁,3例(6.1%)位于胃后壁。33例(67.3%)穿孔长径≥3 cm。术后3例(6.1%)发生切口感染,2例(4.1%)吻合口漏;1例术后48 h发现大量气液胸,再次手术证实为食道重复并食道穿孔。(5)49例中,35例(71.4%)的病因为先天性胃壁肌层缺损,4例(8.2%)为损伤,10例(20.4%)为自发性穿孔。(6)49例中,8例(16.3%)死亡,36例(73.5%)存活,5例(10.2%)术后放弃治疗。剔除5例放弃治疗的患儿后,存活组中发病到手术时间≤12 h及穿孔长径<3 cm患儿的比例高于死亡组61.1%(22/36)与1/8,χ^2=4.404;41.7%(15/36)与0/8];死亡组合并感染性休克的比例高于存活组6/8与22.2%(8/36),χ^2=6.147](P值均<0.05)。结论新生儿胃穿孔病死率较高,先天性胃壁肌层缺损是新生儿胃穿孔的病理基础和主要病因,突然出现的腹胀是其主要的临床表现。尽早手术有助于提高治愈率。

Clinical characteristics and prognostic factors of neonatal gastric perforation

Objective To investigate the clinical characteristics and experience in the diagnosis and treatment of neonatal gastric perforation,and the factors influencing prognosis.Methods This was a retrospective analysis involving 49 neonatal gastric perforation cases who underwent surgical treatment in the Neonatal Surgery Department of Shanxi Children's Hospital from January 2008 to December 2017.Their clinical data,including manifestations,auxiliary examinations,operations,and prognosis,were analyzed.According to the prognosis,these patients were divided into two groups,survival group,and fatality group.Independent sample t-test or continuity correction Chi-square(or Fisher's exact)test was used for statistical analysis.Results(1)Of the 49 cases,29(59.2%)were boys,and 20(40.8%)were girls.There were 30(61.2%)premature and 19(38.8%)full-term babies.Their birth weight ranged between 1010 and 5000 g with an average of(2450±700)g.Low birth weight infants accounted for 59.2%(29/49).There were 11 cases(22.4%)having perinatal adverse events,17(34.7%)complicated by septic shock before the operation,and six(12.2%)with digestive tract malformation.Two cases(4.1%)underwent resuscitation due to postnatal asphyxia;two(4.1%)received mechanical ventilation due to respiratory distress syndrome;12(24.5%)received indwelling were indwelled gastric tube or gastric lavage.(2)The average onset time of neonatal gastric perforation in the 49 cases was(3.8±2.0)d after birth,and 47(95.9%)of them presented initial symptoms within one week,including 36 within four days.Twenty-five cases(51.0%)were operated within 12 h after the onset.(3)The common first symptoms include abdominal distention69.4%(34/49)]and abdominal distension complicated with vomiting(24.5%,12/49).Thirty-nine cases(79.6%)showed a large amount of free gas under the diaphragm,compressed and down-moving liver,and decreased or disappeared stomach bubble in the preoperative abdominal radiograph.(4)All cases received emergency laparotomy and primary gastric wall repair after admission.During the operation,27(55.1%)of all the cases had perforation at the greater curvature,five(10.2%)at the lesser curvature,14(28.6%)at the anterior wall,and three(6.1%)at the posterior wall.Perforation larger than 3 cm in diameter was found in 33 cases(67.3%).Three cases(6.1%)had postoperative wound infection;two(4.1%)developed anastomotic leakage;one was complicated by pneumohydrothorax 48 h after the operation due to esophageal duplication and perforation,which was confirmed by a second operation.(5)Of the 49 cases,35(71.4%)were due to congenital gastric wall muscular defect,four(8.2%)were caused by iatrogenic injury,and 10(20.4%)were spontaneous perforation.(6)Among all cases,36(73.5%)survived,while eight(16.3%)died,and five(10.2%)withdraw treatment after the operation.After excluding the five cases giving up treatment after the operation,the proportion of patients who underwent operation within 12 h after onset or had the perforation<3 cm in diameter was higher in the survival group than in the fatality group61.1%(22/36)vs.1/8,χ^2=4.404,P<0.05;41.7%(15/36)vs.0/8,P<0.05],and the incidence of septic shock before the operation was lower22.2%(8/36)vs.6/8,χ^2=6.147,P<0.05].Conclusions Neonatal gastric perforation shows a high mortality rate,and its underlying pathologic etiology is congenital gastric wall muscle defect.Abrupt abdominal distension is the main clinical manifestation.Early operation is critical to improving neonatal prognosis.