新生儿坏死性小肠结肠炎手术探查指征评价体系的临床研究  

Evaluation systems of surgical exploration for necrotizing enterocolitis

作　　者：胡博[1] 戴春娟[1] 赵旭稳 王金虎[1] 包国强[1] 

机构地区：[1]天津市儿童医院新生儿外科,300074

出　　处：《中华小儿外科杂志》2015年第2期89-94,共6页Chinese Journal of Pediatric Surgery

摘　　要：目的探讨以Duck腹部X线评分（Duke abdominal assessment scale,DAAS）及七项代谢紊乱（seven clinical metrics of metabolic derangement, MD7）的发生频数来评估新生儿坏死性小肠结肠炎（necrotizing enterocolitis，NEC）适宜的手术探查时机，谋求对NEC相对客观的病情评估，使手术时机向最佳理论时点趋近。方法回顾性分析我院新生儿外科自2012年6月至2014年10月治疗新生儿坏死性小肠结肠炎38例。其中男26例，女12例。按照修正Bell分期标准，Ⅰ期8例，Ⅱ期16例，Ⅲ期14例。入院时年龄2～33d，足月儿15例，早产儿23例；体质量〉2500g 16例，2000-2500g 12例，1500-2000 g9例，〈1500g 1例。结果全部患儿中15例经保守治疗7～22d病愈，另23例患儿分别于人院后的1～13d DAAS≥7分或MD7发生频数≥3而接受手术治疗。8例行开腹手术，15例行腹腔镜手术，其中5例中转开腹。术中见肠坏死10例；肠穿孔9例（1例多发穿孔），穿孔部位分别位于回肠3例，回盲部1例，升结肠3例，横结肠2例，降结肠1例；4例肠壁多处呈局灶性暗紫色，肿胀僵直，伴腹腔脓性渗出。肠穿孔修补并肠造瘘1例，肠切除肠吻合3例，肠切除肠吻合并肠造瘘9例，肠切除并肠造瘘2例，肠造瘘5例，单纯腹腔引流3例。造瘘术后发生横结肠狭窄1例，切除狭窄段后横结肠端端吻合治愈。手术患儿治愈19例，死亡3例，放弃1例，手术治愈率82．6％。DAAS≥7分的20例患儿和MD7发生频数≥3的17例患儿中，发生肠穿孔和肠坏死的分别为9例、9例和9例、6例。19例肠坏死肠穿孔的患儿中DAAS≥7分有18例，MD7发生频数≥3的有15例。DAAS≥7分的18例患儿中1例发生肠坏死。MD7发生频数〈3的21例患儿中4例发生肠坏死。即以MD7发生频数评估NEC是否发生肠坏死或穿孔的真阳性率78．9％（15／19），真阴性率89．5％（17／19），DAAS的真阳性率94．7％（18／19），真阴Objective To explore the appropriate surgical exploration for necrotizing enterocolitis with Duke abdominal assessment scale （DASS） and seven clinical metrics of metabolic derangement （MD7） and discuss the best operative opportunity. Methods Retrospective analyses were performed for the clinical data of 38 confirmed cases NEC from June 2012 to October 2014. There were 26 males and 12 females with an age range of 2-33 days. According to revised Bell staging scheme, there were Ⅰ （n = 8）, Ⅱ （n = 16） and Ⅲ（n = 14）. And there were 15 full-term newborns and 23 preterms. Their weights were 〉2 500 g （n = 16）, 2 000-2 500 g （n = 12） ; 1 500-2 000 g （n = 9） and 〈1 500 g （n = 1）. Results Among them, 15 cases were conservatively cured within 7-22 days while the remainder underwent surgery for DAAS ≥7 or MD7 ≥3 within 1-13 days. The procedure included laparotomy （n = 8）, laparoscopy （n = 15） and conversion into laparotomy （n = 5）. Intestinal necrosis was found in 10 cases. Among 9 cases of, perforation, there was multiple perforation （n = 1）. The perforation sites included ileum （n = 3）, ileocecus （n = 1 ）, ascending colon （n = 3）, transverse colon 07 = 2） and descending colon （n = 1）. Intestine had focal dark purple and became swollen and stiff with abdominal purulent exudates （n = 4）. There were intestinal perforation repair ＆ enterostomy （n = 1）, intestinal resection ＆ anastomosis （ω = 3）, intestinal resection anastomosis ＆ enterostomy （n= 9）, 2 cases to intestinal resection ＆ enterostomy （n = 2）, enterostomy （n = 5）, abdominal cavity drainage （n = 3） and enterostomy with transverse colostomy stricture healed by intestinal resection anastomosis （n = 1）. The curative rate of surgery was 82. 6% （19/23）. Three cases died while another gave up treatment. For 20 cases with DAAS≥7, the numbers of bowel perforation and necrosis were 9 and 9 cases respectively. For 17 cases with MD7≥3, the numbers of

关 键 词：小肠结肠炎 坏死性 外科手术 新生儿 

分 类 号：R726.5[医药卫生—儿科]