Bianchi A, Dickson A P
Neonatal Surgical Unit, St Mary's Hospital, Manchester, England.
J Pediatr Surg. 1998 Sep;33(9):1338-40. doi: 10.1016/s0022-3468(98)90002-1.
In a pilot study of 14 children, born when the authors were on a 1:5 "on take" for neonatal referrals, a policy evolved of elective delayed midgut reduction without anaesthesia or sedation in the incubator on the neonatal surgical unit. There was no other form of selection, and it was fortunate that the authors did not encountered any adverse criteria in this small series.
Bowel reduction, which was pain free, was undertaken conventionally with the same attention and with no greater difficulty than under general anesthesia. Delaying midgut reduction for more than 4 hours led to more stable cardiovascular, respiratory, and renal parameters. Moderate lower limb congestion cleared rapidly.
At the end of the procedure, all children were conscious, and 12 were alert and indistinguishable from normal babies. A mild periumbilical infection developed in two patients. Eleven of the 12 surviving children established enteral nutrition within 11 to 32 days, eight within 18 days. Another child with ileal atresia and bowel dilatation required bowel tailoring and lengthening (LILT) to allow enteral nutrition. All are physically and developmentally normal, and none has required umbilical herniorrhaphy or umbilicoplasty. All except one have a "scarless" abdomen and an aesthetically normal umbilicus. In marked comparison, two children immediately and obviously were unwell with abdominal pain, tachycardia, and metabolic acidosis. Abdominal wall cellulitis rapidly developed in both. At laparotomy one had a midgut volvulus and died at 22 months of short bowel syndrome (SBS) and the other with a perforated segmental ileal atresia died at 7 months of Enterobacter cloacae septicaemia.
Our small study suggests that delayed midgut reduction without anaesthesia appears safe, carrying no additional morbidity or mortality. It helps avoid anaesthesia, muscle relaxants, and ventilation and has obvious resource benefits. The conscious child is a safety asset, and any postreduction deviation from a "normal, well-perfused, comfortable, and painfree" child is an indication for urgent laparotomy. This "minimal intervention management," when applicable, has become our preferred first option for children with gastroschisis. Further extension of this study will determine those not eligible for this technique and establish "exclusion criteria."
在一项针对14名儿童的初步研究中，作者在新生儿转诊时按1:5的比例“随叫随到”，由此形成了一项政策，即在新生儿外科病房的保温箱中对中肠复位进行选择性延迟，且不使用麻醉或镇静剂。没有其他形式的选择，幸运的是，在这个小样本系列中作者没有遇到任何不利标准。
进行无痛的肠复位，操作方式与常规相同，所给予的关注相同，且难度并不比全身麻醉时更大。将中肠复位延迟超过4小时会使心血管、呼吸和肾脏参数更稳定。下肢中度充血迅速消退。
手术结束时，所有儿童都保持清醒，其中12名警觉，与正常婴儿无异。两名患者出现轻度脐周感染。12名存活儿童中有11名在11至32天内开始肠内营养，8名在18天内开始。另一名患有回肠闭锁和肠扩张的儿童需要进行肠裁剪和延长术（LILT）以实现肠内营养。所有儿童身体和发育均正常，且均未进行脐疝修补术或脐成形术。除一名儿童外，所有儿童的腹部均“无瘢痕”，脐部外观正常。相比之下，有两名儿童立即出现明显不适，伴有腹痛、心动过速和代谢性酸中毒。两人均迅速发展为腹壁蜂窝织炎。剖腹探查时，一名儿童患有中肠扭转，22个月时死于短肠综合征（SBS），另一名患有节段性回肠闭锁穿孔的儿童7个月时死于阴沟肠杆菌败血症。
我们的小型研究表明，无麻醉延迟中肠复位似乎是安全的，不会增加额外的发病率或死亡率。它有助于避免麻醉、肌肉松弛剂和通气，且具有明显的资源效益。清醒的儿童是一项安全保障，复位后任何偏离“正常、灌注良好、舒适且无痛”的儿童表现都是紧急剖腹探查的指征。这种“最小干预管理”在适用时已成为我们对腹裂患儿的首选方案。进一步扩大这项研究将确定哪些儿童不适合这项技术，并确定“排除标准”。
