Department of Pediatric Surgery of the University Hospitals, Strasbourg, France.
J Pediatr Surg. 2013 Mar;48(3):488-95. doi: 10.1016/j.jpedsurg.2012.09.060.
Publications aiming to prove the feasibility and safety of thoracoscopic CDH-repair in neonates grow in numbers. Some teams use selection criteria, but none have proven statistical evidence. The aim of this study is to detect risk factors for failure of thoracoscopic primary closure of CDH in neonates.
In 8 centers performing minimal access surgery (MAS), complete prenatal, postnatal, and operative data were evaluated for a retrospective study concerning patients with thoracoscopic congenital diaphragmatic hernia (CDH) repair. Most of the selection criteria and risk factors mentioned in the literature were analyzed. Two groups were defined: Group A - neonates who tolerated thoracoscopic primary repair, and Group B - neonates who required conversion or presented with major complications after thoracoscopic repair. Univariate and multivariate logistic regressions were used to compare these two groups.
From 2006 to 2010, thoracoscopy was performed in 40 neonates: Group A consisting of 28 neonates, and Group B 9 patients. Three patients were excluded because of insufficient data or major associated malformations. Significant statistical differences were found in Group B for postnatal PaCO2 >60 mmHg, need of iNO during postnatal stabilization, intrathoracic position of the stomach, pulmonary hypertension signs on the postnatal cardiac ultrasound, and preoperative OI >3.0. On multivariate analysis, only an OI >3.0 was significantly associated with conversion or major post-operative complication of thoracoscopic primary repair.
CDH can be safely repaired in the neonatal period by thoracoscopy. The limiting factor for thoracoscopic CDH repair is PPHN. The best preoperative indicator for PPHN is OI. Prospective studies are nonetheless necessary to prove the effectiveness of using these risk factors as selection criteria to help design surgical management protocols for neonates presenting CDH.
越来越多的出版物旨在证明新生儿胸腔镜 CDH 修复的可行性和安全性。一些团队使用了选择标准，但没有一个有统计学证据。本研究旨在检测新生儿胸腔镜 CDH 一期修复失败的危险因素。
在 8 个进行微创外科手术（MAS）的中心，对接受胸腔镜先天性膈疝（CDH）修复的患者进行了回顾性研究，评估了完整的产前、产后和手术数据。分析了文献中提到的大多数选择标准和危险因素。将患者分为两组：A 组 - 能够耐受胸腔镜一期修复的新生儿，B 组 - 需要转换或胸腔镜修复后出现严重并发症的新生儿。使用单变量和多变量逻辑回归比较两组。
2006 年至 2010 年，40 名新生儿接受了胸腔镜手术：A 组 28 名，B 组 9 名。因数据不足或存在严重合并畸形，3 名患者被排除在外。B 组在出生后 PaCO2 >60mmHg、出生后稳定期需要 iNO、胃在胸腔内位置、出生后心脏超声有肺动脉高压征象和术前氧合指数（OI）>3.0 方面有显著统计学差异。多变量分析显示，只有 OI >3.0 与胸腔镜一期修复的转换或严重术后并发症显著相关。
新生儿胸腔镜 CDH 修复是安全的。胸腔镜 CDH 修复的限制因素是 PPHN。PPHN 的最佳术前指标是 OI。尽管如此，仍需要前瞻性研究来证明将这些危险因素用作选择标准以帮助制定患有 CDH 的新生儿手术管理方案的有效性。
