胸腔镜手术治疗新生儿先天性膈疝复发的影响因素分析及其对复发膈疝的治疗效果

Analysis of influencing factors for recurrence after thoracoscopic repair of congenital diaphragmatic hernia in neonates and its treatment effect on recurrence.

目的探讨影响胸腔镜治疗新生儿先天性膈疝(congenital diaphragmatic hernia,CDH)复发的相关因素及膈疝复发的疗效。方法回顾性分析2013年1月至2019年7月由安徽省儿童医院进行胸腔镜手术的45例先天性膈疝患者的临床资料,探讨与术后膈疝复发可能有关的影响因素。结果45例中,术后复发8例,总复发率17.8%。复发组术前有25%的患者同时合并肺动脉高压和粗大动脉导管未闭,而未复发组术前无一例合并此情况,差异有统计学意义(P=0.03);缺损范围≥5 cm×4 cm的大型膈肌缺损CDH患者术后复发率(45.5%)明显高于缺损范围<5 cm×4 cm的小、中型膈肌缺损患者(8.8%),差异有统计学意义(χ2=5.329,P=0.02)。其中2013—2015年复发组手术时间为(132.83±49.32)min,明显长于未复发组(87.92±22.47)min,差异有统计学意义(t=2.779,P=0.01)。8例复发患者中,1例死亡;6例接受再次手术后治愈,无再次复发;1例接受再次手术后仍复发,第三次手术后治愈,之后无复发。结论术前有肺动脉高压合并粗大动脉导管未闭、缺损范围≥5 cm×4 cm的大型膈肌缺损以及在胸腔镜手术学习曲线早期、手术时间更长的胸腔镜治疗新生儿先天性膈疝,复发率更高。

Objective To explore the relevant influencing factors of recurrence after thoracoscopic repair of congenital diaphragmatic hernia(CDH)in neonates and its treatment effect on recurrence.Methods Clinical data were analyzed retrospectively for 45 CDH neonates undergoing thoracoscopic repair from January 2013 to July 2019.The relevant factors related to postoperative recurrence were statistically analyzed.Results Eight cases recurred with a total postoperative recurrence rate of 17.8%.Preoperation 25%of them had both pulmonary hypertension and large patent ductus arteriosus(PDA)in recurrence group while none in non-recurrence group and the difference was statistically significant(P=0.03).The postoperative recurrence rate of CDH was significantly higher in children with large diaphragm defect(defect size≥5 cm×4 cm)than that in those with small/medium diaphragm defect(defect size<5 cm×4 cm)(45.5%vs.8.8%)and the difference was statistically significant(χ2=5.329,P=0.02).From 2013 to 2015,the duration of surgery was significantly longer in recurrence group than that in non-recurrence group[(132.83±49.32)vs.(87.92±22.47)min]and the difference was statistically significant(t=2.779,P=0.01).And 1/8 recurrent cases died.Six children were cured after reoperation without secondary recurrence.One child still had recurrence after a second operation and became cured after a third operation.Conclusion Preoperative pulmonary hypertension plus large PDA,larger diaphragm defect with a size≥5 cm×4 cm and longer surgery duration in early period of thoracoscopic learning curve are associated with higher recurrent hernia rate after thoracoscopic repair of CDH in neonates.