Tan Yew-Wei, Banerjee Debasish, Cross Kate M, De Coppi Paolo, Blackburn Simon C, Rees Clare M, Giuliani Stefano, Curry Joe I, Eaton Simon
Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital, London, UK.
Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital, London, UK; Stem Cells & Regenerative Medicine, DBC, Great Ormond Street Institute of Child Health, University College London, UK.
J Pediatr Surg. 2018 Oct;53(10):1883-1889. doi: 10.1016/j.jpedsurg.2018.04.009. Epub 2018 Apr 13.
BACKGROUND/PURPOSE: Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch.
We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P<0.05.
In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months). Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p=0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p=0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p=0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p=0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair.
In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence.
Systematic review LEVEL OF EVIDENCE: 3A.
背景/目的：莫尔加尼膈疝（MH）较为罕见。我们报告了基于在MH修补术中常规使用补片以控制复发的经验。进行了一项系统评价和荟萃分析，以研究与微创手术及补片使用相关的复发情况和并发症。
我们回顾性分析了2012年至2017年在我院接受首次修补术的所有MH病例，以确定复发率和并发症发生率。进行了一项与MH的微创手术（MIS）和补片修补相关的MEDLINE检索，以进行系统评价。纳入了1997年至2017年发表的、有可用随访数据的合格文章。测量的主要结局为复发和并发症。在比较队列中对开放手术与MIS以及MIS组中的初次修补与补片修补进行荟萃分析。连续数据以中位数（范围）表示，统计学显著性为P<0.05。
在我院，12例年龄为17个月（22天至7岁）的连续患者接受了MH的腹腔镜补片修补术，其中1例转为开腹手术。在8个月（1至48个月）的随访期内未发生复发或严重并发症。从文献综述中纳入了36篇文章，并与当前系列相结合。所有均为回顾性病例报告或系列研究，其中6篇为同时进行MIS和开放修补的比较队列。最终共296例来自37个系列的患者用于分析：80例行开放修补（4例使用补片），216例行MIS修补（32例使用补片），补片使用率为12%。有13例复发（4%）：开放修补与MIS修补之间无差异（4/80对比9/216，p=0.75）；初次修补后的复发率为13/260（5%），但36例补片修补未发生复发。荟萃分析显示开放修补与MIS修补在复发方面无差异（p=0.83），而补片修补与初次修补相比复发减少14%，尽管未达到统计学显著性（p=0.12）。有13例并发症（5%）：开放修补与MIS修补之间无差异（5/80对比8/216，p=0.35）。1例接受腹腔镜补片修补的患者发生了小肠梗阻。
在MH中，MIS修补与开放修补的复发率和并发症发生率相当。使用补片似乎在降低复发方面有额外益处。
系统评价 证据级别：3A
