Ⅰ期无缝合肠管还纳术治疗先天性腹裂

目的 总结Ⅰ期无缝合肠管还纳术治疗先天性腹裂的经验和体会.方法 回顾性分析2007年12月至2011年8月收治的24例先天性腹裂患儿资料,15例采用气管内麻醉下Ⅰ期无缝合肠管还纳术,9例采用人工囊袋分期修复术.将两组患儿的术后进食时间及住院时间进行对比.结果 Ⅰ期无缝合组治愈13例,1例因双肾发育不良放弃,1例因硬肿症死亡;分期组9例全部治愈出院,分期组患儿的术后进食时间及住院时间明显长于Ⅰ期无缝合组.结论 采用气管内麻醉下实施Ⅰ期无缝合肠管还纳修复术,有条件地扩大了Ⅰ期无缝合肠管还纳修复方法治疗的适应证,使更多的先天性腹裂患儿免受二次手术打击,而且口服喂养时间明显提前,缩短了住院时间,也就减少了住院费用,是一种安全可靠且美容的方法.     

先天性腹裂的诊疗体会

目的总结先天性腹裂患儿的治疗经验。方法回顾性分析21例新生儿先天性腹裂患儿的病例资料。19例采用传统全麻插管下I期复位缝合术,2例采用非全麻气管插管下I期免缝手术。结果19例全麻气管插管I期复位缝合术的患儿中,治愈18例,死亡1例,死亡原因为坏死性小肠结肠炎、多器官功能衰竭。2例非全麻气管插管下I期免缝手术患儿均痊愈出院。所有存活患儿均获随访,随访时间3个月至7年,患儿均生长发育正常。结论手术是治疗先天性腹裂的主要方法,产前诊断为产房手术提供了可能,妥善的围手术期处理是手术成功的保障。     

非麻醉下床边应用免缝Silo袋处理新生儿腹裂

目的 介绍非麻醉状态下于床边应用免缝Silo袋分期处理无法Ⅰ期关闭的新生儿腹裂。方法 2004年3月和7月．收治2例新生儿腹裂，分别出生后2h和4h，1例肠管污染严重，另1例合并有肠旋转不良和胎粪性肠梗阻，2例均在清醒状态下于NICU床边应用免缝Silo袋Ⅰ期处理无法回纳腹腔的肠管，2例分别于第6d和第7d在肠管完全回纳腹腔后至手术室全麻下行腹壁关闭脐部成形术，其中例2同期行Ladd’s术和肠内胎粪清除术。结果 2例患儿术后恢复好，脐部Ⅰ期愈合，分别随访5个月和2个月，生长发育好。结论非麻醉状态下床边应用免缝Silo袋分期处理无法Ⅰ期回纳的新生儿腹裂是一简便安全的方法，并可推广至产房早期处理腹裂患儿，将有效减少患儿肠管的继发性水肿和炎症，提高生存率。     

先天性腹裂外科治疗的麻醉体会

目的总结新生儿先天性腹裂修补术的麻醉体会。方法回顾性分析23例新生儿先天性腹裂修补术的麻醉过程。结果3例采用全麻后Ⅰ期关腹直接复位缝合术，14例先采用非麻醉下免缝Silo袋Ⅰ期免缝手术，5～7d后在气管插管全麻下行Ⅱ期复位缝合术，只放置Silo袋、后期死亡或放弃治疗4例；未经任何治疗自动出院2例。手术患儿中12例麻醉过程较平稳，5例术中血压轻度下降，经加快输血输液等处理后血压回升，无麻醉死亡，均顺利完成手术。术后死亡3例，1例死于多脏器功能衰竭，2例术后肺膨胀不良死于呼吸衰竭。随访时间4个月至4年，患儿均生长发育正常。结论手术是治疗先天性腹裂的主要方法，新生儿先天性腹裂复位修补术的围手术处理关键是麻醉保障，而麻醉的重点是气道管理和保证循环功能稳定。     

