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中华妇幼临床医学杂志(电子版) ›› 2022, Vol. 18 ›› Issue (06) : 703 -711. doi: 10.3877/cma.j.issn.1673-5250.2022.06.012

论著

新生儿消化道穿孔患儿的临床特点及治疗结局
李佳丽1, 吴杨2, 张莉1, 夏斌1, 何洋1, 陈忠1, 唐军1,†(), 母得志1   
  1. 1四川大学华西第二医院儿科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
    2四川大学华西医院小儿外科，成都　610041
  • 收稿日期:2022-04-07 修回日期:2022-10-10 出版日期:2022-12-01
  • 通信作者: 唐军

Clinical characteristics and outcomes of neonatal gastrointestinal perforation

Jiali Li1, Yang Wu2, Li Zhang1, Bin Xia1, Yang He1, Zhong Chen1, Jun Tang1,†(), Dezhi Mu1   

  1. 1Department of Neonatology, Key Laboratory of Birth Defects and Related Disseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
    2Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2022-04-07 Revised:2022-10-10 Published:2022-12-01
  • Corresponding author: Jun Tang
  • Supported by:
    National Natural Science Foundation of China(82171710)
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引用本文：

李佳丽, 吴杨, 张莉, 夏斌, 何洋, 陈忠, 唐军, 母得志. 新生儿消化道穿孔患儿的临床特点及治疗结局[J]. 中华妇幼临床医学杂志(电子版), 2022, 18(06): 703-711.

Jiali Li, Yang Wu, Li Zhang, Bin Xia, Yang He, Zhong Chen, Jun Tang, Dezhi Mu. Clinical characteristics and outcomes of neonatal gastrointestinal perforation[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2022, 18(06): 703-711.

目的

探讨新生儿消化道穿孔患儿的病因、临床特点、治疗和结局。

方法

选取2020年1月至2022年4月四川大学华西第二医院新生儿科收治的63例新生儿消化道穿孔患儿为研究对象。采取回顾性分析方法，根据消化道穿孔部位，将其分为肠穿孔组(n＝51)、胃穿孔组(n＝8)和穿孔部位不明组(n＝4)。回顾性分析所有患儿的一般临床资料、实验室及影像学检查结果、手术相关情况、术后治疗及预后等。本研究遵循的程序符合四川大学华西第二医院伦理委员会规定，通过该伦理委员会批准(审批文号：医学科研2022伦审批第〔141〕号)。

结果

①消化道穿孔原因：胃穿孔组患儿均因先天性胃壁肌层缺损所致(8/8)；肠穿孔组患儿中，由于NEC、自发性肠穿孔(SIP)、肠闭锁、食管闭锁合并食管气管瘘、胎粪性腹膜炎与先天性巨结肠所致穿孔各为38例(74.5%)、7例(13.7%)、3例(5.9%)、1例(2.0%)、1例(2.0%)与1例(2.0%)；其余4例穿孔部位不明。②临床表现：患儿均以腹胀、气促、呼吸困难、反应差等为主要表现。③辅助检查：其中53例(81.0%，51/63)患儿的腹部X射线摄片检查结果提示腹腔游离气体。④治疗措施：60例(95.2%)接受手术治疗(剖腹探查术为38例，仅行腹腔引流术为12例，腹腔引流术+剖腹探查术为10例)，3例采取保守治疗措施。⑤治疗结局：40例(63.5%)治愈出院，17例(27.0%)主动要求出院，6例(9.5%)住院死亡。45例(75.0%，45/60)接受手术患儿术后恢复肠内营养。

结论

NEC、SIP、先天性胃壁肌层缺损是导致新生儿消化道穿孔的主要病因。结合临床表现及影像学检查结果尽早识别、积极外科手术，或可降低新生儿消化道穿孔患儿死亡率。

关键词: 婴儿，新生，疾病, 胃肠道, 穿孔, 胃肠外营养, 小肠结肠炎，坏死性, 剖腹术, 保守治疗, 婴儿，新生
Objective

To investigate the etiology, clinical characteristics, treatment and outcomes of neonatal gastrointestinal perforation.

