胸腔镜下新生儿先天性膈疝微创手术的病死率及相关因素分析

潘守东; 代婷; 纪莹童; 陈刚; 马立霜; 晏馥霞

doi:10.16766/j.cnki.issn.1674-4152.002006

胸腔镜下新生儿先天性膈疝微创手术的病死率及相关因素分析

doi: 10.16766/j.cnki.issn.1674-4152.002006

1.
北京协和医学院中国医学科学院, 北京 100730
2.
首都儿科研究所附属儿童医院麻醉科, 北京 100020
3.
首都儿科研究所附属儿童医院普通(新生儿)外科, 北京 100020
4.
中国医学科学院阜外医院麻醉中心, 北京 100037

基金项目:

首都临床特色应用研究基金资助 Z181100001718096

详细信息

通讯作者:
晏馥霞，E-mail：yanfuxia@sina.com

中图分类号: R722.19
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出版历程
- 收稿日期: 2020-11-29
- 网络出版日期: 2022-02-16

Analysis of mortality and related factors in neonates with congenital diaphragmatic hernia undergoing thoracoscopic minimally invasive surgery

1.
Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China

摘要

摘要: 目的以胸腔镜为代表的微创手术，在新生儿先天性膈疝(congenital diaphragmatic hernia, CDH)中的应用日益增多。本研究的目的是分析在微创外科时代，新生儿CDH的病死率及其相关因素。方法收集2016年1月—2019年12月在首都儿科研究所附属儿童医院行手术治疗的所有新生儿先天性膈疝病例，分析术后30 d内病死率。根据入组患儿术后30 d内是否存活，分为存活组和死亡组，比较2组一般资料，术前、术中和术后可能预测因素的差异。结果研究期间共有50例CDH新生儿在我院接受手术治疗，其中32例(64.0%)在胸腔镜下完成手术，术后30 d内死亡15例(病死率为30.0%)。存活组与死亡组比较，≤孕25周产前诊断(P=0.006)、低出生体重(＜2 500 g，P=0.029)、合并简单先天性心脏病(P=0.037)、术前使用高频震荡通气(HFOV，P < 0.001)、术前氧合指数(OI，P=0.007)、美国麻醉医师体格分级(ASA分级，P=0.014)、手术时年龄(P=0.045)、开腹手术(P < 0.001)和术毕OI(P < 0.001)共9项因素差异有统计学意义。结论在微创外科时代，新生儿先天性膈疝的术后30 d病死率为30.0%，主要与患儿自身病情危重程度有关；微创手术在改善新生儿膈疝转归中的价值仍需要进行更深入研究。
- 新生儿 /
- 先天性膈疝 /
- 转归 /
- 相关因素 /
- 胸腔镜手术
Abstract: Objective To analyze the mortality and related factors of neonatal congenital diaphragmatic hernia (CDH) in the era of minimally invasive surgery. Minimally invasive surgery, represented by thoracoscopy, has been increasingly used for repair in neonates. Methods All neonates with CDH undergoing surgical repair in children's Hospital affiliated to Capital Institute of Pediatrics from January 2016 to December 2019, were retrospectively reviewed, and the mortality within 30 days after surgery was analyzed. The neonates were divided into survival group and death group according to whether they were survived within 30 days after surgery. The general information, preoperative, intraoperative and postoperative predictors of mortality were compared between the two groups. Results During the data collection period, a total of 50 cases of neonates with CDH underwent surgical repair in our hospital, of which 32 (64.0%) were completed with thoracoscopy. Fifteen neonates died within 30 days after surgery, and the mortality rate was 30.0%. There were significant differences in 9 factors between survival group and death group, including prenatal diagnosis before 25 weeks gestational age (P=0.006), low birth weight (< 2 500 g, P=0.029), combined with simple congenital heart disease (P=0.037), preoperative use of high-frequency oscillatory ventilation (HFOV, P < 0.001), preoperative oxygenation index (OI, P=0.007), American Society of Anesthesiologists (ASA) physical states (P=0.014), age at surgery after birth (P=0.045), open laparotomy (P < 0.001) and postoperative OI (P < 0.001). Conclusion In an era of minimally invasive surgery, neonates with CDH has a mortality rate of 30% within 30 days after surgery, mainly related to the severity of the disease itself. The potential of minimally invasive surgery on improving the outcome of neonatal diaphragmatic hernia should be further studied.
- The newborn /
- Congenital diaphragmatic hernia /
- Outcome /
- Related factors /
- Thoracoscopy

