Department of Surgery, Kaiser Permanente Los Angeles Medical Center, 4760W Sunset Blvd, 3rd floor, Los Angeles, CA 90027, USA.
Department of Surgery, Kaiser Permanente Los Angeles Medical Center, 4760W Sunset Blvd, 3rd floor, Los Angeles, CA 90027, USA.
J Pediatr Surg. 2022 Jul;57(7):1201-1204. doi: 10.1016/j.jpedsurg.2022.02.037. Epub 2022 Mar 13.
Patent ductus arteriosus (PDA) can be a significant hemodynamic problem in preterm infants leading to increased morbidity and mortality. PDA ligation is therefore considered an urgent procedure in infants who have failed medical therapy. However, there is controversy regarding optimal timing and decision to operate. This study aimed to evaluate the outcomes and efficacy of PDA ligation in very low birth weight premature infants.
We performed a retrospective review of our institution's database and included very low birth weight premature infants (<1500 g) who underwent PDA ligation from 2008 to 2019 among 6 centers within the Southern California Kaiser Permanente network system. Indications for PDA ligation were variable but included congestive heart failure, respiratory failure, necrotizing enterocolitis, renal failure, and contraindications to medical therapy. PDA ligations were performed via thoracotomy incisions with ligations using a clip or tie. The primary outcome measure was mortality, and secondary outcomes included various postoperative morbidities.
A total of 449 patients met criteria and were included in the study. The mean birth weight was 735 g (125 g-1460 g), and mean gestational age was 25 weeks (21-36 weeks). The mean operating room time was 28 min (9-84 min). 97% of PDAs were clipped, and 3% were tied. Comorbidities at the time of operation included bronchopulmonary dysplasia (59%), retinopathy of prematurity (39%), intraventricular hemorrhage (28%), and necrotizing enterocolitis (10%). There were 2 (0.4%) operative deaths, 15 (3%) deaths within 30 days, and 20 (4%) deaths within 1 year. Other postoperative outcomes included recurrent laryngeal nerve injury (1%), chylothorax (1%), pneumothorax (0.4%), and 3 (0.6%) reoperations.
Very low birthweight premature infants with hemodynamically and clinically significant PDA are complicated patients. The risks of surgical ligation must be weighed against the potential clinical benefits. The mortality rate in our patient group within our hospital system is lower than those reported in the literature. Surgical ligation appears to be a safe and acceptable option for treatment of this complex problem, especially when medical therapy fails. Further studies are needed to elucidate specific independent risk factors that are associated with morbidity and mortality to further improve outcomes.
Level II TYPE OF STUDY: Prognosis study.
动脉导管未闭（PDA）可导致早产儿出现显著的血流动力学问题，增加发病率和死亡率。因此，对于药物治疗无效的婴儿，PDA 结扎被认为是一种紧急手术。然而，关于最佳手术时机和决策仍存在争议。本研究旨在评估极低出生体重早产儿行 PDA 结扎的结果和疗效。
我们对我院数据库进行了回顾性分析，纳入了 2008 年至 2019 年间在南加州 Kaiser Permanente 网络系统的 6 个中心接受 PDA 结扎的极低出生体重早产儿（<1500g）。PDA 结扎的指征各不相同，但包括充血性心力衰竭、呼吸衰竭、坏死性小肠结肠炎、肾衰竭和药物治疗禁忌证。PDA 结扎通过开胸切口进行，使用夹子或缝线结扎。主要结局指标为死亡率，次要结局包括各种术后并发症。
共有 449 名患者符合标准并纳入研究。平均出生体重为 735g（125g-1460g），平均胎龄为 25 周（21-36 周）。平均手术室时间为 28 分钟（9-84 分钟）。97%的 PDA 采用夹闭，3%采用结扎。手术时的合并症包括支气管肺发育不良（59%）、早产儿视网膜病变（39%）、脑室内出血（28%）和坏死性小肠结肠炎（10%）。有 2 例（0.4%）手术死亡，30 天内死亡 15 例（3%），1 年内死亡 20 例（4%）。其他术后结局包括喉返神经损伤（1%）、乳糜胸（1%）、气胸（0.4%）和 3 例（0.6%）再次手术。
患有血流动力学和临床意义显著 PDA 的极低出生体重早产儿是复杂的患者。必须权衡手术结扎的风险与潜在的临床益处。我们医院系统的患者死亡率低于文献报道。手术结扎似乎是治疗这种复杂问题的安全且可接受的选择，特别是在药物治疗失败时。需要进一步的研究来阐明与发病率和死亡率相关的具体独立危险因素，以进一步改善结局。
II 级，研究类型：预后研究。
