Dewitt Daughtry Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida.
Division of Pediatric Surgery, DeWitt Daughtry Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
J Surg Res. 2020 Nov;255:396-404. doi: 10.1016/j.jss.2020.05.079. Epub 2020 Jun 30.
There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol.
Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05.
Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%).
Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival.
对于患有外科坏死性小肠结肠炎（sNEC）或自发性肠穿孔（SIP）的早产儿，目前对于最佳手术治疗方法尚无明确共识；因此，制定了一个方案以指导初始腹腔引流（PD）与初始剖腹手术（LAP）之间的手术决策。我们旨在评估方案实施后的结果。
包括多家城市医院的前后研究。在实施外科方案指导治疗（2014 年 6 月至 2019 年 6 月）后，纳入患有 sNEC/SIP 的早产儿。出生体重<750g 且<2 周龄且无气腹或门静脉积气的患者，穿孔后给予 PD 治疗。PD 患者出现临床恶化或持续有胎粪/胆汁引流时，行后续 LAP。与机构历史对照相比，比较方案前后的特征和结果。设定 P<0.05 有统计学意义。
方案前和方案后队列分别包含 35 例和 73 例患者。历史对照 PD（14±13d）和方案后 PD 组之间干预时的年龄存在统计学显著差异（P=0.01），PD 患者的出生体重（716±212g 比 610±141g，P=0.02）和 LAP 患者的估计胎龄（27±1.7 周比 31±4 周，P=0.002）。与历史对照的 13%（3/23）相比，方案后 27%（12/44）的 PD 患者行 PD 作为确定性手术。所有 PD 婴儿（73%比 65%）、所有 LAP 婴儿（75%比 70%）以及初始 PD 和后续 LAP 婴儿（82%比 67%）的方案后生存率均有提高的趋势。
sNEC/SIP 中外科方案的应用与 PD 作为确定性手术的成功率提高和生存率提高相关。
