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。     

单肺Fontan手术1例

病儿 男,4岁.全身发绀4年余.查体:发育正常,营养中等,心率110次/min,血压98/65 mmHg(1 mm Hg=0.133kPa),SpO20.68,双肺未闻及于湿罗音.     

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.     

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.     

新生儿骶尾部畸胎瘤术后肛门直肠功能随访

目的评估新生儿骶尾部畸胎瘤术后的肛门直肠功能。方法对2008年2月至2014年1月在南京医科大学附属儿童医院新生儿外科手术治疗的新生儿骶尾部畸胎瘤患儿进行肛门直肠功能随访。记录资料包括:入院时年龄、症状和体征、手术方式、Altman分型和组织病理学分类。依据Krickenbeck分类法评估肛门直肠功能:有无自主排便、粪污等级和便秘等级。结果共计92例患儿(男/女=21/71)纳入本次研究,平均入院年龄(18.5±6.6)d(1~25 d),Altman分型Ⅰ型57例(62.0%),Ⅱ型25例(27.1%),Ⅲ型10例(10.9%)。全部患者均手术切除肿瘤及尾骨。依据Krickenbeck分类法共28例(30.4%)患儿存在肛门直肠功能障碍,其中21例(22.8%)便秘(Ⅰ型13例,Ⅱ型6例,Ⅲ型2例),7例(7.6%)污粪(Ⅰ型4例,Ⅱ型2例,Ⅲ型1例)。不同性别、组织病理学分类、手术方式患儿术后肛门直肠功能障碍的发生率存在差异,但差异无统计学意义(χ~2=3.795,P=0.051;χ~2=3.341,P=0.188;χ~2=1.737,P=0.187)。Ⅰ型、Ⅱ型和Ⅲ型患儿肛门直肠功能障碍发生率无统计学差异(χ~2=0.040,P=0.980)。Ⅱ型和Ⅲ型患儿术后出现肛门直肠功能障碍和未发生肛门直肠功能障碍者肿瘤大小比较,差异有统计学意义(t=4.003,P=0.025;t=2.796,P=0.017)。结论新生儿骶尾部畸胎瘤患儿术后可能并发肛门直肠功能障碍,其中便秘最常见,小部分患儿存在污粪。     

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。     

系膜成形联合经鼻置空肠营养管治疗新生儿高位空肠Ⅲb型闭锁

目的评估系膜成形联合经鼻置空肠营养管治疗新生儿高位空肠Ⅲb型闭锁的有效性。方法回顾分析南京医科大学附属儿童医院收治的21例先天性高位空肠Ⅲb型闭锁新生儿的临床资料,其中2013年1月至2015年12月共收治10例,手术采用肠切除肠吻合术,术中未经鼻留置空肠营养管(对照组);2016年1月至2019年4月共收治11例,手术方法采用系膜成形,同时术中经鼻留置空肠营养管(系膜成形组)。比较两组患儿术后首次经肛门排便时间、经口喂养时间、静脉营养时间;比较术后并发症发生情况。随访患儿的生长发育情况。结果系膜成形组术后首次排便时间、经口喂养时间及静脉营养时间均较对照组提前[2.8(1.7,3.5)d与5.0(5.0,6.0)d,P<0.05;14.0(13.0,15.3)d与19.5(18.3,20.8)d,P<0.05;30.0(29.5,56.3)d与57.5(56.3,66.3)d,P<0.05]。两组术后均未发生吻合口瘘,但系膜成形组肠梗阻发生率及术后再手术率明显低于对照组[10%与75%,P=0.009;0与62.5%,P=0.007],直接胆红素最高值明显低于对照组[...     

