腔镜与开放手术治疗新生儿先天性膈疝的临床对比研究

发布时间：2018-05-16 04:05

本文选题：新生儿 + 先天性膈疝　；参考：《北京协和医学院》2014年博士论文

【摘要】：研究背景先天性膈疝是新生儿外科危重症之一。目前病因及发病机制尚未明确。外科手术是从根本上治疗CDH的主要手段。目前先天性膈疝外科手术方式包括开放手术和腔镜手术两种。随着微创外科的日益发展,越来越多的中心开始对新生儿膈疝行腔镜下膈疝修补术治疗。目前有研究认为腔镜手术具有打击小、术后恢复快、切口美观等优点,可作为新生儿先天性膈疝的治疗途径之一。但是,腔镜手术与开放手术治疗新生儿CDH的适应症是否相同,腔镜手术是否会有严重的并发症,应如何防范和处理,经开放和腔镜两种途径手术后患儿的临床疗效是否相当都值得进一步积累更多的患儿资料进行研究。本次研究通过回顾性对比分析2002年-2014年我院收治的先天性膈疝患儿的临床资料,通过比较开放手术与腔镜手术行新生儿膈肌修补术的临床效果,探讨新生儿膈疝腔镜手术的临床疗效、安全性和有效性,从而为进一步开展腔镜下膈肌修补术治疗新生儿CDH提供参考和依据。目的对比腔镜手术和开放手术治疗新生儿膈疝的临床疗效,探讨腔镜下治疗新生儿膈疝的可行性及安全性,为进一步开展腔镜下膈肌修补术治疗新生儿先天性膈疝提供参考和依据。方法本研究回顾性分析我院2002年6月至2014年2月采取手术治疗的59例新生儿膈疝患儿的病例资料。根据手术方式分为腔镜手术组和开放手术组,其中腔镜手术组19例,10例采用胸腔镜,9例采用腹腔镜；开放手术组40例。对比两组患儿的年龄、体重、手术时间、手术出血量、及术后住院时间,术后并发症及有无复发等资料,进行统计学分析比较。为比较术者手术经验对围手术期观察指标的影响,本研究按照腔镜手术开展的时间顺序分为近5年腔镜组(n=11,2009年3月-2014年2月)和以往腔镜组(11=8,2002年6月-2009年2月),比较两组上述观察指标的差异。结果 1.两组患儿的年龄[(3.4±0.2)d vs.(4.1±0.5)d,P=0.654]、体重[(3.3±0.3)kgvs.(3.5±0.2)kg, P=0.815]基本相同,无统计学差异。 2.腔镜手术组的手术时间(115.6±31.2min),长于开放手术组的(92.5±19.4min)；腔镜手术组术中出血量(1.53±0.22ml)、住院时间(14.2±2.7d)、术后通气时间(1.8±0.2d)、术后抗生素使用时间(2.8±0.2d)均明显少于开放手术组的(6.59±0.94ml)、(21.5±3.5d)、(5.1±0.9d)、(4.8±0.3d),差异有统计学意义(P0.05)。 3.腔镜手术组和开放手术组两组术后24h PCO2[(47.8±1.8mmHg)vs(48.6±1.5mmHg)]、术后胸腔积液发生率(10.5%vs7.5%)、复发率(15.8%vs5%)、存活率(94.7%vs95%)等观察指标的比较,差异无统计学意义(P0.05)。 4.腔镜手术组按手术开展的时间顺序比较,近5年腔镜组在手术时间(103.2±21.4min)、住院时间(13.8±2.1d)、复发率(9%)均少于以往腔镜组的(121.8±35.3min)、(15.2±2.7d)、(25%),但差异无统计学意义。结论 1.本研究结果表明腔镜膈疝修补术安全、可行,具有术中出血少、创伤小、恢复快等优点,临床效果与开放手术相当,适用于新生儿先天性膈疝的手术治疗。 2.随着术者的经验积累以及腔镜技术的发展,腔镜膈疝修补术的手术操作时间可以逐渐缩短,甚至接近开放膈肌修补术时间。 3.采用腹腔镜或胸腔镜膈肌修补术,应该根据术者自身经验以及患者的实际情况进行合理的选择,并且随着腔镜设备的更新换代以及技术的进步,腔镜下膈疝修补术的适应症可以进一步扩大。
[Abstract]:Research background
Congenital diaphragmatic hernia is one of the critical diseases in newborn surgery. The etiology and pathogenesis are not yet clear. Surgical operation is the main means to cure CDH fundamentally. The current surgical methods of congenital diaphragmatic hernia include two kinds of open surgery and endoscopic surgery. With the development of minimally invasive surgery, more and more centers begin to hernia of the newborn The treatment of diaphragmatic hernia under the cavity mirror is considered as one of the ways to treat neonatal congenital diaphragmatic hernia. However, whether endoscopic surgery is the same with open surgery for neonatal CDH and whether endoscopic surgery will have serious complications and should have serious complications. How to prevent and deal with the clinical efficacy of the two ways after open and endoscopic surgery is worth further accumulation of more children's data to study.
By comparing the clinical data of congenital diaphragmatic hernia in our hospital in -2014 2002, the clinical effect, safety and effectiveness of diaphragmatic hernia surgery of neonatal diaphragmatic hernia were discussed by comparing the clinical effects of open surgery and endoscopic surgery for neonatal diaphragmatic repair, so as to further develop the diaphragm of the diaphragm. The repair is a reference and basis for the treatment of neonatal CDH.
objective
The clinical efficacy of endoscopic surgery and open surgery in the treatment of neonatal diaphragmatic hernia is discussed, and the feasibility and safety of endoscopic treatment of neonatal diaphragmatic hernia are discussed in order to provide reference and basis for further endoscopic diaphragmatic repair for neonatal congenital diaphragmatic hernia.
