先天性尿道直肠膈缺陷关闭的两阶段途径：协作性外科手术实践中的成功演变。
The dual-staged pathway for closure in cloacal exstrophy: Successful evolution in collaborative surgical practice.
机构信息
Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA.
出版信息
J Pediatr Surg. 2019 Sep;54(9):1761-1765. doi: 10.1016/j.jpedsurg.2019.01.005. Epub 2019 Apr 8.
INTRODUCTION
A successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures.
METHODS
A prospective database of 1332 Exstrophy-Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected.
RESULTS
There are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011).
CONCLUSION
The standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes.
LEVEL OF EVIDENCE
Level III, retrospective comparative study.
引言
成功关闭腹壁和膀胱对于先天性尿道直肠膈缺陷（CE）的治疗至关重要。本研究调查了作者所在机构在过去 40 年中的关闭结果和实践。自 1995 年以来，作者所在机构采用双阶段途径（DSP）对 CE 进行了标准化关闭和管理。DSP 包括分期膀胱关闭、分期或同期截骨术以及术后使用外固定器进行固定。作者假设 DSP 为 CE 关闭提供了更好的结果。
方法
对 1975 年至 2015 年期间接受先天性尿道直肠膈缺陷（CE）治疗的 1332 例尿道上裂-会阴型尿道下裂（EEC）患者的前瞻性数据库进行了回顾性研究。对于间隙大于 4cm 的 CE 患者，DSP 包括分期截骨术和分期膀胱关闭术。为了评估 DSP，作者所在机构的关闭结果在其实施前后的两个相等的 20 年期间进行了比较。收集了手术时机、术后管理、手术并发症和结局的数据。
结果
数据库中有 142 例 CE 患者。本研究中，有 49 例 CE 患者（50 次关闭）符合纳入标准。1975 年至 1994 年期间，关闭成功率为 88%（16 例中的 14 例），而 DSP 的成功率为 100%（n=34），p=0.098。22 例（65%）采用了一期和 12 例（35%）二期 DSP 进行了闭合。DSP 的总体并发症发生率与以前的闭合相似（29%比 19%，p=0.508）。自采用 DSP 以来，接受关闭治疗的患者的术前间隙通常较大（7.2cm 比 5.1cm，p=0.011）。
结论
标准化的 DSP 关闭在过去 20 年中已成功应用于 34 例原发性和再发性 Cloacal 闭合。通过这种方法，作者认为 DSP 提供了更大的患者安全性和更好的结果。
证据等级
III 级，回顾性比较研究。
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