Methods

From January 2020 to April 2022, 63 neonates with gastrointestinal perforation were selected into this study. According to different kinds of digestive tract perforation, they were divided into intestinal perforation group (n=51), gastric perforation group (n=8) and unknown perforation group (n=4). The general clinical data, laboratory and imaging findings, operation-related conditions, postoperative treatment and prognosis of those 63 newborns were retrospectively analyzed. The procedure followed in this study conformed to the regulations of the Ethics Committee of West China Second University Hospital, Sichuan University and was approved by the Ethics Committee[2022(141)].

Results

①Causes of perforation: gastric perforations of neonates in gastric perforation group all were caused by congenital myometrial defect of gastric wall (8/8). Intestinal perforations of neonates in intestinal perforation group all were caused by various diseases, including neonatal necrotizing enterocolitis (NEC) (74.5%, 38/51), spontaneous intestinal perforation (SIP) (13.7%, 7/51), intestinal atresia (5.9%, 3/51), tracheoesophageal fistula and esophageal atresia (TEA) (2.0%, 1/51), meconium peritonitis (2.0%, 1/51) and Hirschsprung′s disease (2.0%, 1/51). ②Clinical manifestations: the main clinical manifestations were abdominal distension, shortness of breath, dyspnea and poor reaction, et al. ③Auxiliary inspection: 53 newborns (81.0%, 53/61) with gastrointestinal perforation showed the free gas in abdominal X-ray examination. ④Treatment: among 63 newborns, 60 cases (95.2%) underwent exploratory laparotomy, among them, 38 cases underwent laparotomy, 12 cases underwent abdominal drainage, and 10 cases underwent abdominal drainage + laparotomy. Other 3 cases were treated conservatively. ⑤Outcomes: 45 newborns (75.0%, 45/60) recovered enteral nutrition after operation, 40 cases (63.5%) were cured and discharged, 17 cases (27.0%) were discharged against medical advice, 6 patients (9.5%) died in hospital.

Conclusions

NEC, SIP and congenital myometrial defect of gastric wall are the main causes of neonatal gastrointestinal perforation. Combined with clinical manifestations and imaging examination, early identification and active surgery may reduce the mortality rate of neonatal digestive tract perforation.

