新生儿坏死性小肠结肠炎的外科处理

Surgical Treatment of Neonatal Necrotizing Enterocolitis

目的探讨新生儿坏死性小肠结肠炎(NEC)如何选择合适的手术时机、手术方式及围术期预防措施。方法回顾性分析本院1999年5月-2009年5月收治的45例NEC患儿的临床资料,根据临床治疗方案不同,将其分为非手术组和手术组,并比较高危因素在2组间的差异。手术组具体手术方式主要根据术中肠管坏死程度及范围决定。手术组17例患儿根据转归不同分为治愈组和死亡组,并比较预后因素在2组间的差异。结果对13个可能高危因素进行单因素分析,气腹、腹穿阳性、固定肠襻、肠壁积气、腹壁水肿或红斑、临床病情恶化、腹部拒按、腹部X线平片未见气体的腹水、肠鸣音消失在手术组与非手术组间差异均有统计学意义(Pa≤0.05),腹壁包块、PLT计数<100.0×109L-1、严重消化道出血、WBC异常(WBC≤5.0×109L-1或≥20.0×109L-1)组间比较差异均无统计学意义(Pa>0.05)。手术组行单纯肠穿孔修补术+腹腔冲洗引流术2例、肠切除肠吻合术+腹腔冲洗引流术2例、肠外置或切除坏死肠管后行肠造瘘10例、仅能行腹腔冲洗引流术3例。对8个可能的预后因素进行单因素分析,出生体质量、感染性休克、代谢性酸中毒、PLT减少、腹壁红肿或红斑在治愈组和死亡组间比较差异均有统计学意义(Pa≤0.05),而胎龄、窒息缺氧、CRP组间比较差异均无统计学意义(Pa>0.05)。结论 NEC是否需要手术,应依赖对手术高危因素的密切观察和整体情况的综合考虑,同时选择合适的手术方式,积极改善影响围术期预后、能纠治的不良因素,有助于提高NEC的治愈率。

Objective To explore the chance of the optimum operative indication, an appropriate operative therapy and a preventive measures during the perioperative period in neonatal necrotizing enterocolitis（NEC）. Methods Data of documented 45 cases with NEC were reviewed in Yuying Children＇s Hospital from May. 1999 to May. 2009 and were analyzed retrospectively. Based on the different therapies,45 eases were divided into non - operative group and operative group, and higher risk factor differences between 2 groups were compared. Surgical therapies were chosen according to the severity and extent of bowel necrosis. Seventeen cases in the operative group were further divided into the recovered group and death group,and differences of risk factor in prognosis between 2 groups were compared. Results Thirteen possible higher risk factors were analyzed by single factor research. The differences between non - operative group and operative group in pneumoperi- toneum, positive paracentesis, pneumatosis intestinalis, fixed loop on serial X - rays, abdominal erythema and edema, clinical deterioration, ab- dominal tenderness ,gasless abdomen/aseites and gurgling sound disappearance were statistically siguiflcant（Pa ≤0.05 ） while the differences in the rest 4 factors（ abdominal mass, PLT count 〈 100.0 × 109 L-1, severe alimentary tract hemorrhage and abnormality of WBC ≤5.0 × 109 L-1 or ≥20.0 × 109 L-1） were not statistically significant（ P 〉 0.05 ）. In operative group,2 cases underwent simple closure operation plus drainage and irrigation to peritoneal operation ;2 cases underwent intestinal resection -enteroanatomosis plus drainage and irrigation to perito- neal operation, 10 cases of bowel out placed or enterostomy after intestinal resection ;3 cases received the drainage and irrigation to peritoneal cavity. The differences in 8 possible risk factors in prognosis （birth weight, septic shock, metabolic acidosis, thrombocytopenia, abdominal erythema and edema） were statistically significant（ P,≤0.05 ）, while the differences in gestational ages, perinatal asphyxia, CRP were not statis- tically significant （ P 〉 0.05 ）. Conclusions Based on an overall consideration of various factors, the need for surgical treatment of NEC chil- dren depends mainly on a close monitor of higher risk factor and the overall conditions of the patients. Choosing an appropriate operative met- hod and correcting what can be corrected during the perioperative period may lift the cure rate of NEC.