右腋下小切口入路手术治疗先天性心脏病患儿的临床疗效

Clinical effect of right subaxillary small incision approach on children with congenital heart disease

目的分析右腋下小切口入路手术在先天性心脏病(CHD)患儿中的应用价值。方法选取2015年1月至2017年9月河南省儿童医院收治的86例CHD患儿,按简单随机法分为对照组和观察组,每组各43例。对照组实施胸骨正中切口手术,观察组实施右腋下小切口入路手术,比较2组总有效率、切口满意度、手术一般情况(体外循环时间、手术时间、主动脉阻断时间、术中失血量)、术后相关情况(胸腔引流量、术后监护时间、术后辅助通气时间、住院时间、住院费用)、Wong-Baker面部表情量表(FPS-R)评分、麻醉后(T1)、术毕(T2)、入监护病房(T3)、拔管前(T4)呼吸功能指标,即呼吸道峰压(PIP)及肺泡气-动脉血氧分压差[p(A-a)(O2)]水平及并发症发生率。结果1.观察组切口满意度[90.70%(39/43例)]高于对照组[62.79%(27/43例)],2组比较差异有统计学意义(χ2=9.382,P=0.002)。2.观察组体外循环时间、手术时间、主动脉阻断时间分别为(68.94±8.26)min、(2.33±0.21)h、(28.79±7.32)min,与对照组[(67.11±9.11)min、(2.25±0.31)h、(30.02±6.88)min]比较差异均无统计学意义(均P>0.05)。3.观察组术中失血量[(89.87±11.25)mL]少于对照组[(105.91±31.01)mL],差异有统计学意义(t=3.189,P=0.002)。4.观察组术后监护时间[(30.55±10.39)h]、术后辅助通气时间[(9.68±2.19)h]、住院时间[(9.61±2.17)d]、胸腔引流量[(90.36±26.14)mL]、住院费用[(36956.15±1097.84)元]均低于对照组[(41.39±9.93)h、(12.72±3.81)h、(12.33±3.15)d、(163.24±29.36)mL、(45271.97±1134.55)元],差异均有统计学意义(t=4.946、4.536、4.663、12.157、34.540,均P<0.01)。5.观察组术后1 d、2 d、3 d、4 d FPS-R评分分别为(4.02±0.41)分、(3.41±0.15)分、(2.55±0.20)分、(1.16±0.27)分,低于对照组[(5.21±0.89)分、(5.02±0.63)分、(4.12±0.67)分、(3.05±0.39)分],差异均有统计学意义(t=7.963、16.302、14.724、26.128,均P<0.01)。6.观察组T1、T2、T3、T4时刻p(A-a)(O2)及PIP与对照组比较差异均无统计学意义(均P>0.05);观察组并发症发生率[6.98%(3/43例)]与对照组[4.65%(2/43例)]比较差异无统计学意义(χ2=0.000,P>0.05)。结论右腋下小切口入路手术不影响CHD患儿呼吸功能,可提高切口满意度,减少失血量,加快患儿术后恢复,改善术后疼痛程度,减轻家长经济负担,术中熟练准确操作可减少或避免相关并发症的发生,保证手术安全性。

Objective To analyze the clinical effect of right subaxillary small incision approach on children with congenital heart disease(CHD).Methods Eighty-six patients with CHD admitted to Henan Children′s Hospital from January 2015 to September 2017 were enrolled in this study.The patients were randomly divided into the control group and the observation group with 43 cases each group.The control group underwent sternal median incision,and the observation group underwent right subaxillary small incision.The total effective rate,incision satisfaction,general conditions of surgery(cardiopulmonary bypass time,operation time,aortic occlusion time,intraoperative blood loss),postoperative related conditions(thoracic drainage volume,postoperative monitoring time,postoperative assisted ventilation time,hospitalization time,hospitalization expenses),Wong-Baker facial expression scale(FPS-R)score,as well as the respiratory function index including the levels of peak inspiratory pressure(PIP)and alveolar-arterial oxygen pressure difference[p(A-a)(O2)]after anesthesia(T1),after operation(T2),at admission to intensive care unit(T3)and before extubation(T4)and complication rate between 2 groups were compared.Results(1)The incision satisfaction in the observation group[90.70%(39/43 cases)]was higher than that in the control group[62.79%(27/43 cases)],and the difference was statistically significant(χ2=9.382,P=0.002).(2)There was no significant difference in the the extracorporeal circulation time,operation time and aortic block time between the two groups[observation group:(68.94±8.26)min,(2.33±0.21)h,(28.79±7.32)min;control group:(67.11±9.11)min,(2.25±0.31)h,(30.02±6.88)min](P>0.05).(3)The intraoperative blood loss[(89.87±11.25)mL]in the observation group was less than that in the control group[(105.91±31.01)mL],which difference was statistically significant(t=3.189,P=0.002).(4)Also there was significant difference in postoperative monitoring time,postoperative assisted ventilation time,hospitalization time,thoracic drainage volume and hospitalization expenses between the two groups(the observation group:postoperative monitoring time(30.55±10.39)h,postoperative assisted ventilation time[(9.68±2.19)h,hospitalization time(9.61±2.17)d,thoracic drainage volume(90.36±26.14)mL,hospitalization expenses(36956.15±1097.84)yuan;the control group:(41.39±9.93)h,(12.72±3.81)h,(12.33±3.15)d,(163.24±29.36)mL and(45271.97±1134.55)yuan](t=4.946,4.536,4.663,12.157,34.540,all P<0.01).(5)FPS-R scores at 1,2,3,4 d postoperatively in the observation group were(4.02±0.41),(3.41±0.15),(2.55±0.20)and(1.16±0.27)points,while those in the control group were respectively(5.21±0.89),(5.02±0.63),(4.12±0.67)and(3.05±0.39)points,which differences were statistically significant(t=7.963,16.302,14.724,26.128,all P<0.01).(6)There was no significant difference in p(A-a)(O2)and PIP between the two groups at T1,T2,T3 and T4(all P>0.05).There was no significant difference in the complication rate between the observation group[6.98%(3/43 cases)]and the control group[4.65%(2/43 cases)](χ2=0.000,P>0.05).Conclusions Right subaxillary small incision approach does not affect the respiratory function of children with CHD,which can improve the satisfaction of incision,reduce the amount of blood loss,accelerate postoperative recovery of children,relieve postoperative pain,and reduce the financial burden of parents.Besides,intra-operative proficient and accurate operations can reduce or avoid the occurrence of related complications and ensure the safety of surgery.