Key words: Infant, newborn, diseases, Gastrointestinal tract, Perforation, Parenteral nutrition, Enterocolitis, necrotizing, Laparotomy, Conservative treatment, Infant, newborn
表1 3组新生儿消化道穿孔患儿一般临床资料
项目 肠穿孔组(n＝51) 胃穿孔组(n＝8) 穿孔部位未明组(n＝4)
性别[例数(%)]
男 27(52.9) 8 2
女 24(38.1) 0 2
出生胎龄[周，M(Q1，Q3)] 34.0(30.6~37.9) 33.2(30.6~34.7) 28.3(26.0~31.3)
出生体重[g，M(Q1，Q3)] 1 930(1 350~2 850) 1 880(1 365~2 138) 1 010(770~1 260)
穿孔日龄[d，M(Q1，Q3)] 8(5~16) 2.5(1.3~3.0) 6.0(2.5~8.8)
足月儿[例数(%)]a 15(29.4) 0 0
早产儿[例数(%)]a 36(70.6) 8 4
28周≤出生胎龄<32周[例数(%)]a 15(29.4) 3 2
出生胎龄<28周[例数(%)]a 5(9.8) 0 2
2 500 g<出生体重≤3 999 g[例数(%)]a 16(31.4) 0 0
出生体重<2 500g[例数(%)]a 35(68.6) 8 4
1 000 g≤出生体重<1 500 g[例数(%)]a 15(29.4) 3 2
出生体重<1 000 g[例数(%)]a 5(9.8) 0 2
IVF-ET[例数(%)]a 11(21.6) 1 1
生后1 min Apgar评分≤7分[例数(%)]a 12(27.3) 0 2
外院转入[例数(%)]a 31(60.8) 3 0
本院出生[例数(%)]a 20(39.2) 5 4
表2 3组新生儿消化道穿孔患儿腹水培养和血培养病原菌分布
病原菌 腹水培养 血培养 合计
胃穿孔组(n＝4) 肠穿孔组(n＝18) 胃穿孔组(n＝1) 肠穿孔组(n＝5) 穿孔部位未明组(n＝1)
G－菌 2 7 1 1 0 11
肺炎克雷伯菌 1 2 1 1 — 5
铜绿假单胞菌 1 — — — — 1
大肠埃希菌 — 2 — — — 2
阴沟肠杆菌 — 1 — — — 1
鲍曼不动杆菌 — 1 — — — 1
脆弱拟杆菌 — 1 — — — 1
G+菌 3 17 0 4 1 25
溶血葡萄球菌 2 3 — 1 — 6
口腔/缓症链球菌 1 — — — — 1
屎肠球菌 — 9 — 1 1 10
粪肠球菌 — 3 — — — 3
表皮葡萄球菌 — 2 — 1 — 3
金黄色葡萄球菌 — — — 1 — 1
合计 5 24 1 5 1 36
表3 3组新生儿消化道穿孔患儿治疗方案
组别 例数 仅剖腹探查术 仅腹腔引流术 腹腔引流术+剖腹探查术 保守治疗
肠穿孔组 51 31(60.8) 10(19.6) 9(17.6) 1(0.2)
胃穿孔组a 8 7 0 1 0
穿孔部位未明组a 4 0 2 0 2
合计 63 38(60.3) 12(20.0) 10(15.9) 2(3.2)
表4 不同病因所致新生儿消化道穿孔的临床特点
项目 NEC组(n＝38) 非NEC组(n＝20) 病因未明组(n＝5)c
性别[例数(%)]
男 20(52.6) 15(75.0) 2
女 18(47.3) 5(25.0) 3
出生胎龄[周，M(Q1，Q3)] 35.0(30.5，35.0) 32.4(30.6，34.7) 29.6(26.3，31.3)
出生体重[g，M(Q1，Q3)] 1 995.0(1 395.0，2 907.0) 1 685.0(1 315.0，2 222.5) 1 040.0(840.0，1 300.0)
穿孔日龄[d，M(Q1，Q3)] 9.5(5.8，17.0) 3.5(2.0，8.5) 4.0(2.5，8.5)
足月儿[例数(%)] 12(31.6) 3(15.0) 0
早产儿[例数(%)] 26(68.4) 17(85.0) 5
辅助检查
气腹[例数(%)] 30(78.9) 16(80.0) 5(100.0)
腹水培养(G+例数/G－例数)a 16/7 4/2 －
血培养(G+例数/G－例数)b 1/1 3/1 1/0
术前Hb最低值[g/L，M(P1，P100)] 107(79，194) 151(92，195) 111(75，196)
术前PLT最低值[×109/L，M(P1，P100)] 111.5(4.0，534.0) 235(6.0，554.0) 49.0(47.0，170.0)
术前CRP>10 mg/L[%(n/n′)] 86.8(33/38) 26.3(5/19) 0(0/3)
治疗方案[%(n/n′)]
仅剖腹探查术 57.9(22/38) 84.2(16/19) 0(0/3)
仅腹腔引流术 21.1(8/38) 5.3(1/19) 100.0(3/3)
腹腔引流术+剖腹探查术 21.1(8/38) 10.5(2/19) 0(0/3)
术后恢复肠内营养[%(n/n′)] 76.3(29/38) 73.7(14/19) 66.7(2/3)
手术至恢复喂养时间[d，M(P1，P100)] 7.0(3.0，19.0) 7.5(3.0，21.0) 14.5(14.0，15.0)
结局[例数(%)]
治愈出院 26(68.4) 13(65.0) 1
住院死亡 3(7.9) 3(15.0) 0
自动出院 9(23.7) 4(20.0) 4
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