新生儿单纯性胎粪性肠梗阻临床诊治:单中心10年经验回顾

Diagnosis and treatments in simple meconium ileus in neonates: ten-year experience in a single center

目的总结新生儿单纯性胎粪性肠梗阻(SMI)的临床特点,以提高对该病的诊治水平,减少阴性探查手术。方法回顾性分析2008年1月至2018年5月在武汉儿童医院新生儿外科住院的45例SMI患儿,收集患儿孕周、出生体质量、治疗方法、住院时间及随访结果等临床资料。按照手术与否分成手术组及保守治疗组:手术组行回肠末端造瘘,术中选取造瘘口处病检了解有无神经节细胞,肠造瘘术后3~6个月行关瘘手术。保守治疗组禁食、静脉营养支持、1:1氨碘醇灌肠(可反复灌肠)及经鼻胃管注入1:1氨碘醇、温9 g/L盐水洗肠1~2次/d。腹胀缓解,大便通畅后逐渐过渡到正常饮食。按照患儿就诊时间段分成前期治疗组(2008年1月至2013年5月)和后期治疗组(2013年6月至2018年5月),比较SMI治疗方案与孕周、体质量、就诊时间段的关系,采用t检验以及χ^2检验分析不同分组条件下的患儿临床资料。结果45例患儿未发现囊性病变,24例行末端回肠造瘘术,保守治疗21例。手术病例术中所见肠管外观均表现为全结肠型先天性巨结肠(HD)样改变,回肠的狭窄段、移行段及扩张段肠管术后病检均可见神经节细胞。手术组和保守治疗组在孕周、出生体质量上差异均无统计学意义(均P>0.05),但在住院时间上差异有统计学意义[(21.19±5.13) d比(12.29±3.85) d,t=6.628,P=0.000]。肠造瘘病例并发症包括:伤口感染(2例)、造瘘肠管脱垂(2例)、术后反复的水电解质紊乱(21例)、营养不良(21例)。关瘘术后电话或门诊随访5~9年,患儿并无肠神经节细胞发育不良的临床表现。在保守治疗组中,早产儿20例,足月儿1例;手术治疗组中,早产儿22例,足月儿2例,治疗方式和孕周、出生体质量并不相关(P>0.05),而与诊治时间段有关(P<0.05)。结论SMI在国内汉族新生儿中尤其是早产儿中并非少见,对于腹部体征稳定的患儿,经肛门行氨碘醇灌肠具备诊断及治疗的双重意义,必要时可反复进行。保守治疗可使绝大多数患儿免于手术探查,提高对该病的认识能有效减少阴性手术探查。

Objective To improve the accuracy of the diagnosis and decrease the unnecessary surgical exploration in neonates with simple meconium ileus (SMI) by analyzing clinical characteristics of SMI. MethodsForty-five neonates identified as SMI from January 2008 to May 2018 had been collected, and the data of pregnancy, birth weight, treatments, hospital stay and results of follow-up were included.The patients were divided into 2 groups: surgical group and non-surgical group.The surgical group underwent enterostomy at the end of ileum, meanwhile, the intestinal wall was biopsied for checking the existence of ganglion cells.All the neonates in the surgical group underwent stoma closure in 3 to 6 months postoperatively.The non-surgical group received fasting, intravenous nutritional support, enema with amiotol diluted into 11 or injected into the stomach by the gastric tube.They all received enema with warm salt (9 g/L) 1-2 times per day.Once the abdominal dilation was mitigated and autonomous defecation obtained, the neonates gradually began the oral feeding and weaned from the total parenteral nutrition(TPN). The 45 neonates were also divided into earlier group (from January 2008 to May 2013) and later group (from June 2013 to May 2018) according to the time of diagnosis.The relationships between the SMI treatment choice and the pregnancy, birth weight and time of diagnosis were analyzed. ResultsNo cystic fibrosis lesions were found in 45 neonates, of which 21 and 24 neonates were in non-surgical group and surgical group, respectively.In the operation, the intestine presented similar anatomy to the total Hirschsprung′s disease.However, the ganglion was observed not only in the stricture, transitional and dilated zone of ileum, but also in the colon.There were no significant differences in the pregnancy and birth weight in both groups(P>0.05), but there was significant difference in the duration of hospitalization [(21.19±5.13) d vs.(12.29±3.85) d, P=0.000]. There were complications in those patients who had undergone enterostomy, including wound infection (2 cases), prolapse of stoma (2 cases), water and electrolyte disorders (2 cases), malnutrition (21 cases). After the stoma closure, no signs of ganglion cell dysplasia were found in follow-up.In non-surgical group, there were 20 pre-term reonates and 1 full-term neonate, respectively.In surgical group, there were 22 pre-term reonates and 2 full-term neonate, respectively.Neither pregnancy nor birth weight was related to the choice of treatment (P>0.05), but the time when to be admitted was highly related to the choice of treatment (P<0.05). ConclusionsIt is not rare for the occurrence of SMI in neonates in China, especially in preterm neonates.Amiotol may have effects not only on diagnosis but also on treatment of SMI, which can be applied repeatedly.Non-surgical treatment can help most of the neonates with SMI to avoid surgical exploration.Enhancing apprehension about the SMI may have great advantages to decrease the rate of unnecessary laparotomy.