小肠黏膜下层生物补片在腹裂修补术中的应用

目的 探讨小肠黏膜下层生物补片在腹裂修补术中的作用.方法 2010年6月至2015年5月,我们对20例腹裂患儿采用生物补片进行修复,其中12例采用小肠黏膜下层(SIS)生物补片一期修补腹壁缺损(SIS组),8例采用脱细胞真皮生物补片一期修补腹壁缺损(真皮组),与2006年6月至2010年5月收治的14例未用任何组织替代物、强行一期修补的腹裂患儿(对照组)的临床资料进行比较,观察胎龄、出生体重、出生至手术时间、缺损大小、暴露于腹腔外脏器情况、术后机械通气情况、术后开始进食时间、住院时间、切口感染、腹壁疝的发生率等指标.结果 三组患儿平均胎龄、出生体重、出生至手术时间、缺损大小、腹腔脏器脱出情况之间差异无统计学意义;SIS组12例患儿中仅2例患儿术后需机械通气,平均通气时间24 h,真皮组2例患儿需机械通气,平均通气时间19h,对照组10例患儿需机械通气,平均机械通气时间39 h,补片组机械通气的必要性和通气时长显著低于对照组,补片组中SIS组和真皮组机械通气的必要性和通气时长差异无统计学意义;SIS组和真皮组术后的开始进食时间分别是(186.5±37.7)h、(173.3±41.5)h,显著少于对照组开始进食时间(256.1±41.8)h;SIS组和真皮组的住院时间分别是(16.2±3.0)d、(15.1±2.2)d,显著少于对照组的住院时间(19.4±3.6)d;SIS组术后无切口感染发生,有2例术后3个月发生切口疝,1年后自行愈合,无需再次手术修补;真皮组术后3例发生切口感染、排异反应,经伤口换药、去除补片后瘢痕愈合,有2例术后5个月发生切口疝,2例约1年后逐渐自行愈合,无需再次手术修补;对照组5例发生切口感染,经换药后好转,3例切口裂开,蝶形胶布固定换药后瘢痕愈合,5例术后3个月发生切口疝,3例1年后逐渐愈合,2例2年后未愈合施行手术修补.结论 对腹壁缺损大、腹腔容积小的腹裂患儿可以采用一期补片修复的方式,以减少分期手术率、术后机械通气,降低术后腹腔压力,有利于肠道功能恢复;小肠黏膜下层(SIS)和脱细胞真皮组织补片均能用于修复腹壁缺损,但小肠黏膜下层在生物相容性、抗感染等方面优于脱细胞真皮组织.     

生理盐水袋治愈新生儿腹裂一例

患儿 :男 ,出生后 1ｄ。患儿部分胃及小肠暴露于腹腔外 ,外露肠管粗大与肥厚 ,表面充血、肿胀 ,表面纤维性渗出。术中所见 :脐部稍偏右侧有一直径为6ｃｍ裂口 ,裂口处腹壁全层缺损 ,暴露的肠管表面无任何包膜 ,裂口与脐之间有正常皮肤 ,腹腔明显狭小。诊断为先天性腹裂 ,拟行分期腹裂修补术。选用医用生理盐水袋 ,术前消毒后备用。操作方法 :选用囊袋法修补腹裂。将外露于腹腔外肠管装入生理盐水袋内 ,再将生理盐水袋与裂口周围腹壁全层缝合 ,封闭腹腔。术后悬吊囊袋避免压迫腹腔。从术后第 3ｄ开始 ,逐渐适当紧缩囊袋加压 ,使腹腔逐渐扩大 …     

新生儿先天性腹裂10例

腹裂是新生儿期严重的腹壁发育畸形。我院于 1994～2 0 0 2年 12月共收治 10例 ,存活 7例 ,现总结报告如下。临床资料一、一般资料　本组 10例 ,男 7例 ,女 3例 ;孕龄 35～ 39周 ,出生体重 2 .0～ 3.0kg ,日龄 1～ 14h ,平均 8h。 6例可见小肠、结肠暴露在腹壁外 ,4例可见胃、小肠、结肠脱出腹腔。8例入院时已排胎便 ,2例肛诊时排出。腹裂均位于脐右侧 ,裂口 3～ 5cm ,4例外院转入 ,6例本院产科出生 ,其中 3例保留脐带 10～ 2 5cm。二、手术方法　均急诊手术。采用气管内插管麻醉。温消毒液彻底冲洗暴露肠管 ,消毒周围皮肤 ,检查肠管有无闭…     

