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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2024, Vol. 20 ›› Issue (01) : 18 -24. doi: 10.3877/cma.j.issn.1673-5250.2024.01.003

先天性膈疝专辑

不同手术方式治疗先天性膈疝的临床分析：一项单中心回顾性研究
袁翠霞1, 吴雨昊1, 赵录1, 雷洪波1, 金鑫1, 李洪波1, 王刚1, 代江涛1, 潘征夏1, 吴春1, 李勇刚1,†()   
  1. 1. 重庆医科大学附属儿童医院胸心外科、国家儿童健康与疾病临床医学研究中心、儿童发育疾病研究教育部重点实验室、结构性出生缺陷与器官修复重建重庆市重点实验室，重庆　401144
  • 收稿日期:2023-10-08 修回日期:2024-01-12 出版日期:2024-02-01
  • 通信作者: 李勇刚

Clinical analysis of different surgical modalities for the treatment of congenital diaphragmatic hernia: a single-center retrospective study

Cuixia Yuan1, Yuhao Wu1, Lu Zhao1, Hongbo Lei1, Xin Jin1, Hongbo Li1, Gang Wang1, Jiangtao Dai1, Zhengxia Pan1, Chun Wu1, Yonggang Li1,†()   

  1. 1. Department of Cardiothoracic Surgery, Children′s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Diseases Research, Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing 401144, China
  • Received:2023-10-08 Revised:2024-01-12 Published:2024-02-01
  • Corresponding author: Yonggang Li
  • Supported by:
    Postdoctoral Science Foundation Project of Natural Science Foundation of Chongqing(CSTB2023NSCQ-BHX0010)
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袁翠霞, 吴雨昊, 赵录, 雷洪波, 金鑫, 李洪波, 王刚, 代江涛, 潘征夏, 吴春, 李勇刚. 不同手术方式治疗先天性膈疝的临床分析：一项单中心回顾性研究[J]. 中华妇幼临床医学杂志(电子版), 2024, 20(01): 18-24.

Cuixia Yuan, Yuhao Wu, Lu Zhao, Hongbo Lei, Xin Jin, Hongbo Li, Gang Wang, Jiangtao Dai, Zhengxia Pan, Chun Wu, Yonggang Li. Clinical analysis of different surgical modalities for the treatment of congenital diaphragmatic hernia: a single-center retrospective study[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2024, 20(01): 18-24.

目的

探讨不同手术方式治疗先天性膈疝(CDH)患儿的临床治疗效果。

方法

选择2013年1月至2023年8月重庆医科大学附属儿童医院收治的158例CDH患儿为研究对象。①根据手术方式及手术入路，被分为开胸组-1(n＝7)、开腹组-1(n＝61)、胸腔镜组-1(n＝85)及腹腔镜组-1(n＝5)。胸腔镜组-1与腹腔镜组-1 CDH患儿中，中转开放手术治疗的CDH患儿为12例，术后死亡CDH患儿为7例。②除外首次CDH修补术后死亡及腔镜手术中转开放手术的19例CDH患儿后，对139例CDH患儿进一步根据手术方式及手术入路，将其分为开胸组-2(n＝6)、开腹组-2(n＝58)、胸腔镜组(n＝71)与腹腔镜组(n＝4)。采用回顾性分析方法，对上述分组CDH患儿的手术时月龄、手术时间、术中出血量、术中输血率、术后胸腔引流管置管时间、术后呼吸机使用时间、住院天数、术后肺部相关并发症及CDH复发率等进行Kruskal-Wallis H秩和检验或χ2检验比较。本研究遵循的程序经本院伦理委员会批准[审批文号：(2024)年伦审(研)第(39)号]。

结果

本研究CDH患儿的总体死亡率为5.1%(8/158)。12例中转开放手术的CDH患儿中，胸腔镜组-1中转开胸手术者为3例、中转开腹手术者为8例；腹腔镜组-1中转开腹手术者为1例。开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿手术时间、术中出血量留置时间分别总体比较，差异均有统计学意义(P<0.05)；而术中输血率、术后胸腔引流管、术后呼吸机使用时间及住院天数分别比较，则差异均无统计学意义(P>0.05)；术后肺部并发症情况中，9例(6.5%)发生气胸：开腹组-2为4例、胸腔镜组-2为5例；3例(2.2%)发生乳糜胸：开腹组-2为1例、胸腔镜组-2为2例；2例发生肺不张(1.4%)，均为开腹组-2 CDH患儿；这4组患儿术后气胸、乳糜胸、肺不张发生率分别比较，差异均无统计学意义(P>0.05)。随访结果显示，7例CDH患儿术后复发，总体CDH复发率为5.0%；开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿术后复发率比较，差异无统计学意义(P>0.05)。

结论

采取不同手术方式治疗CDH患儿，均安全、有效，并各有优劣，手术方式的选择需综合考虑患儿病情、外科医师技术特点及手术条件。开放手术在CDH患儿中仍然占据重要地位，但是胸腔镜微创手术已成为CDH患儿的优选术式。

关键词: 疝，横膈，先天性, 胸廓切开术, 剖腹术, 胸腔镜, 腹腔镜, 外科手术, 儿童
Objective

To explore the clinical effect of different surgical methods in the treatment of congenital diaphragmatic hernia (CDH).

