Mavroudis C, Backer C L, Gevitz M
Department of Surgery, Northwestern University Medical School, Chicago, Illinois.
Ann Surg. 1994 Sep;220(3):402-9; discussion 409-10. doi: 10.1097/00000658-199409000-00016.
The authors reviewed a large surgical experience (during five decades) with ligation and division of patent ductus arteriosus (PDA) in light of previously reported historical standards and present-day alternatives.
Ligation of PDA was first performed by Gross in 1938. Various surgical techniques used since then have included ligation and division, simple ligation, and hemaclip application. Recently introduced therapies include percutaneous transcatheter ductal closure devices (PTDC) and video-assisted thoracotomy (VAT). Percutaneous transcatheter ductal closure device protagonists cite surgical recurrence rates as high as 22% to justify continued application.
Between 1947 and 1993, 98.2% of 1108 patients (premature babies excluded) had interruption of PDA by ligation and division. Recent improvements have included muscle-sparing thoracotomy, minimal use of tube thoracostomy, and same-day surgery.
Mortality was zero and morbidity (4.4%) has been low over time. Mean age at surgery has decreased from 5.9 +/- 3.3 years to 3.6 +/- 3.8 years (p < 0.001); patients requiring blood transfusion decreased from 34% to 4.6% (p < 0.001); and length of hospital stay (LOS) has decreased from 12.1 +/- 2.9 days to 3.8 +/- 2.1 days (p < 0.001). Length of stay for the last 27 patients was 2.8 +/- .8 days. Patient ductus arteriosus recurrence rate is zero with this technique.
Recurrence rates for PTDC are high with as yet unknown consequences of large catheter vascular access, endocarditis, or left pulmonary artery stenosis. Video-assisted thoracotomy for PDA interruption has the potential for uncontrolled exsanguinating hemorrhage. Open thoracotomy for PDA ligation and division can be performed safely and without recurrence through a muscle-sparing incision with short LOS. All other therapeutic interventions must be compared to these standards.
作者根据先前报道的历史标准和当今的替代方法，回顾了五十年来对动脉导管未闭（PDA）进行结扎和切断的大量手术经验。
1938年格罗斯首次实施PDA结扎术。自那时起使用的各种手术技术包括结扎和切断、单纯结扎以及应用血管夹。最近引入的治疗方法包括经皮导管封堵装置（PTDC）和电视辅助胸腔镜手术（VAT）。经皮导管封堵装置的支持者引用高达22%的手术复发率来证明该方法仍需继续应用的合理性。
1947年至1993年间，1108例患者（不包括早产儿）中有98.2%通过结扎和切断术实现了PDA闭合。近期的改进包括保留肌肉的开胸术、尽量少用胸腔闭式引流术以及当日手术。
死亡率为零，且随着时间推移发病率（4.4%）一直较低。手术平均年龄从5.9±3.3岁降至3.6±3.8岁（p<0.001）；需要输血的患者从34%降至4.6%（p<0.001）；住院时间（LOS）从12.1±2.9天降至3.8±2.1天（p<0.001）。最后27例患者的住院时间为2.8±0.8天。采用该技术患者的动脉导管未闭复发率为零。
PTDC的复发率很高，同时大导管血管通路、心内膜炎或左肺动脉狭窄的后果尚不清楚。电视辅助胸腔镜手术治疗PDA有导致无法控制的大出血的风险。通过保留肌肉的切口进行开胸PDA结扎和切断术可以安全实施且无复发，住院时间短。所有其他治疗干预措施都必须与这些标准进行比较。
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