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表 1 CDH患儿一般资料

项目	统计数据
性别[例(%)]
男	28(56.0)
女	22(24.0)
产前诊断[例(%)]	44(88.0)
产前诊断时间[M(P₂₅，P₇₅)，孕周]	26(23，31)
出生后诊断时间[M(P₂₅，P₇₅)，h]	16(2，69)
膈疝位置位于左侧[例(%)]	41(82.0)
剖宫产[例(%)]	36(72.0)
出生时孕龄[M(P₂₅，P₇₅)，孕周]	38(37，39)
出生体重(x±s，g)	3 012.6±570.6
早产儿[例(%)]	7(14.0)
低体重儿[＜2 500 g，例(%)]	8(16.0)
分娩后1 min内气管插管[例(%)]	44(88.0)
入院时年龄[M(P₂₅，P₇₅)，h]	2(1，11)
手术时年龄[M(P₂₅，P₇₅)，h]	28(24，40)
心脏超声诊断肺动脉高压[例(%)]	35(70.0)
合并其他畸形[例(%)]
先天性心脏病^a	44(88.0)
泌尿系统畸形^b	15 (30.0)
中枢神经系统畸形^c	6(12.0)
消化系统畸形^d	6(12.0)
多指	1(2.0)
术前通气方式[例(%)]
自主呼吸	3(6.0)
常频机械通气	32(64.0)
HFOV	15(30.0)
ASA分级[例(%)]
3级	20(40.0)
4级	26(52.0)
5级	4(8.0)
手术方式[例(%)]
胸腔镜/腹腔镜手术^e	38(76.0)
中转开腹	6(12.0)
开腹手术	12(24.0)
手术时间(x±s，min)	161.4±73.1
麻醉时间(x±s，min)	242.8±92.8
术中气道峰压[M(P₂₅，P₇₅)，cm H₂O]	23(20，26)
术中液体平衡[x±s，mL/(kg·h)]	6.4±4.6
术后转归[例(%)]
治愈出院	35(70.0)
死亡	15(30.0)
存活组术后机械通气时间[M(P₂₅，P₇₅)，h]	107(61，186)
死亡组术后死亡时间[M(P₂₅，P₇₅)，h]	48(10，81)
注：^a中卵圆孔未闭36例(72.0%)，动脉导管未闭38例(76.0%)，房间隔缺损8例(16.0%)，室间隔缺损4例(8.0%)，肺动脉狭窄1例(2.0%)；^b中肾盂扩张11例(22.0%)，隐睾、尿道狭窄、多囊肾、异位肾各1例(各2.0%)；^c中侧脑室囊肿6例(12.0%)；^d中肠旋转不良5例(10.0%)、胆总管囊肿1例(2.0%)；^e中胸腔镜手术37例，腹腔镜手术1例。

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表 2 存活组与死亡组CDH患儿一般资料比较

项目	存活组(n=35)	死亡组(n=15)	统计量	P值
性别(例)
男	21	7	0.758^b	0.384
女	14	8
≤孕25周产前诊断(例)
是	11	11	7.483^b	0.006
否	24	4
膈疝位置(例)
左侧	29	12	0.058^b	0.810
右侧	6	3
分娩方式(例)
剖宫产	24	12	0.680^b	0.409
自然分娩	11	3
分娩后即刻(≤1 min)插管(例)
是	29	15	2.922^b	0.087
否	6	0
早产(出生孕周＜37，例)
是	3	4	2.856^b	0.091
否	32	11
低体重儿(出生体重＜2 500 g，例)
是	3	5	4.790^b	0.029
否	32	10
Apgar评分[M(P₂₅, P₇₅)，分]
1 min	9(9, 10)	9(9, 10)	-1.065^c	0.287
5 min	10(9, 10)	9(9, 10)	-1.650^c	0.099
10 min	10(10, 10)	10(9, 10)	-0.252^c	0.801
入院年龄(h)	2(1, 14)	1(1, 2)	-1.147^c	0.251
超声诊断肝脏疝入(例)
是	7	2	0.688^b	0.407
否	15	9
超声诊断肺动脉高压(例)
是	23	12	1.020^b	0.312
否	12	3
合并简单先天性心脏病^a(例)
是	33	11	4.365^b	0.037
否	2	4
术前HFOV(例)
是	5	10	13.719^b	＜0.001
否	30	5
术前OI[M(P₂₅, P₇₅)]	6(4，8)	13(6，22)	-2.699^c	0.007
手术时年龄[M(P₂₅, P₇₅)，h]	29(25，46)	26(16，31)	-2.002^c	0.045
手术时体重(x±s，kg)	3.1±0.7	2.8±0.6	-1.628^d	0.110
急诊手术(例)
是	20	11	1.168^b	0.280
否	15	4
ASA分级(例)
3	18	2	6.349^b	0.014
4~5	17	13
手术时间(x±s，min)	164.8±75.4	153.5±69.1	-0.496^d	0.622
麻醉时间(x±s，min)	249.9±92.5	226.3±94.5	-0.819^d	0.417
开腹手术(例)
是	7	11	12.963^b	＜0.001
否	28	4
术中见肝脏疝入(例)
是	7	7	3.704^b	0.054
否	28	8
术中使用补片(例)
是	3	3	1.299^b	0.254
否	32	12
术中液体平衡[M(P₂₅, P₇₅)，mL/(kg·h)]	6(4，9)	5(3，10)	-0.245^c	0.807
术毕OI[M(P₂₅, P₇₅)]	6(4，10)	23(11，64)	-3.631^c	＜0.001
注：^a中包括卵圆孔未闭、动脉导管未闭、房间隔缺损和(或)室间隔缺损；^b为χ²值，^c为Z值，^d为t值。

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