Cherian Jacob, Staggers Kristen A, Pan I-Wen, Lopresti Melissa, Jea Andrew, Lam Sandi
Division of Pediatric Neurosurgery, Texas Children's Hospital, and.
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
J Neurosurg Pediatr. 2016 Oct;18(4):416-422. doi: 10.3171/2016.1.PEDS15674. Epub 2016 Jun 3.
OBJECTIVE Due to improved nutrition and early detection, myelomeningocele repair is a relatively uncommon procedure. Although previous studies have reviewed surgical trends and predictors of outcomes, they have relied largely on single-hospital experiences or on databases centered on hospital admission data. Here, the authors report 30-day outcomes of pediatric patients undergoing postnatal myelomeningocele repair from a national prospective surgical outcomes database. They sought to investigate the association between preoperative and intraoperative factors on the occurrence of 30-day complications, readmissions, and unplanned return to operating room events. METHODS The 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric database (NSQIP-P) was queried for all patients undergoing postnatal myelomeningocele repair. Patients were subdivided on the basis of the size of the repair (< 5 cm vs > 5 cm). Preoperative variables, intraoperative characteristics, and postoperative 30-day events were tabulated from prospectively collected data. Three separate outcomes for complication, unplanned readmission, and return to the operating room were analyzed using univariate and multivariate logistic regression. Rates of associated CSF diversion operations and their timing were also analyzed. RESULTS A total of 114 patients were included; 54 had myelomeningocele repair for a defect size smaller than 5 cm, and 60 had repair for a defect size larger than 5 cm. CSF shunts were placed concurrently in 8% of the cases. There were 42 NSQIP-defined complications in 31 patients (27%); these included wound complications and infections, in addition to others. Postoperative wound complications were the most common and occurred in 27 patients (24%). Forty patients (35%) had at least one subsequent surgery within 30 days. Twenty-four patients (21%) returned to the operating room for initial shunt placement. Unplanned readmission occurred in 11% of cases. Both complication and return to operating room outcomes were statistically associated with age at repair. CONCLUSIONS The NSQIP-P allows examination of 30-day perioperative outcomes from a national prospectively collected database. In this cohort, over one-quarter of patients undergoing postnatal myelomeningocele repair experienced a complication within 30 days. The complication rate was significantly higher in patients who had surgical repair within the first 24 hours of birth than in patients who had surgery after the 1st day of life. The authors also highlight limitations of investigating myelomeningocele repair using NSQIP-P and advocate the importance of disease-specific data collection.
目的 由于营养改善和早期检测，脊髓脊膜膨出修补术是一种相对不常见的手术。尽管先前的研究回顾了手术趋势和预后预测因素，但它们很大程度上依赖于单中心经验或基于住院数据的数据库。在此，作者报告了来自全国前瞻性手术结局数据库的接受产后脊髓脊膜膨出修补术的儿科患者的30天结局。他们试图研究术前和术中因素与30天并发症、再入院和非计划重返手术室事件发生之间的关联。
方法 对2013年美国外科医师学会国家外科质量改进计划儿科数据库（NSQIP-P）中所有接受产后脊髓脊膜膨出修补术的患者进行查询。患者根据修补面积大小（<5 cm对>5 cm）进行细分。从前瞻性收集的数据中列出术前变量、术中特征和术后30天事件。使用单因素和多因素逻辑回归分析并发症、非计划再入院和重返手术室这三个不同结局。还分析了相关脑脊液分流手术的发生率及其时机。
结果 共纳入114例患者；54例因缺损面积小于5 cm接受脊髓脊膜膨出修补术，60例因缺损面积大于5 cm接受修补术。8%的病例同时进行了脑脊液分流术。31例患者（27%）发生了4个NSQIP定义的并发症；这些包括伤口并发症和感染，以及其他并发症。术后伤口并发症最为常见，27例患者（24%）发生。40例患者（35%）在30天内至少进行了一次后续手术。24例患者（21%）因初次放置分流管重返手术室。11%的病例发生了非计划再入院。并发症和重返手术室结局在统计学上均与修补时的年龄相关。
结论 NSQIP-P允许从全国前瞻性收集的数据库中检查30天围手术期结局。在这个队列中，超过四分之一接受产后脊髓脊膜膨出修补术的患者在30天内发生了并发症。出生后24小时内接受手术修补的患者并发症发生率明显高于出生后第1天以后接受手术的患者。作者还强调了使用NSQIP-P研究脊髓脊膜膨出修补术的局限性，并提倡收集疾病特异性数据的重要性。
