小肠结肠炎,坏死性%外科手术%新生儿
小腸結腸炎,壞死性%外科手術%新生兒
소장결장염,배사성%외과수술%신생인
Enterocolitis,necrotizing%Surgical procedures,operative%Neonate
目的 探讨以Duck腹部X线评分(Duke abdominal assessment scale,DAAS)及七项代谢紊乱(seven clinical metrics of metabolic derangement,MD7)的发生频数来评估新生儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)适宜的手术探查时机,谋求对NEC相对客观的病情评估,使手术时机向最佳理论时点趋近.方法 回顾性分析我院新生儿外科自2012年6月至2014年10月治疗新生儿坏死性小肠结肠炎38例.其中男26例,女12例.按照修正Bell分期标准,Ⅰ期8例,Ⅱ期16例,Ⅲ期14例.入院时年龄2～33 d,足月儿15例,早产儿23例;体质量＞2 500 g 16例,2 000～2 500 g 12例,1 500～2 000 g 9例,＜1 500 g 1例.结果 全部患儿中15例经保守治疗7～22 d病愈,另23例患儿分别于入院后的1～13 d DAAS≥7分或MD7发生频数≥3而接受手术治疗.8例行开腹手术,15例行腹腔镜手术,其中5例中转开腹.术中见肠坏死10例;肠穿孔9例(1例多发穿孔),穿孔部位分别位于回肠3例,回盲部1例,升结肠3例,横结肠2例,降结肠1例;4例肠壁多处呈局灶性暗紫色,肿胀僵直,伴腹腔脓性渗出.肠穿孔修补并肠造瘘1例,肠切除肠吻合3例,肠切除肠吻合并肠造瘘9例,肠切除并肠造瘘2例,肠造瘘5例,单纯腹腔引流3例.造瘘术后发生横结肠狭窄1例,切除狭窄段后横结肠端端吻合治愈.手术患儿治愈19例,死亡3例,放弃1例,手术治愈率82.6％.DAAS≥7分的20例患儿和MD7发生频数≥3的17例患儿中,发生肠穿孔和肠坏死的分别为9例、9例和9例、6例.19例肠坏死肠穿孔的患儿中DAAS≥7分有18例,MD7发生频数≥3的有15例.DAAS＜7分的18例患儿中1例发生肠坏死.MD7发生频数＜3的21例患儿中4例发生肠坏死.即以MD7发生频数评估NEC是否发生肠坏死或穿孔的真阳性率78.9％(15/19),真阴性率89.5％(17/19),DAAS的真阳性率94.7％(18/19),真阴性率89.5％(17/19).DAAS≥7分同时MD7发生频数≥3时的真阳性率为100％(14/14),其中包括全部9例肠穿孔患儿.经ROC曲线分析,两个评价体系对NEC病情评估都有较高的临床诊断准确性.结论 由于DAAS及MD7发生频数这两个评价体系临床操作方便,且相对客观,可以考虑在此基础上建立内外科共识的NEC会诊转诊指征.同时这两个评价体系的结果也可以作为气腹以外NEC手术指征的重要补充,争取在肠坏死但尚未穿孔前及时手术干预,降低NEC穿孔概率,谋求广泛患儿更好的远期预后.
