新生儿膈疝术后ECMO支持下治疗腹腔间隔室综合征

Treatment of abdominal compartment syndrome with extracorporeal membrane oxygenation support during neonatal diaphragmatic hernia surgery:one case report with a literature review

目的总结新生儿体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)支持下行膈疝修补术后腹腔间隔室综合征(abdominal compartment syndrome,ACS)的处理经验。方法回顾性分析广州市妇女儿童医疗中心1例ECMO支持下行经腹膈疝修补术、术后发生ACS经使用切口保护器行开腹减压术成功救治的患儿临床资料。以"congenital diaphragmatic hernia"、"extracorporeal membrane oxygenation"和"abdominal compartment syndrome"为检索词检索Pubmed、Web of science数据库相关文献;以"先天性膈疝"、"体外膜肺氧合"和"腹腔间隔室综合征"为检索词检索万方医学网、中华医学期刊网及中国知网相关文献;剔除重复病例后进行文献复习,总结新生儿于ECMO下行膈疝修补术后ACS的诊治方法。结果本例患儿于孕中期产检发现胎儿左侧膈疝,产前评估为重度肺发育不良。于39+6周剖宫产娩出,生后收入新生儿外科监护室。因呼吸不能维持,于生后第19小时行ECMO支持,生后第2天在ECMO支持下行经腹膈疝修补术。术后第4天出现ACS经保守治疗无效后于监护室床旁行开腹减压术,术中应用切口保护器保持腹腔开放取得良好效果。开腹减压术后第3天撤离ECMO,第5天关腹,生后第38天痊愈出院,随访至术后4个月无膈疝复发。共检索到相关文献16篇(共报道53例ACS患者),均为英文文献,其中4篇报道了CDH术后合并ACS共6例,其中4例行开腹减压术治疗;另外12篇报道了ECMO术后发生ACS共47例,其中37例行开腹减压术治疗。结论开腹减压术是新生儿于ECMO支持下行膈疝修补术、术后发生ACS的有效外科治疗手段,切口保护器应用于新生儿开腹减压术效果良好,值得推广。

Objective To summarize the experiences of diagnosing and treating abdominal compartment syndrome(ACS)after patch repairing of neonatal congenital diaphragmatic hernia(CDH)under extracorporeal membrane oxygenation(ECMO).Methods Retrospective reviews were conducted for the clinical data of ACS neonates due to CDH undergoing patch repairing under ECMO.Management and surgical procedure of ACS were systematically summarized.The databases of PubMed,Web of Science,Wanfang,China Academic Journals(CAJ)and China National Knowledge Infrastructure(CNKI)were searched with such keywords as"congenital diaphragmatic hernia","extracorporeal membrane oxygenation"and"abdominal compartment syndrome".Duplicate literatures were excluded and managements of ACS after patch repairing of neonatal CDH under ECMO summarized.Results One fetus with left-side CDH ultrasonically detected in second trimester was diagnosed as severe pulmonary hypoplasia.He was transferred immediately into our unit after a delivery by cesarean section at 39+6 weeks.ECMO support was provided after 19-hour mechanical ventilation and laparotomy patch repair of CDH was performed at 2 days post-birth.ACS was detected and treated with decompressive laparotomy(DL)at 4 days after repairing CDH.And a wound protector was utilized for keeping abdominal open during DL.ECMO was withdrawn at Day 3 and abdominal closure occurred at Day 5 post-DL.He was discharged at Day 38 post-birth.No recurrence occurred during a follow-up period of 4 months.A total of 16 English literature reports were reviewed.Four reports described 6 cases of CDH with postoperative ACS and 4 of them underwent DL.While another 12 reports examined 47 cases ACS under ECMO support and 37 of them underwent DL.Conclusions DL is effective for ACS during patch repair of neonatal CDH under ECMO.And wound protector is recommended for DL in neonates.