Hou Longlong,Lin Tulian,He Qiuming,et al.Prenatal identification of hernia sac in congenital diaphragmatic hernia and its effect on prognosis[J].Journal of Clinical Pediatric Surgery,2022,21(09):827-832.[doi:10.3760/cma.j.cn101785-202206003-006]
先天性膈疝疝囊的产前识别及其对预后的影响
- Title:
- Prenatal identification of hernia sac in congenital diaphragmatic hernia and its effect on prognosis
- Keywords:
- Hernias; Diaphragmatic; Congenital/CO; Prenatal Diagnosis/MT; Infant; Newborn; Prognosis
- 摘要:
- 目的 评估胎儿磁共振（magnetic resonance，MR）产前识别先天性膈疝（congenital diaphragmatic hernia，CDH）疝囊的准确性以及疝囊对CDH预后的影响。方法 以2013年1月1日至2020年12月31日在广州市妇女儿童医疗中心行胎儿MR评估、且生后行手术干预的62例CDH患儿为研究对象，根据是否存在疝囊分为疝囊组（n=26）和非疝囊组（n=36），收集并对比两组患儿产前评估、产时情况、临床特征及预后等情况。结果 62例CDH患儿中，共26例术中证实存在疝囊，其中18例通过胎儿MR发现疝囊且术中得到证实，MR产前识别CDH疝囊的灵敏度为69.2%（18/26）。两组患儿总肺容积实测值与预测值的比值（observed/expected total fetal lung volume，o/e TFLV）、性别构成、出生胎龄、出生体重、1分钟及5分钟Apgar评分、手术方式及术中使用补片情况、缺损大小、呼吸机辅助通气时间、住院时间、持续肺动脉高压（persistent pulmonary hypertension of newborn，PPHN）及体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）使用率等比较，差异均无统计学意义（P>0.05）。疝囊组患儿具有更高的预测肺容积比（percentage of predicted lung volume，PPLV），差异有统计学意义（P<0.05）；疝囊组患儿缺损位于右侧及肝疝入的比例高于非疝囊组（P<0.05）；疝囊组患儿存活率为100%，非疝囊组患儿存活率为86.1%，差异具有统计学意义（P<0.05）。结论 MR能够在产前较好识别CDH是否存在疝囊；有疝囊CDH患儿产前肺发育程度评估指标整体优于无疝囊CDH患儿，且出生后存活率更高。
- Abstract:
- Objective To evaluate the accuracy identification of hernia sac in congenital diaphragmatic hernia (CDH) by fetal magnetic resonance and examine the prognostic effect of hernia sac on CDH.Methods From January 1, 2013 to December 31, 2020, 62 CDH neonates receiving fetal magnetic resonance (MR) and undergoing surgical intervention were selected as subjects.According to the presence or absence of hernia sac, they were divided into two groups of hernia sac (n=26) and non-hernia sac (n=36).Prenatal profiles, intrapartum status, clinical features and outcomes of CDH were compared between two groups.Results Hernia sac was detected in 18 infants during fetal period and the detection rate of fetal MR for hernia sac was 69.2%.No significant inter-group differences existed in o/e TFLV, gender, gestational age, birth weight, 1/5-min Apgar score, surgical approach, patch usage, defect size, days of ventilation, hospital stay or utilization rate (P>0.05).The hernia sac group had a higher PPLV (P < 0.05).As compared with non-hernia sac group, there were more right-side CDH children and more cases of liver herniation in hernia sac group (P < 0.05).The survival rate was 100% in hernia sac group and 86.1% in non-hernia sac group and the difference was statistically significant (P < 0.05).Conclusion MR can well identify the presence of a hernia sac in CDH during prenatal period.Hernia sac group has better prenatal assessment parameters with a higher postnatal survival.
参考文献/References:
[1] Jancelewicz T, Brindle ME, Guner YS, et al.Toward standardized management of congenital diaphragmatic hernia:an analysis of practice guidelines[J].J Surg Res, 2019, 243:229-235.DOI:10.1016/j.jss.2019.05.007.
[2] 林土连, 吕俊健, 何秋明, 等.胎儿膈疝不同程度分级的临床特征及预后[J].临床小儿外科杂志, 2021, 20(9):832-836.DOI:10.12260/lcxewkzz.2021.09.006. Lin TL, Lyu JJ, He QM, et al.Association of fetal diaphragmatic hernia severity with prenatal parameters[J].J Clin Ped Sur, 2021, 20(9):832-836.DOI:10.12260/lcxewkzz.2021.09.006.
[3] Chock VY, Danzer E, Chung S, et al.In-Hospital morbidities for neonates with congenital diaphragmatic hernia:the impact of defect size and laterality[J].J Pediatr, 2022, 240:94-101.e6.DOI:10.1016/j.jpeds.2021.09.001.
[4] 吕俊健, 林土连, 吴强, 等.超声心动图对先天性膈疝患者接受体外膜肺氧合治疗的预测作用研究[J].临床小儿外科杂志, 2021, 20(9):814-818, 824.DOI:10.12260/lcxewkzz.2021.09.003. Lyu JJ, Lin TL, Wu Q, et al.Prediction of extracorporeal membrane oxygenation in children with congenital diaphragmatic hernia by echocardiography[J].J Clin Ped Sur, 2021, 20(9):814-818, 824.DOI:10.12260/lcxewkzz.2021.09.003.
