Terui Keita, Nagata Kouji, Ito Miharu, Yamoto Masaya, Shiraishi Masayuki, Taguchi Tomoaki, Hayakawa Masahiro, Okuyama Hiroomi, Yoshida Hideo, Masumoto Kouji, Kanamori Yutaka, Goishi Keiji, Urushihara Naoto, Kawataki Motoyoshi, Inamura Noboru, Kimura Osamu, Okazaki Tadaharu, Toyoshima Katsuaki, Usui Noriaki
Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-8677, Japan.
Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan.
Pediatr Surg Int. 2015 Oct;31(10):891-7. doi: 10.1007/s00383-015-3765-1. Epub 2015 Aug 18.
The optimal surgical approach for neonatal congenital diaphragmatic hernia (CDH) remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of endoscopic surgery (ES) for neonatal CDH.
A systematic literature search was conducted using MEDLINE and the Cochrane Library. Studies that compared surgical approaches for neonatal CDH were selected. Mortality and recurrence of herniation were analyzed as primary endpoints. Each study was evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
Eight observational studies comparing ES and open surgery (OS) met the criteria. As compared with the OS group, the ES group showed both a significantly lower mortality rate [risk ratio (RR) 0.18, 95 % confidence interval (CI) 0.09-0.38, p < 0.0001] and a significantly higher recurrence rate (RR 3.10, 95 % CI 1.95-4.88, p < 0.00001). However, serious selection bias was seen in seven of the eight studies-because the indication of ES had been determined intentionally, the ES groups may have included less severe cases.
Although the evidence was insufficient, ES was clearly associated with more recurrence than was OS. Therefore, ES should not be the routine treatment for every neonate. It is crucially important to select suitable cases for ES.
新生儿先天性膈疝（CDH）的最佳手术方式仍不明确。我们对内镜手术（ES）治疗新生儿CDH的有效性进行了系统评价和荟萃分析。
使用MEDLINE和Cochrane图书馆进行系统的文献检索。选择比较新生儿CDH手术方式的研究。将死亡率和疝复发率作为主要终点进行分析。每项研究均按照推荐分级评估、制定和评价（GRADE）系统进行评估。
八项比较ES和开放手术（OS）的观察性研究符合标准。与OS组相比，ES组的死亡率显著较低[风险比（RR）0.18，95%置信区间（CI）0.09 - 0.38，p < 0.0001]，但复发率显著较高（RR 3.10，95%CI 1.95 - 4.88，p < 0.00001）。然而，八项研究中有七项存在严重的选择偏倚——由于ES的适应症是有意确定的，ES组可能纳入了病情较轻的病例。
尽管证据不足，但ES的复发明显多于OS。因此，ES不应作为每个新生儿的常规治疗方法。为ES选择合适的病例至关重要。
