多学科联合诊疗模式对先天性重症膈疝诊治疗效10年评估

Effect of multidisciplinary treatment on outcomes in infants with congenital diaphragmatic hernia:10-year experience

目的总结上海交通大学医学院附属新华医院小儿外科实施先天性膈疝(congenital diaphragmatic hernia,CDH)患儿产前-产时-产后-随访程序化多学科综合诊疗模式(multidisciplinary treatment,MDT)10年经验,评估MDT诊疗模式对先天性重症膈疝的诊疗效果。方法收集2001年1月至2018年12月在上海交通大学医学院附属新华医院小儿外科诊治的产前诊断CDH患儿临床资料,包括明确诊断时孕周、娩出孕周、Apgar评分、膈疝类型、出生体重、肝脏位置、血气分析指标、手术方式、呼吸机维持时间和住院周期等。将152例产前诊断为膈疝的患儿纳入分析,其中男80例,女72例,左侧膈疝120例,右侧膈疝32例。将2001年1月至2008年2月收治的产前诊断膈疝病例作为非MDT组;2008年3月至2018年12月收治的产前诊断膈疝病例作为MDT组,进行对比分析。其中非MDT组8例,MDT组144例。MDT组患儿均采取多学科综合诊疗模式,包括产前管理(产前诊断、评估与产前咨询)、产时管理(分娩及抢救)、产后管理及围手术期综合管理。结果非MDT组8例,MDT组144例。135例患儿行手术治疗,非MDT组8人均行经腹开放手术;MDT组患儿中,17例因出生后呼吸、循环衰竭死亡而未行手术治疗,127例行手术治疗,66例经腹开放手术,61例为胸腔镜手术。与非MDT组患儿相比,MDT组患儿手术时间延后(4.8±2.3比1.1±0.4)d,胸腔镜辅助手术比例较大(0比48.0%),且治愈率提高(75.0%比37.5%),组间比较,差异均具有统计学意义(P<0.05)。在性别、出生体重、膈疝类型、膈肌缺损大小分级等方面,两组间的差异无统计学意义。结论应用MDT诊疗模式管理CDH患儿,使CDH的诊断和治疗形成无缝连接,有助于提高治愈率。

Objective To summarize our experiences of multidisciplinary treatment(MDT)for infants with congenital diaphragmatic hernia(CDH)and explore its effect on outcomes.Methods The medical records were retrospectively reviewed for 152 CDH infants from January 2001 to December 2018.The relevant clinical data included gestational age at diagnosis and delivery,Apgar score,types of hernia,birth weight,site of liver,admission arterial blood gas analysis,types of surgery,duration of mechanical ventilation and length of hospital stay.They were divided into two groups of non-MDT from January 2001 to February 2008(n=8)and MDT from March 2008 to December 2018(n=144).Their clinical parameters were compared and analyzed.Results There were 80 boys and 72 girls.And the involved side was left(n=120)and right(n=32).A total of 135 children were operated.In non-MDT group,all patients underwent open surgery.In MDT group,17 patients died of cardiorespiratory failure without surgery.Among 127 surgical infants,open(n=66)and mini-invasive(n=78)operations were performed.Compared with counterparts in non-MDT group,those infants in MDT group were more likely to delay in surgical timing[(4.8±2.3)vs.(1.1±0.4)days],higher utilization of thoracoscopy(0 vs.48.0%)and a higher survival rate(75.0%vs.37.5%)(all P<0.05).However,no inter-group differences existed in gender,birth weight,site/size of defect,types of surgery or prenatal diagnosis.Conclusions MDT provides an feasible and effective model for diagnosing and treating CDH with better outcomes.