加速康复外科在新生儿肠旋转不良微创治疗中的应用

目的：评估应用加速康复外科(enhanced recovery after surgery,ERAS)处理模式在新生儿肠旋转不良微创治疗中的安全性及临床效果。方法：出生1～28 d的肠旋转不良患儿75例,明确诊断后根据家长意愿,有45例在围手术期应用加速康复外科处理模式(ERAS组),30例应用传统处理模式(对照组),比较两组患儿手术时间、术中出血量以及术后肠功能恢复时间、总住院时间、住院费用、术后应激指标和并发症发生率等情况。结果：ERAS组和对照组术中出血量及手术费用未见统计学差异(P＞0.05);手术时间ERAS组长于对照组［(111.67±15.61)min vs.(63.00±6.75)min,P＜0.05］;术后肠功能恢复时间和术后总住院时间ERAS组显著短于对照组［(36.33±6.86)h vs.(60.67±12.15)h,P＜0.05;(8.89±1.05)d vs.(12.44±1.59)d,P＜0.05］;术后主要并发症比较：肠扭转复发率ERAS组和对照组无明显差别(P＞0.05),切口感染率、应激反应阳性率和呼吸道感染率ERAS组均低于对照组(0% vs.6.66%,33.33% vs.70%,26.67 % vs.66.67%,P均＜0.05)。术后随访30 d,ERAS组及对照组均没有再入院患儿。结论：加速康复外科处理模式可以应用于新生儿肠旋转不良的微创治疗。     

单肺Fontan手术

Fontan手术经反复改良,目前全腔静脉-肺动脉外通道手术方案已被绝大多数心脏外科医师接受,并获得了较为满意的近、远期效果.随着技术的进步,对于功能性单心室伴一侧肺动脉闭锁或缺如的病人,提出了单肺Foatan手术的外科方案.     

肠液回输对新生儿小肠造瘘术后的加速康复作用

目的：探讨肠液回输对新生儿肠造瘘术后加速康复的意义。方法：回顾分析76例小肠造瘘的新生儿的临床资料,据术后有无进行肠液回输分为研究组和对照组,观察两组患者术后3个月的体重变化、血清总蛋白、白蛋白、前白蛋白、视黄醇结合蛋白、首次再住院时间和远端肠管形态。结果：术后2周高、中、低位造瘘各组比较,研究组和对照组的体重及血清总蛋白、白蛋白、前白蛋白、视黄醇结合蛋白水平指标差异无统计学意义。术后3个月高位造瘘研究组体重增长明显优于对照组［(1.2±0.3) vs. (0.8±0.4),P=0.03］,高位造瘘研究组总蛋白、白蛋白比对照组稍增加［(57.1±7.6) vs. (54.3±9.3),P=0.71;(8.2±8.5) vs. (36.3±6.2),P=0.65］,前白蛋白、视黄醇结合蛋白比对照组显著增高［(92.0±23.1) vs. (81.2±21.7),P＜0.05;(21.6±8.1) vs. (16.5±5.5),P＜0.05);术后3个月中位造瘘研究组体重增长明显优于对照组［(1.7±0.4 vs. 1.3±0.6,P=0.04),总蛋白、白蛋白比对照组稍增加［(60.3±10.3) vs. 58.1±9.0,P=0.78;40.5±9.9 vs. 39.4±7.8,P=0.86］,前白蛋白、视黄醇结合蛋白比对照组显著增高［(110.3±25.3) vs. 92.0±21.2,P＜0.05;23.8±11.0 vs. 18.3±8.9,P＜0.05］;术后3个月低位造瘘研究组体重、总蛋白、白蛋白、前白蛋白、视黄醇结合蛋白均比对照组增加,但差异无统计学意义。中高位造瘘研究组首次再住院时间比对照组明显延迟［(18.6±7.9) vs. 14.2±5.2,P＜0.05;11.2±4.1 vs. 7.1±3.8,P＜0.05］,灌肠造影显示肠液回输后远端肠管形态明显优于对照组。结论：肠液回输能改善中高位肠造瘘术后新生儿的营养状况和远端肠管形态,加速患儿康复。