Methods

From January 2013 to August 2023, retrospectively analysis was performed for the clinical data of 158 hospitalized children with CDH admitted to the Children′s Hospital of Chongqing Medical University. According to different surgical methods and approaches, they were divided into thoracotomy group-1 (n=7), laparotomy group-1 (n=61), thoracoscopic group-1 (n=85) and laparoscopic group-1 (n=5). 12 patients underwent endoscopic conversion and 7 died after surgery. Excluding 19 patients with CDH who died after the first CDH repair and underwent endoscopy conversion, 139 children with CDH were further divided into thoracotomy group-2 (n=6), laparotomy group-2 (n=58), thoracoscopic group-2 (n=71) and laparoscopic group-2 (n=4). The above groups were compared with regards to age of operation, operation time, intraoperative blood loss, incidence of blood transfusion, retention time of postoperative thoracic drainage tube, duration of postoperative ventilator use, hospitalization days, postoperative pulmonary complications and CDH recurrence by retrospective analysis with Kruskal-Wallis H test and chi-square test. The procedures followed in this study have been approved by the Ethics Committee of our hospital (Approval No. 2024-39).

Results

The overall mortality rate of CDH patients was 5.1% (8/158). 12 cases converted open surgery, including 3 cases converted to thoracotomy and 8 cases converted to laparotomy in thoracoscopic group-1, and 1 case converted to laparotomy in laparoscopic group-1. The operative time and intraoperative blood loss were compared among thoracotomy group-2, laparotomy group-2, thoracoscopic group-2 and laparoscopic group-2, and the differences were statistically significant (P<0.05). There was no significant difference in the incidence of intraoperative blood transfusion, the duration of postoperative ventilator use, retention time of postoperative thoracic drainage tube and the days of hospitalization among those four groups (P>0.05). Pulmonary complications were observed in 9 cases (6.5%), including pneumothorax (4 cases in laparotomy group-2 and 5 cases in thoracoscopic group-2). There were 3 cases (2.2%) of chylothorax (1 case in laparotomy group-2 and 2 cases in thoracoscopic group-2). 2 cases (1.4%) of atelectasis were in laparotomy group-2. The differences of incidence rates of pneumothorax, chylothorax, and atelectasis among those four group all were not statistically significant (P>0.05). Follow-up results showed that there were 7 cases (5.0%) of CDH recurrence, and there was no statistical significance among those four groups in incidence of CDH recurrence (P>0.05).

Conclusions

Different operative methods for children with CDH are safe and effective, and each has its own advantages and disadvantages. The choice of operative methods should take into account the patient′s condition, the surgeon′s technical characteristics and the operative conditions. Open surgery still plays an important role in treatment of CDH children, but thoracoscopic minimally invasive surgery has become the preferred method for CDH children.

Key words: Hernias, diaphragmatic, congenital, Thoracotomy, Laparotomy, Thoracoscopes, Laparoscope, Surgical procedures, operative, Child
表1 开胸组-1、开腹组-1、胸腔镜组-1、腹腔镜组-1 CDH患儿手术时月龄、死亡率及中转开放手术率比较
组别 例数 手术时月龄[月，M(Q1，Q3)] 死亡率[例数(%)] 中转开放手术率[例数(%)]
开胸组-1 7 0.2(0.1，8.3) 1(14.3) －a
开腹组-1 61 0.7(0.1，8.2) 3(4.9) －a
胸腔镜组-1 85 5.7(0.2，12.8) 4(4.7) 11(12.9)
腹腔镜组-1 5 17.0(11.0，22.0) 0(0) 1(20.0)
统计量   H＝14.07 χ2＝1.22 χ2＝0.20
P值   0.003 0.638 0.520
表2 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿手术相关情况比较
组别 例数 手术时间[min，M(Q1，Q3)] 术中出血量[mL，M(Q1，Q3)) 术中输血率[例数(%)] 术后胸腔引流管留置时间[d，M(Q1，Q3)] 术后呼吸机使用时间[d，M(Q1，Q3)] 住院天数[d，M(Q1，Q3)]
开胸组-2 6 82.5(71.7，95.0) 6.3(3.5，10.0) 0(0) 0.5(0.2，1.0) 0.5(0.2，1.0) 15.5(13.0，20.0)
开腹组-2 58 85.9(72.5，101.0) 5.0(3.1，8.9) 5(8.6) 5.4(3.1，10.5) 1.0(0.6，4.0) 17.2(13.4，22.2)
胸腔镜组-2 71 64.4(50.2，86.1) 2.1(1.3，3.2) 4(5.6) 5.0(3.4，8.1) 1.0(0.2，3.2) 15.3(12.3，20.4)
腹腔镜组-2 4 110.0(70.0，243.3) 7.5(3.0，15.0) 0(0) 0(0，0) 0.5(0.4，0.7) 15.0(5.0，17.7)
统计量   H＝21.15 H＝36.42 χ2＝0.77 H＝3.85 H＝5.81 H＝2.41
P值   <0.001 <0.001 0.865 0.278 0.121 0.492
表3 开胸组-2、开腹组-2、胸腔镜组-2、腹腔镜组-2 CDH患儿术后肺部相关并发症发生率及CDH复发率比较
组别 例数 肺不张[例数(%)] 气胸[例数(%)] 乳糜胸[例数(%)] CDH复发[例数(%)] CDH复发时间间隔[M(Q1，Q3)]
开胸亚组-2 6 0(0) 0(0) 0(0) 0(0) －a
开腹亚组-2 58 2(3.45) 4(6.9) 1(1.7) 0(0) －a
胸腔镜亚组-2 71 0(0) 5(7.0) 2(2.8) 7(9.9) 5.0(2.0，7.0)
腹腔镜亚组-2 4 0(0) 0(0) 0(0) 0(0) －a
χ2值   4.20 0.34 1.72 6.75 －a
P值   0.312 0.952 0.632 0.068 －a
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