新生儿膈疝胸腔镜治疗后存活率的影响因素分析

目的先天性膈疝(congenital diaphragmatic hernia,CDH)是指因先天性膈肌结构缺损致腹腔内容物疝入胸腔。本研究旨在总结首都儿科研究所附属儿童医院近5年入院诊断为CDH患儿的临床资料,分析CDH患儿生存率的影响因素,为患儿产前及生后病情评估提供循证依据,进而提高CDH患儿诊疗技术。方法本组患儿经产科儿科产前咨询,新生儿外科医生产房待产,生后经绿色通道转运至我中心SNICU,由新生儿外科与超声科、NICU、心脏外科等多学科对患儿进行围术期的联合诊疗,首选胸腔镜治疗。结果2014年4月至2019年12月经我中心普通(新生儿)外科诊治的58例CDH患儿中,42例行胸腔镜手术修补膈肌,35例存活,7例死亡,死亡率占总经治量的12%,其中6例为胸腔镜手术中转为开放手术,4例存活,2例死亡,死亡率占总经治量3%;13例行开放手术修补膈肌,5例存活,8例死亡。另有3例产前诊断发现CDH,术前死亡。存活患儿与死亡患儿在产前诊断孕周、住院时间、有创通气时间、手术时机及手术方式上比较差异存在统计学意义(P<0.05)。结论胸腔镜手术在新生儿CDH治疗中安全可行。产前诊断时间、手术时机、手术方式是预测患儿预后情况的重要指标。

Prenatal evaluations and postnatal diagnosis and treatment of congenital diaphragmatic hernia

Objective Congenital diaphragmatic hernia(CDH)refers to a structural birth defect of diaphragmatic defect.We performed a retrospective analysis and summarized the experiences of thoracoscopy for neonatal diaphragmatic hernia.Methods All children received prenatal consultations at the departments of obstetrics and pediatrics.Neonatal surgeons waited for delivery in delivery room.The children were transferred into SNICU of our center through a green channel of critical newborn transport.The departments of neonatal surgery and ultrasound,NICU,cardiac surgery and other disciplines formulated treatment plans.Thoracoscopy was preferred.After operation,neonatal surgeons continued perioperative treatment in NICU.Results From April2014 to July 2019,there were 42 thoracoscopic cases of neonatal diaphragmatic hernia.35 children survived and7 died.6 cases were converted into open surgery.2 cases survived and another 2 died.Among 13 cases of open repairing,5 survived and 8 died.And 3 cases of CDH were prenatally diagnosed and died preoperatively.The mean postnatal operative time was(30±16)hours,the mean postoperative time of invasive ventilator(5±2)days and the mean hospital stay(21±13)days.After discharge,follow-ups were conducted at outpatient service or by telephone for 1 to 60 months.After pulmonary function exercises,respiratory functions recovered well.The development and activity levels were similar to those of normal same-age children.Conclusion Thoracoscopic surgery is safe and feasible in neonatal CDH treatment.Prenatal diagnosis time,operation timing,operation mode are important indicators to predict the prognosis of children.