[5] Bouchghoul H, Marty O, Fouquet V, et al.Congenital diaphragmatic hernia has a better prognosis when associated with a hernia sac[J].Prenat Diagn, 2018, 38(9):638-644.DOI:10.1002/pd.5326.
[6] Aydin E, Lim FY, Kingma P, et al.Congenital diaphragmatic hernia:the good, the bad, and the tough[J].Pediatr Surg Int, 2019, 35(3):303-313.DOI:10.1007/s00383-019-04442-z.
[7] Grizelj R, Bojani? K, Vukovi? J, et al.Hernia sac presence portends better survivability of isolated congenital diaphragmatic hernia with "Liver-Up"[J].Am J Perinatol, 2017, 34(5):515-519.DOI:10.1055/s-0036-1593765.
[8] Levesque M, Derraugh G, Schantz D, et al.The presence of a hernia sac in isolated congenital diaphragmatic hernia is associated with less disease severity:A retrospective cohort study[J].J Pediatr Surg, 2019, 54(5):899-902.DOI:10.1016/j.jpedsurg.2019.01.016.
[9] Oliver ER, DeBari SE, Adams SE, et al.Congenital diaphragmatic hernia sacs:prenatal imaging and associated postnatal outcomes[J].Pediatr Radiol, 2019, 49(5):593-599.DOI:10.1007/s00247-018-04334-9.
[10] Jawaid W, Sampat K, Losty PD.Does the presence of a hernia sac improve survival in newborns with congenital diaphragmatic hernia? A United Kingdom Single-Center Experience[J].Eur J Pediatr Surg, 2021, 31(3):276-281.DOI:10.1055/s-0040-1713131.
[11] 王伟鹏, 潘伟华, 陈杰, 等.疝囊对先天性膈疝患儿临床结局的影响[J].中华小儿外科杂志, 2019, 40(3):212-215.DOI:10.3760/cma.j.issn.0253-3006.2019.03.005. Wang WP, Pan WH, Chen J, et al.Effect of hernia sac on outcomes in infants with congenital diaphragmatic hernia[J].Chin J Pediatr Surg, 2019, 40(3):212-215.DOI:10.3760/cma.j.issn.0253-3006.2019.03.005.
[12] Zamora IJ, Mehollin-Ray AR, Sheikh F, et al.Predictive Value of MRI Findings for the Identification of a Hernia Sac in Fetuses With Congenital Diaphragmatic Hernia[J].AJR Am J Roentgenol, 2015, 205(5):1121-1125.DOI:10.2214/AJR.15.14476.
[13] 杜立中, 薛辛东, 母得志, 等.新生儿肺动脉高压诊治专家共识[J].中华儿科杂志, 2017, 55(3):163-168.DOI:10.3760/cma.j.issn.0578-1310.2017.03.002. Du LZ, Xue XD, Mu DZ, et al.Expert Consensus on Diagnosing and Treating Neonatal Pulmonary Hypertension[J].Chinese Journal of Pediatrics, 2017, 55(3):163-168.DOI:10.3760/cma.j.issn.0578-1310.2017.03.002.
[14] Kardon G, Ackerman KG, McCulley DJ, et al.Congenital diaphragmatic hernias:from genes to mechanisms to therapies[J].Dis Model Mech, 2017, 10(8):955-970.DOI:10.1242/dmm.028365.
[15] Shieh HF, Barnewolt CE, Wilson JM, et al.Percent predicted lung volume changes on fetal magnetic resonance imaging throughout gestation in congenital diaphragmatic hernia[J].J Pediatr Surg, 2017, 52(6):933-937.DOI:10.1016/j.jpedsurg.2017.03.013.
[16] 吕俊健, 何秋明, 钟微, 等.胎儿期MRI测量预测肺容积比对左侧先天性膈疝患者预后的诊断价值[J].中华围产医学杂志, 2018, 21(11):745-749.DOI:10.3760/cma.j.issn.1007-9408.2018.11.005. Lyu JJ, He QM, Zhong W, et al.Diagnostic value of fetal MRI measurement of lung volume ratio in predicating the prognosis of left congenital diaphragmatic hernia[J].Chinese Journal of Perinatal Medicine, 2018, 21(11):745-749.DOI:10.3760/cma.j.issn.1007-9408.2018.11.005.
[17] Bent DP, Nelson J, Kent DM, et al.Population-based validation of a clinical prediction model for congenital diaphragmatic hernias[J].J Pediatr, 2018, 201:160-165.e1.DOI:10.1016/j.jpeds.2018.05.027.
[18] Delaplain PT, Zhang L, Chen Y, et al.Cannulating the contraindicated:effect of low birth weight on mortality in neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation[J].J Pediatr Surg, 2017, 52(12):2018-2025.DOI:10.1016/j.jpedsurg.2017.08.37.
[19] Brandt JB, Werther T, Groth E, et al.Risk factors for mortality in infants with congenital diaphragmatic hernia:a single center experience[J].Wien Klin Wochenschr, 2021, 133(13-14):674-679.DOI:10.1007/s00508-021-01843-w.
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备注/Memo
收稿日期:2022-06-02。
基金项目:广东省自然科学基金（2020A1515010296）
通讯作者:钟微,E-mail:zhongwei@gwcmc.org