婴儿肥厚性幽门狭窄治疗策略的研究

目的比较肥厚性幽门狭窄患儿不同手术方式及不同围手术期处理策略下的临床疗效，探索更合理的治疗方案。方法回顾性分析上海市两家儿童医疗中心1992—2008年HPS临床病例，按住院时间先后次序每70例分组，按手术方式分普通手术组和腹腔镜组，按手术时间分早手术组（〈48h）和晚手术组（〉48h），按术后喂养时间分早喂养组（〈12h）、较早喂养组（12～24h）和晚喂养组（〉24h），比较临床结果。结果共计277例HPS患儿，其中男239例，女38例，人院日龄10—118d，平均人院日龄（44．4-21）d，出现呕吐至人院时间平均为（23±19）d，平均入院体重（3857±783）g。新近人院病例临床结果较好。腹腔镜手术组较普通手术组手术时间近似，术后住院天数、达全量喂养时间显著缩短，住院费用显著增加，其他结果无显著差异。早手术组临床疗效较好。早喂养组住院天数、达全量喂养时间缩短、住院费用显著降低，而并发症的发生率、呕吐致喂养方案改变的发生率及体重增长等无显著差异。结论对HPS患儿施行腹腔镜手术，可缩短术后达全量喂养时间，促进康复，总住院时间及术后住院时间缩短，医疗费用显著增加。早手术、早期喂养有助于改善临床疗效。术后12h内喂养是安全的，且能进一步改善临床疗效。     

先天性腹裂的临床回顾性研究

目的 归纳总结先天性腹裂的治疗效果及体会,展望今后的临床研究方向.方法 回顾上海新华医院、上海儿童医学中心1996年12月至2007年7月收治的23例腹裂患儿,分析其治疗效果,并分别比较低出生体重儿和正常出生体重儿、顺产儿和剖腹产儿的治疗效果.结果 Ⅰ期关腹治疗3例,治愈2例;免缝Silo袋分期修复14例,治愈12例;只放置Silo袋、但后来死亡或放弃治疗4例;未经任何治疗自动出院2例.该病的总治愈率为60.9%(14/23),病死率为13.0%(3/23),放弃治疗者占26.1%(6/23).低出生体重儿和正常出生体重儿、顺产儿和剖腹产儿的治疗效果差异无统计学意义(P＞0.05).结论 腹裂的治愈率仍有待提高.对难以Ⅰ期关腹的腹裂患儿,床边非麻醉下放置免缝Silo袋、Ⅱ期手术修复是一种安全可靠、操作简便的治疗方式.出生体重和分娩方式未对治疗效果造成影响.     

双水平正压通气和持续呼吸道正压通气在早产儿呼吸窘迫综合征中应用的比较

目的比较呼吸窘迫综合征(RDS)早产儿早期使用双水平正压通气(DuoPAP)和持续呼吸道正压通气(NCPAP)模式是否可以降低插管有创呼吸支持率和支气管肺发育不良(BPD)的发病率。方法本试验为单中心、随机对照研究,将胎龄30～34+6周出生6 h内的RDS早产儿随机分为早期使用DuoPAP组和早期使用NCPAP组,若这2种方式不能维持患儿生命体征则使用气管内插管,并使用肺表面活性物质气管内滴入,接呼吸机辅助呼吸,模式选择为同步间歇指令通气模式和辅助/控制模式。主要观察指标为出生24 h、48 h、72 h总插管有创呼吸支持率及BPD发病率,次要观察指标为使用无创呼吸机支持总时间、有创呼吸机使用时间、总用氧时间、气胸发病率、坏死性小肠结肠炎发病率、脑室内出血发病率(Ⅲ级以上)、全肠道喂养时间、总住院时间。结果入组的67例早产儿随机分为早期DuoPAP组(34例)和早期NCPAP组(33例),2组早产儿出生24 h总插管有创呼吸支持率比较差异无统计学意义(P=0.074),DuoPAP组48 h、72 h总插管有创呼吸支持率明显低于NCPAP组(P=0.030、0.033),但2组BPD发病率比较差异无统计学意义(P=0.979)。2组间次要观察指标比较差异均无统计学意义。结论早期使用DuoPAP可明显降低RDS患儿出生24 h后总插管有创呼吸支持率,但不能降低BPD发病率。     