目的 探討以Duck腹部X線評分(Duke abdominal assessment scale,DAAS)及七項代謝紊亂(seven clinical metrics of metabolic derangement,MD7)的髮生頻數來評估新生兒壞死性小腸結腸炎(necrotizing enterocolitis,NEC)適宜的手術探查時機,謀求對NEC相對客觀的病情評估,使手術時機嚮最佳理論時點趨近.方法 迴顧性分析我院新生兒外科自2012年6月至2014年10月治療新生兒壞死性小腸結腸炎38例.其中男26例,女12例.按照脩正Bell分期標準,Ⅰ期8例,Ⅱ期16例,Ⅲ期14例.入院時年齡2～33 d,足月兒15例,早產兒23例;體質量＞2 500 g 16例,2 000～2 500 g 12例,1 500～2 000 g 9例,＜1 500 g 1例.結果 全部患兒中15例經保守治療7～22 d病愈,另23例患兒分彆于入院後的1～13 d DAAS≥7分或MD7髮生頻數≥3而接受手術治療.8例行開腹手術,15例行腹腔鏡手術,其中5例中轉開腹.術中見腸壞死10例;腸穿孔9例(1例多髮穿孔),穿孔部位分彆位于迴腸3例,迴盲部1例,升結腸3例,橫結腸2例,降結腸1例;4例腸壁多處呈跼竈性暗紫色,腫脹僵直,伴腹腔膿性滲齣.腸穿孔脩補併腸造瘺1例,腸切除腸吻閤3例,腸切除腸吻閤併腸造瘺9例,腸切除併腸造瘺2例,腸造瘺5例,單純腹腔引流3例.造瘺術後髮生橫結腸狹窄1例,切除狹窄段後橫結腸耑耑吻閤治愈.手術患兒治愈19例,死亡3例,放棄1例,手術治愈率82.6％.DAAS≥7分的20例患兒和MD7髮生頻數≥3的17例患兒中,髮生腸穿孔和腸壞死的分彆為9例、9例和9例、6例.19例腸壞死腸穿孔的患兒中DAAS≥7分有18例,MD7髮生頻數≥3的有15例.DAAS＜7分的18例患兒中1例髮生腸壞死.MD7髮生頻數＜3的21例患兒中4例髮生腸壞死.即以MD7髮生頻數評估NEC是否髮生腸壞死或穿孔的真暘性率78.9％(15/19),真陰性率89.5％(17/19),DAAS的真暘性率94.7％(18/19),真陰性率89.5％(17/19).DAAS≥7分同時MD7髮生頻數≥3時的真暘性率為100％(14/14),其中包括全部9例腸穿孔患兒.經ROC麯線分析,兩箇評價體繫對NEC病情評估都有較高的臨床診斷準確性.結論 由于DAAS及MD7髮生頻數這兩箇評價體繫臨床操作方便,且相對客觀,可以攷慮在此基礎上建立內外科共識的NEC會診轉診指徵.同時這兩箇評價體繫的結果也可以作為氣腹以外NEC手術指徵的重要補充,爭取在腸壞死但尚未穿孔前及時手術榦預,降低NEC穿孔概率,謀求廣汎患兒更好的遠期預後.
목적 탐토이Duck복부X선평분(Duke abdominal assessment scale,DAAS)급칠항대사문란(seven clinical metrics of metabolic derangement,MD7)적발생빈수래평고신생인배사성소장결장염(necrotizing enterocolitis,NEC)괄의적수술탐사시궤,모구대NEC상대객관적병정평고,사수술시궤향최가이론시점추근.방법 회고성분석아원신생인외과자2012년6월지2014년10월치료신생인배사성소장결장염38례.기중남26례,녀12례.안조수정Bell분기표준,Ⅰ기8례,Ⅱ기16례,Ⅲ기14례.입원시년령2～33 d,족월인15례,조산인23례;체질량＞2 500 g 16례,2 000～2 500 g 12례,1 500～2 000 g 9례,＜1 500 g 1례.결과 전부환인중15례경보수치료7～22 d병유,령23례환인분별우입원후적1～13 d DAAS≥7분혹MD7발생빈수≥3이접수수술치료.8례행개복수술,15례행복강경수술,기중5례중전개복.술중견장배사10례;장천공9례(1례다발천공),천공부위분별위우회장3례,회맹부1례,승결장3례,횡결장2례,강결장1례;4례장벽다처정국조성암자색,종창강직,반복강농성삼출.장천공수보병장조루1례,장절제장문합3례,장절제장문합병장조루9례,장절제병장조루2례,장조루5례,단순복강인류3례.조루술후발생횡결장협착1례,절제협착단후횡결장단단문합치유.수술환인치유19례,사망3례,방기1례,수술치유솔82.6％.DAAS≥7분적20례환인화MD7발생빈수≥3적17례환인중,발생장천공화장배사적분별위9례、9례화9례、6례.19례장배사장천공적환인중DAAS≥7분유18례,MD7발생빈수≥3적유15례.DAAS＜7분적18례환인중1례발생장배사.MD7발생빈수＜3적21례환인중4례발생장배사.즉이MD7발생빈수평고NEC시부발생장배사혹천공적진양성솔78.9％(15/19),진음성솔89.5％(17/19),DAAS적진양성솔94.7％(18/19),진음성솔89.5％(17/19).DAAS≥7분동시MD7발생빈수≥3시적진양성솔위100％(14/14),기중포괄전부9례장천공환인.경ROC곡선분석,량개평개체계대NEC병정평고도유교고적림상진단준학성.결론 유우DAAS급MD7발생빈수저량개평개체계림상조작방편,차상대객관,가이고필재차기출상건립내외과공식적NEC회진전진지정.동시저량개평개체계적결과야가이작위기복이외NEC수술지정적중요보충,쟁취재장배사단상미천공전급시수술간예,강저NEC천공개솔,모구엄범환인경호적원기예후.
