极低出生体重儿动力性肠梗阻的外科干预指征与治疗策略研究

Surgical treatments for very-low-birth-weight infants with dynamic intestinal obstruction

目的探讨极低出生体重儿动力性肠梗阻的外科干预指征及治疗策略。方法回顾性分析2007年1月至2017年12月上海儿童医学中心收治的10例经手术治疗的极低出生体重儿动力性肠梗阻病例的临床资料。所有患儿均经正规内科治疗(治疗时间17～36 d)无效而行剖腹探查术,术中未发现肠道畸形,均行末端回肠造瘘术以及肠活检术。待患儿体重≥5 kg时,行二次手术关闭造瘘。收集同时期10例经内科保守治疗成功的肠动力不足、喂养不耐受的极低出生体重儿的临床资料作为对照组,通过各项指标(呕吐次数、胃潴留次数、暂禁食或减少奶量与喂奶次数等)比较手术组和对照组患儿肠动力障碍严重程度的差异。结果手术组患儿肠动力障碍较对照组更严重,内科治疗无效。手术组10例患儿中9例存活,1例死亡。存活的患儿生长发育良好,二期手术关闭造瘘后,7例排便正常,2例有轻度便秘。两次手术病理结果提示患儿肠神经节细胞有逐渐发育成熟的过程。结论对于患有动力性肠梗阻的极低出生体重儿,经内科正规治疗3周仍然无效者,应及时行末端回肠造瘘术。待患儿体重≥5 kg时可择期行关闭造瘘术,关造瘘前应充分评估远端肠管是否通畅以及肠神经节细胞发育情况。

Objective To explore the surgical indications and treatment strategies for very-low-birthweight（ VLBW） infants with dynamic intestinal obstruction. Methods Retrospective reviews were conducted for the clinical data of 10 VLBW infants with dynamic intestinal obstruction between January 2007 and December 2017. Since standard medical treatment（ 17 to 36 days） was ineffective,they were all operated. No intestinal malformations were found during laparotomy. Then ileostomy plus intestinal biopsy were performed. A secondary surgery was performed for closing stoma when these infants weighed over 5 kg. Another 10 VLBW infants with insufficient intestinal motility and feeding intolerance responding to conservative treatment were used as control group. Several severity indicators of intestinal motility disorders（ e. g. frequencies of vomiting,stomach retention,temporary fasting or temporary reduction of milk） were compared between two groups. Results Intestinal motility disorders were more severe in surgical group than those in control group. Standard medical treatments were ineffective and there were 9 survivors and 1 death in surgical group. The survivors showed excellent growth and development. After a secondary surgery,there were normal defecation（ n = 7） and mild constipation（ n = 2）. Pathological findings of two-stage surgeries hinted at gradual maturation of gut ganglion cells. Conclusion For VLBW infants with dynamic intestinal obstruction,ileostomy should be performed at terminal ileum when standard 3-week medical treatment is ineffective. A secondary surgery should be performed for closing stoma when weights exceeded 5 kg. A complete evaluation of patency of distal bowel and development of gut ganglion cells is recommended before a secondary surgery for closing stoma.