应用免缝SILO袋分期治疗新生儿腹裂临床研究

目的　介绍应用免缝SILO袋分期治疗新生儿腹裂。方法　收集芝加哥大学儿童医院 1998年 1月至2 0 0 2年 7月应用免缝SILO袋分期治疗 15例腹裂患儿。患儿体重 2 1～ 3 5kg ,根据腹壁缺损大小选择环口直径 3～ 5cm的SILO袋。脏器回纳腹腔后择期关闭腹壁。结果　 15例患儿全部顺利分期关闭腹壁缺损。 2例 (13 3% )SILO袋在使用中滑出腹壁 ,立即于床边重新放置SILO袋。SILO袋平均使用天数为 3 7d ,完全经口进食平均为2 2d。 1例患儿伴有小肠闭锁做肠吻合后再安置SILO袋。随访 3个月至 4年 ,15例全部存活。结论　应用免缝SILO袋分期关闭腹壁缺损是一种安全、可靠、有效的方法。     

自体脐带片修补先天性腹裂

目的　报告用新生儿自体保留的脐带做成脐带片 ,修补先天性腹裂的临床观察。方法　自 1995年 5月～ 2 0 0 0年 6月 ,用自体脐带片修补新生儿腹裂 6例 ,患儿入院后立即清洗消毒 ,根据保留脐带的大小分别获得 3.0～ 3.5cm× 5 .0～ 8.0cm大小的脐带片 ,保留左侧基部 ,右侧脐片与裂开的腹壁边缘间断缝合。结果　 1例术后第 4周发生肠粘连、肠梗阻 ,家长放弃再手术而死亡 ,5例治愈出院。随访 4例 ,随访时间 3个月～ 3年 ,3例上皮覆盖后无切口疝 ,1例遗留小型腹壁疝 ,待Ⅱ期修补。患儿营养发育良好。结论　自体脐带片是患儿自身的生物活性组织 ,无毒性 ,无抗原性 ,并具有一定的弹性 ,修补腹裂后 ,能有效的减轻腹腔压力 ,并且取材容易     

The primary management of testicular maldescent in gastroschisis

Gastroschisis (GS) is the commonest abdominal-wall defect in the Western world. The conventional practice has been reduction of the viscera and closure of the abdominal wall as an emergency procedure. The testis is often a part of the prolapsed viscera along with the bowel loops, stomach, fallopian tube, etc. The primary management of prolapsed (PT) (3) and intra-abdominal (5) testes (IAT) in this condition was studied in 16 consecutive male babies with GS, each was managed by simple reposition of the testes and closure of the abdominal wall. The babies were followed up for spontaneous descent of the testes. At 18-month follow-up, all five IAT had descended into the scrotum spontaneously and were palpably normal. Of the three extra-abdominal PT, two had descended into the scrotum and were normal in size and on palpation. One was palpable in the superficial inguinal pouch. Simple reposition of the testes into the abdomen and closure of the abdominal defect is the correct approach for primary management of PT or IAT in a newborn with GS. Accepted: 6 September 2000     

先天性腹裂治疗方式20年系统评价

目的客观呈现20年来一期手术关腹和Silo技术分期修复治疗的先天性腹裂患儿存活情况。方法检索相关数据库，对两种方法治疗的腹裂患儿的存活率进行Meta分析，比较其差异。结果Meta分析显示，1988—2007年一期关腹组术后存活率高于Silo分期修复组，敏感性分析结果与之一致。亚组分析显示，1988。1997年两组存活率差异无统计学意义，1998。2007年一期关腹组存活率高于Silo分期修复组。结论1988—2007年一期手术关腹患儿术后存活率高于Silo技术分期修复。由于病例分组存在选择偏倚，难以得出一期关腹效果优于Silo技术分期修复的结论。     