Method
This study retrospectively analyzed the data of 59 cases of neonatal diaphragmatic hernia in our hospital from June 2002 to February 2014. According to the surgical methods, the endoscopic surgery group and the open operation group were divided into endoscopic surgery group and open operation group, including 19 cases with endoscopic surgery, 10 cases with thoracoscopy, 9 cases of laparoscopy, 40 cases in open surgery group. The age and body of the two groups were compared. Weight, operative time, operative blood loss, postoperative hospital stay, postoperative complications and recurrence were compared and analyzed statistically.
In order to compare the effect of surgical experience on perioperative observation, the time sequence of endoscopic surgery was divided into 5 years' endoscopic group (n=112009 March -2014 February) and previous endoscopic group (11=82002 June -2009 February), and the differences of the above observation indexes were compared in the two groups.
Result
1. the age of the two groups was (3.4 + 0.2) d vs. (4.1 + 0.5) d, P=0.654], weight [(3.3 + 0.3) kgvs. (3.5 + 0.2) kg, P=0.815] was basically the same, there was no statistical difference.
The operation time of 2. endoscopic surgery group (115.6 + 31.2min) was longer than that in open operation group (92.5 + 19.4min), the amount of bleeding (1.53 + 0.22ml), hospitalization time (14.2 + 2.7d), postoperative ventilation time (1.8 + 0.2d), and postoperative antibiotic use time (2.8 + 0.2d) were significantly less than that of open operation group (6.59 + 0.94ml), (21.5 + 3.5D), (5.1 + 0.9). D), (4.8 + 0.3d), the difference was statistically significant (P0.05).
3. 24h PCO2[(47.8 + 1.8mmHg) vs (48.6 + 1.5mmHg) after operation group and open operation group. The incidence of pleural effusion (10.5%vs7.5%), recurrence rate (15.8%vs5%), survival rate (94.7%vs95%) and other observation indexes were not statistically significant (P0.05).
4. according to the time sequence of operation, endoscopic group was compared with the operation time (103.2 + 21.4min) and hospitalization time (13.8 + 2.1d), and the recurrence rate (9%) was less than that of the previous endoscopic group (121.8 35.3min), (15.2 + 2.7d), (15.2 + 2.7d), (25%), but the difference was not significant.
conclusion
1. the results of the study show that endoscopic diaphragmatic hernia repair is safe and feasible. It has the advantages of less bleeding, less trauma and rapid recovery. The clinical effect is equivalent to the open operation. It is suitable for the surgical treatment of congenital diaphragmatic hernia of the newborn.
2. with the accumulation of experience and the development of endoscopic technique, the operation time of the endoscopic diaphragmatic hernia repair can be gradually shortened and even close to the opening of the open phrenic muscle repair.
3. the use of laparoscopic or thoracoscopic diaphragmatic repair should make a reasonable choice according to the experience of the operator and the actual situation of the patient. With the renewal of the endoscope and the progress of the technique, the indication of the endoscopic diaphragmatic hernia repair can be further expanded.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R726.5

【参考文献】