风险分层分析延迟性先天性膈疝修复术：手术时机是否重要？

A risk-stratified analysis of delayed congenital diaphragmatic hernia repair: does timing of operation matter?

机构信息

Department of Surgery, The Methodist Hospital and Research Institute, Houston, TX; The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.

The Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, TX; The Children's Memorial Hermann Hospital, Houston, TX.

出版信息

Surgery. 2014 Aug;156(2):475-82. doi: 10.1016/j.surg.2014.04.015. Epub 2014 Jun 21.

DOI:10.1016/j.surg.2014.04.015

PMID:24962186

Abstract

BACKGROUND

Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns and, despite improved outcomes with multimodality therapies, optimal timing of repair remains undefined. We sought to evaluate the influence of surgical timing on patient outcomes and hypothesized that delayed repair does not improve survival in CDH.

METHODS

Prospectively collected data from 1,385 CDH Registry infants without preoperative extracorporeal membrane oxygen therapy (ECMO) were evaluated. Patients were stratified by timing of repair: Day of life (DOL) 0-3 (group 1), 4-7 (group 2), or >8 (group 3), and the effect of surgical timing on mortality was determined by logistic regression and risk-adjusted for severity of illness.

RESULTS

The unadjusted odds ratio (OR) for mortality increased significantly with delayed repair (group 2, 1.73 [95% CI, 1.00-2.98; group 3, 3.42 [95% CI, 1.97-5.96]). However, when adjusted for severity of illness, delay in repair did not predict increased mortality (group 2, 1.2 [95% CI, 0.7-2.2]; group 3, 1.4 [95% CI, 0.8-2.6]), nor did it portend an increased need for postoperative ECMO (group 2, 1.1 [95% CI, 0.5-2.4]; group 3, 0.5 [95% CI, 0.2-1.4]).

CONCLUSION

After adjustment for known risk factors, the timing of CDH repair in low-risk infants does not seem to influence mortality. However, specific clinical parameters guiding timing of elective CDH repair remain unknown.

摘要

背景

先天性膈疝（CDH）仍然是新生儿死亡的一个重要原因，尽管采用多模式治疗后结果有所改善，但修复的最佳时机仍未确定。我们旨在评估手术时机对患者结局的影响，并假设延迟修复不会改善 CDH 患者的生存率。

方法

对 1385 名先天性膈疝登记处婴儿的前瞻性收集数据进行了评估，这些婴儿在接受术前体外膜氧合治疗（ECMO）。根据修复时机将患者分层：生后第 0-3 天（第 1 组）、4-7 天（第 2 组）或>8 天（第 3 组），并通过逻辑回归确定手术时机对死亡率的影响，并根据疾病严重程度进行风险调整。

结果

未经调整的死亡率比值比（OR）随着修复时间的延迟而显著增加（第 2 组，1.73[95%CI，1.00-2.98]；第 3 组，3.42[95%CI，1.97-5.96]）。然而，当根据疾病严重程度进行调整时，修复时间的延迟并不能预测死亡率的增加（第 2 组，1.2[95%CI，0.7-2.2]；第 3 组，1.4[95%CI，0.8-2.6]），也不能预示术后需要 ECMO 的可能性增加（第 2 组，1.1[95%CI，0.5-2.4]；第 3 组，0.5[95%CI，0.2-1.4]）。