胸腔镜手术与开放手术修复中小先天性膈疝的疗效比较
Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias.
作者信息
Criss Cory N, Coughlin Megan A, Matusko Niki, Gadepalli Samir K
机构信息
C.S. Mott Children's Hospital 1540 Hospital Dr., Ann Arbor, MI 48108.
C.S. Mott Children's Hospital 1540 Hospital Dr., Ann Arbor, MI 48108.
出版信息
J Pediatr Surg. 2018 Apr;53(4):635-639. doi: 10.1016/j.jpedsurg.2017.09.010. Epub 2017 Sep 25.
INTRODUCTION
Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.
METHODS
All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients <36weeks gestation, birth weight <1500g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.
RESULTS
The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs. 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p=0.28). Median time to recurrence was 88days for the open repair and 183days (IQR 165-218) for the thoracoscopic group. There were no mortalities in either group.
CONCLUSIONS
In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.
LEVEL OF EVIDENCE
Level III.
引言
对于先天性膈疝（CDH）修复术采用胸腔镜手术还是开放手术的适应症尚不清楚，因为缺损大小、疾病严重程度和患者特征的变异性带来了挑战。很少有研究对两种技术进行患者和疾病匹配的比较。我们旨在比较低风险人群中小至中等大小疝缺损的开放修复术与胸腔镜修复术的临床结果。
方法
回顾性分析2006年至2016年间在一家学术儿童医院接受小（A型）和中（B型）大小缺损的CDH修复术的所有新生儿。排除孕周<36周、出生体重<1500g或需要体外生命支持的患者。记录人口统计学数据，包括CDH严重程度指数和疝的特征。主要结局参数为复发情况。次要结局包括住院时间、机械通气时间、达到目标喂养的时间和死亡率。
结果
接受胸腔镜修复术（35例）和开放修复术（16例）的51例患者在患者和疝的特征方面相似，两组的中位随访时间均为2年。接受胸腔镜修复术的患者住院时间较短（16天对23天，p = 0.03）、呼吸机使用天数较少（5天对12天，p = 0.02）、开始肠内喂养的天数较少（5天对10天）以及达到目标喂养的天数较少（11天对20天，p = 0.006）。胸腔镜组较高的复发率（17.1%对6.3%）无统计学意义（p = 0.28）。开放修复术的复发中位时间为88天，胸腔镜组为183天（四分位间距165 - 218天）。两组均无死亡病例。
结论
对于出生时患有小至中等大小缺损的低风险患者，胸腔镜手术与缩短住院时间、减少机械通气天数和缩短喂养时间相关；然而，复发率有升高趋势。
证据水平
三级。
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