Gastroschisis: primary closure is possible in most newborns

For more than 15 years, we have practiced a policy of primary repair in cases of gastroschisis. Regardless of the appearance of the intestine and the size of the abdominal cavity, a primary repair has always been considered the method of choice. Twenty-five cases treated consecutively at our departments from February 1984 to April 1990 were investigated. A majority of the infants were preterm and of low birth weight. A majority also had severe bowel abnormalities. In 1 case a delayed repair with a silo had to be performed. In 2 others a small fascial defect had to be temporarily covered with a silastic patch, but in the remaining 22 cases (88%) a primary repair could be carried out without significant morbidity. Two infants died, 1 from severe neonatal asphyxia and cerebral hemorrhage and 1 from liver failure associated with a short-bowel syndrome (the only silo case). It is our belief that primary closure is possible and should be considered in most newborns. Correspondence to: L. Olsen     

Prenatally diagnosed gastroschisis: a case for preterm delivery?

The successful surgical closure of gastroschisis is invariably followed by a prolonged ileus. Early delivery of infants with prenatally diagnosed gastroschisis has been advocated as a method of limiting the intestinal damage that occurs in utero. This study examines 47 infants with gastroschisis. The mean gestational age of the infants was 37.5 weeks, although there was no policy of induction of premature labour. The mortality for the series was 4% (2 deaths). The mean duration of post-operative ileus was 14.1 days and the mean duration of hospital stay was 38.4 days. There was no correlation between gestational age and duration of ileus or hospital stay. Analysing infants born at 36 weeks' gestation as a separate group also failed to show statistically significant differences for duration of ileus or hospital stay. As gestational age does not correlate with time taken for intestinal function to recover, elective preterm delivery of the infant with prenatally diagnosed gastroschisis is not recommended. Delivery by caesarean section conferred no benefit in this study.     

The effect of mode of delivery on outcome in fetuses with gastroschisis

The postoperative course in neonates with gastroschisis after successful surgical repair is complicated by prolonged ileus. Elective cesarean section (CS) has been advocated to limit damage to the bowel due to labor and compression in the narrow birth canal and to prevent retrograde infection. We reviewed the records of 58 infants with gastroschisis treated between 1977 and 1993; 12 were delivered by CS for obstetrical reasons and 46 were delivered vaginally (V). Mortality was higher in the CS group (V = 1/46, CS = 4/12). Both groups differed significantly with respect to birth weight and gestational age; gestational age, however, had no influence on morbidity and mortality. Primary contamination was significantly lower in the CS group (V = 29/42, CS = 3/12). However, no difference was found regarding infectious complications. No complications could be attributed directly to the mode of delivery. Since these data do not show any significant advantages of CS on morbidity and mortality, we do not recommend CS for fetuses with gastroschisis diagnosed prenatally.     

Gastroschisis closure: a technique for improved cosmetic repair

Gastroschisis closure is performed either primarily or after staged reduction of the prolapsed bowel. A technique for surgical closure of the abdominal wall defect is described which allows for an almost scarless appearance of the abdominal surface with preservation of a midline umbilicus.     

Cryptorchidism in boys with congenital abdominal wall defects

Cryptorchidism (CPT) has been suggested to be common in boys with congenital abdominal wall defects (CAWD). It has been hypothesized that the low intra-abdominal pressure in both omphalocele (OMP) and gastroschisis (GS) and brain malformations in patients with OMP contribute to the high incidence of CPT. To determine the incidence of CPT in boys with OMP and GS and to assess the relationship of CPT to the size of the AWD, prematurity, and concomitant anomalies, the hospital records and autopsy reports of 113 boys with CAWD (OMP n = 75; GS n = 38) were reviewed. Twelve (16.0%) boys with OMP had undescended testes; 5 (41.0%) of those had bilateral and 4 (23.5%) intra-abdominal undescended testes. The occurrence of CPT in OMP patients did not correlate with the size of the AWD, birth weight, or gestational age. However, congenital cardiac anomalies and cleft lip and palate were significantly more common (P < 0.05) among those with CPT. Two (5.0%) boys with GS, both of whom were born prematurely, had inilateral CPT. In patients with OMP, the incidence of CPT was significantly higher than that of healthy children. There was a correlation between CPT and congenital midline defects such as cardiac anomalies and cleft lip and palate. In patients with GS, the incidence of CPT only slightly exceeded that of normal children and may have been related to prematurity. Accepted: 6 January 1997