膈神经移位术对小儿呼吸系统远期影响的临床研究

目的探讨膈神经移位术对不同年龄小儿呼吸系统的远期影响及其规律。方法从1998年3月至2001年4月收治34例臂丛神经损伤患儿,按手术时年龄分为0~12个月组(17例),13~36个月组(11例)和37~60个月组(6例)。手术方式均采用膈神经移位术,术后随访3~7年,平均4.03年。随访时以34名同龄健康儿童作为对照进行配对(身高、体重、性别相同)研究。行常规体检、肺功能(潮气、通气功能及脉冲振荡检查)测定、血气分析及胸透观察膈肌活动度。结果与对照组相比,膈神经移位术时年龄0~12、13~36个月组患儿肺容量及肺顺应性较低(最大肺活量为0.9L±0.2L、1.2L±0.4Lvs.1.3L±0.3L、1.4L±0.5L,一秒量为0.8L±0.1L、0.9L±0.1Lvs.1.0L±0.1L、1.0L±0.1L,均P<0.05),而37~60个月组肺功能与对照组差异无统计学意义(最大肺活量为1.6L±0.4Lvs.1.8L±0.5L,一秒量为1.5L±0.1Lvs.1.6L±0.3L,均P>0.05)。3组患儿血气分析结果与对照组比较均无明显差异。胸透显示膈神经移位术后,患侧膈顶较对侧抬高0.5~3.5个肋间,平均1.93个肋间,膈顶高度差各组间差异有统计学意义(均P<0.05)。术时年龄0~12、13~36个月组患儿术后反复性呼吸道感染的发生率分别为47.1%(8/17例)和27.3%(3/11例),胸廓畸形的发生率分别为41.2%(7/17例)、9.1%(1/11例),术时年龄0~12个月的患儿尚有17.6%(3/17例)出现不同程度的消化系统症状,而术时年龄37~60个月组的患儿均无上述临床表现。结论年龄小于3岁的患儿行膈神经移位术可能对呼吸系统、胸廓发育及消化系统产生不良影响,手术年龄越小影响越显著,而3岁以上患儿膈神经切断无上述影响。

Long-term impact of transfer of phrenic nerve on respiratory system of children: a clinical study of 34 cases

OBJECTIVE: To study the long-term impact of transfer of phrenic nerve on respiratory system of children. METHODS: Thirty-four children with brachial plexus injury, 25 boys and 9 girls, underwent transfer of phrenic nerve and were divided into 3 groups according to the age when they underwent operation: group of the age of 0 - 12 months (n = 17), group of 13 - 36 months (n = 11), and group of 37 - 60 months (n = 6). Thirty-four sex, height, and body weight-matched healthy children were used as controls. Follow-up, including physical examination, pulmonary function examination (tidal volume, ventilation, etc), blood gas analysis, and chest radiography, was conducted for 4.03 years (3 - 7 years). RESULTS: The values of maximum vital capacity of the group of 0 - 12 months and group of 13 - 36 months were 1.0 L +/- 0.2 L and 1.2 L +/- 0.4 L, both significantly lower than those of the corresponding control groups (1.3 L +/- 0.3 L and 1.4 L +/- 0.5 L, both P < 0.05). The values of one-second vital capacity of the group of 0 - 12 months and group of 13 - 36 months were 0.8 L +/- 0.1 L and 0.9 L +/- 0.1 L, both significantly lower than those of the corresponding control groups (1.0 L +/- 0.1 L and 1.0 L +/- 0.1 L, both P < 0.05). However, the values of the maximum vital capacity and one-second vital capacity of the group of 37 - 60 months were 1.6 L +/- 0.3 L and 1.8 L +/- 0.5 L respectively, both not significantly different from those of the controls (both P > 0.05). The results of blood gas analysis of the 3 operation groups were not significantly different from those of the corresponding controls. Chest radiograph showed that the diaphragm top was raised by 1.93 intercostal spaces (0.5 - 3.5 intercostal spaces) in comparison with the contralateral sides with significant differences between the group of 0 - 12 months and the group of 13 - 36 months and between the group of 0 - 12 months and the group of 37 - 60 months (both P < 0.05). The recurrent respiratory infection rate and of the groups of 0 - 12 months and 13 - 36 months were 47.1% and 27.3% respectively, both significantly higher than that of the group of 37 - 60 months (0%). The thorax deformity rate of the groups of 0 - 12 months and 13 - 36 months were 41.2% and 9.1% respectively, both significantly higher than that of the group of 37 - 60 months (0%). Three of the children in the group of 0 - 12 months (17.6%) had digestive system symptoms. CONCLUSION: Transfer of phrenic nerve operated on children younger than 3 years may cause abnormalities of respiratory system, thorax, and digestive system. The younger the patients the more severe the consequences of the operation. The children older than 3 years tolerate the operation better.