Objective To explore the appropriate surgical exploration for necrotizing enterocolitis with Duke abdominal assessment scale (DASS) and seven clinical metrics of metabolic derangement (MD7) and discuss the best operative opportunity.Methods Retrospective analyses were performed for the clinical data of 38 confirmed cases NEC from June 2012 to October 2014.There were 26 males and 12 females with an age range of 2-33 days.According to revised Bell staging scheme,there were Ⅰ (n =8),Ⅱ (n =16) and Ⅲ (n =14).And there were 15 full-term newborns and 23 preterms.Their weights were ＞2 500 g (n =16),2 000-2 500 g (n =12) ; 1 500-2 000 g (n =9) and ＜1 500 g (n =1).Results Among them,15 cases were conservatively cured within 7-22 days while the remainder underwent surgery for DAAS ≥7 or MD7 ≥3 within 1-13 days.The procedure included laparotomy (n =8),laparoscopy (n =15) and conversion into laparotomy (n =5).Intestinal necrosis was found in 10 cases.Among 9 cases of,perforation,there was multiple perforation (n =1).The perforation sites included ileum (n =3),ileocecus (n =1),ascending colon (n =3),transverse colon (n =2) and descending colon (n =1).Intestine had focal dark purple and became swollen and stiff with abdominal purulent exudates (n =4).There were intestinal perforation repair & enterostomy (n =1),intestinal resection & anastomosis (w=3),intestinal resection anastomosis & enterostomy (n =9),2 cases to intestinal resection & enterostomy (n =2),enterostomy (n =5),abdominal cavity drainage (n =3) and enterostomy with transverse colostomy stricture healed by intestinal resection anastomosis (n =1).The curative rate of surgery was 82.6％ (19/23).Three cases died while another gave up treatment.For 20 cases with DAAS ≥7,the numbers of bowel perforation and necrosis were 9 and 9 cases respectively.For 17 cases with MD7≥3,the numbers of bowel perforation and necrosis were 9 and 6 cases respectively.And 1/18 cases with DAAS＜7 and 4/21 cases with MD7＜3 had intestinal necrosis.The true positive rate of DAAS scores was 94.7％ (18/ 19) and true negative rate 89.5％(17/19) ; the true positive rate of MD7 was 78.9％(15/19) and true negative rate 89.5 ％ (17/19).But for both DAAS ≥7 and MD7 ≥3,the true positive rate was 100％ (14/14) and this group included 9 cases with intestinal perforation.The receiver operating characteristic (ROC) curve indicated that DAAS and MD7 had higher diagnostic accuracies of identifying intestinal necrosis and perforation of NEC cases.Conclusions DAAS and MD7 are relatively objective and convenient in clinical practices.It is necessary to reach a consultation consensus between internal medicine and surgery.These two evaluation methods may be used as an important supplement of NEC surgical indications for other than pneumoperitoneum.It guides surgical intervention to reduce the incidence of preoperative perforation and achieve a better long-term prognosis.
