腹腔镜手术治疗新生儿十二指肠梗阻单中心5年回顾

A 5-year single-center retrospect of laparoscopic surgery for neonatal duodenal obstruction

目的探讨新生儿十二指肠梗阻的影像学诊断和微创手术方式与疗效。方法2014年1月至2019年1月,采用腹腔镜手术治疗207例新生儿十二指肠梗阻患儿,其中男138例,女69例,手术年龄范围1~28d,手术年龄(7.41±7.81)d。比较新生儿十二指肠梗阻的产前诊断、腹部X线平片、B超及上消化道造影的阳性率。微创手术方式:十二指肠隔膜采用隔膜切除、十二指肠吻合术(纵切横缝);十二指肠闭锁及环形胰腺采用十二指肠菱形吻合或侧侧吻合术;肠旋转不良采用Ladd's术。术后随访2月~5年。比较住院时间和术后并发症发生率。结果产前诊断、腹部X线平片、B超及上消化道造影的阳性率为别为35.3%、55.1%、86.5%及92.9%,差异有统计学意义(P<0.05)。肠旋转不良组、十二指肠隔膜或闭锁组和环形胰腺组住院时间分别为(16.03±7.39)d、(21.96±10.58)d、(20.77±10.42)d,肠旋转不良组较其他两组差异有统计学意义(均P<0.05)。术后吻合口瘘1例(0.48%);术后不同时期出现肠梗阻16例(7.73%),其中肠旋转不良9例(5例行再次手术治疗);十二指肠隔膜及闭锁6例(4例行再次手术治疗),环形胰腺1例(再次手术治疗)。3组并发症发生率差异无统计学意义(P>0.05)。结论新生儿十二指肠梗阻的上消化道造影阳性率最高,但B超仍然是首选的诊断方法,越来越多的患儿在产前能得到确诊。微创手术是小儿外科发展趋势。腹腔镜手术是治疗新生儿十二指肠梗阻的有效方法。吻合口部位梗阻是十二指肠隔膜或闭锁及环形胰腺术后主要并发症,而术后粘连引起肠扭转复发是肠旋转不良Ladd’s术后主要并发症。

Objective To discuss the approach of imaging diagnosis and the result of minimally invasive surgery for neonatal duodenal obstruction. Methods From January, 2014 to January, 2019, 207 children with neonatal duodenal obstruction treated by laparoscopic surgery were chosen for the paper;of whom, 138 were male and 69 female. The age of surgery was 1 to 28 d, with an average of (7.41±7.81) d. The positive rates of antenatal diagnosis, abdominal X-ray, B-ultrasound, and upper gastrointestinal contrast of neonatal duodenal obstruction were compared. Minimally invasive surgery: diaphragm excision was adopted for duodenal septum, duodenal diamond anastomosis or side-to-side anastomosis for duodenal atresia and annular pancreas, and Ladd's surgery for malrotation. The patients were followed up for 2 months to 5 years. The hospital stay and incidence of postoperative complications were compared. Results The positive rates of antenatal diagnosis, abdominal X-ray, B-mode ultrasound, and upper gastrointestinal contrast were 35.3%, 55.1%, 86.5%, and 92.9%, respectively, with statistical differences (P < 0.05). The hospital stay of the malrotation group, the duodenal septum or atresia group, and the annular pancreas group were (16.03±7.39) d,(21.96±10.58) d, and (20.77±10.42) d, respectively;that of the malrotation group was statistically different from those of the other two groups (P < 0.05). 1 case(0.48%) had postoperative anastomotic fistula;16 (7.73%) intestinal obstruction at different stages after surgery, of which 9 were malrotation (5 cases reoperated);6 duodenal septum and atresia (4 cases reoperated);and 1 annular pancreas (reoperated). There was no statistical difference in complications among the three groups (P > 0.05). Conclusion The positive rate of upper gastrointestinal contrast of neonatal duodenal obstruction is the highest;B-ultrasound remains the preferred diagnostic approach;and an increasing number of child patients can be diagnosed before birth. Minimally invasive surgery is a growing trend of pediatric surgery, while laparoscopic surgery is an effective approach for neonatal duodenal obstruction. Anastomotic obstruction is the main complication of duodenal septum or atresia and annular pancreas after surgery, while the recurrence of volvulus caused by postoperative adhesion is the main complication of Ladd's surgery.