Cao Xuqing,Pan Xiaoxue,Shen Chun.Clinical features and outcomes of intestinal strictures after conservative measures for necrotizing enterocolitis[J].Journal of Clinical Pediatric Surgery,2024,(02):135-139.[doi:10.3760/cma.j.cn101785-202203001-007]
新生儿坏死性小肠结肠炎保守治疗后肠狭窄的临床特点及诊治探讨
- Title:
- Clinical features and outcomes of intestinal strictures after conservative measures for necrotizing enterocolitis
- 摘要:
- 目的 总结新生儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)保守治疗后因肠狭窄行手术治疗患儿的临床特点和诊治经验,比较NEC单发与多发肠狭窄的预后情况。方法 回顾性分析2014年1月至2020年12月复旦大学附属儿科医院新生儿外科收治的67例行NEC保守治疗后发生肠狭窄且接受手术治疗患儿的临床资料,收集患儿基本信息、NEC发病情况、肠狭窄术前检查、手术情况及术后恢复情况,分析NEC保守治疗后的临床特点及与肠狭窄发生之间的关系、手术预后以及诊治经验。将肠狭窄患儿分为单发狭窄组和多发狭窄组,比较两组预后情况。结果 67例行NEC保守治疗后出现肠狭窄的患儿中,术前经肛门造影阳性率为83.9%(47/56)。60例行一期肠切除肠吻合术,7例行肠造瘘术。中位手术时间为发生NEC后第39天,中位手术时体重为2.53 kg。术中证实单发肠狭窄34例(34/67,50.7%),多发肠狭窄33例(33/67,49.3%)。共123处狭窄,除1处狭窄横跨小肠和结肠(自末端回肠至乙状结肠)以外,小肠狭窄65处［以末端回肠为主(37处)］,结肠狭窄57处［以升结肠为主(27处)］。2例术后放弃治疗,2例一期吻合患儿因病情加重改行肠造瘘术,其中1例死亡,1例于术后12个月关闭造瘘。6例出院后出现并发症,其中肠管脱垂2例,黏连性肠梗阻4例;其余61例均恢复良好。手术治疗NEC保守治疗后肠狭窄的长期存活率为95.5% (64/67)。多发狭窄组切除肠管长度和手术时间显著长于单发狭窄组,差异有统计学意义(P＜0.05);但两组达到全肠内喂养时间和术后并发症情况比较,差异无统计学意义(P＞0.05)。结论 NEC保守治疗后肠狭窄的发生率虽然不高,但多发狭窄比例较高;且狭窄好发于末端回肠和结肠,术前下消化道造影阳性率较高。术中应仔细探查、彻底切除狭窄段;多发狭窄通常不影响术后恢复及预后。
- Abstract:
- Objective To summarize the clinical features of intestinal stricture after conservative measures for neonatal necrotizing enterocolitis (NEC) and compare the outcomes of single and multiple stricture groups.Methods From January 2014 to December 2020,retrospective review was performed for the relevant clinical data of 67 neonates operated for post-NEC intestinal strictures.Basic information, NEC onset time,Bell stage,radiographic studies,surgical approach postoperative complications were recorded.Then they were assigned into two groups of single stricture and multiple strictures and the prognosis between two groups were compared.Results Positive rate of preoperative contrast enema was 83.9%.Primary end-to-end anastomosis (n=60) and enterostomy (n=7) were performed at a median of 39 days after NEC with a median weight of 2.53 kg.Multiple strictures were detected in 33 neonates (49.3%) while the remainders had only 1 stricture.There were a total of 123 strictures.Except for 1 stricture spanning small intestine and colon (from terminal ileum to sigmoid colon),65 strictures were present in small intestine,including terminal ileum (n=37) and colon (n=57)(ascending colon,n=27).Two cases underwent enterostomy later due to disease deterioration and 1 died at Month 2 after discharge.Another child accepted enterostomal closure 12 months later.Complications included intestinal prolapse (n=2) and adhesive intestinal obstruction (n=4).The long-term survival rate of intestinal strictures after conservative measures was 95.5%(64/67).Length of bowel resection (P<0.001) and operative duration (P=0.008) were significantly longer in multiple-stricture group than those in single-stricture group.However,no significant inter-group difference existed in time to complete enteral feeding (P=0.862) or postoperative complications (P=0.347).Conclusions Despite a low incidence of intestinal strictures after conservative measures for NEC,multiple strictures account for a large proportion.The strictures occur predominantly in terminal ileum and colon.Contrast enema is valuable for preoperative examination.All intestinal segments should be carefully explored intraoperatively.And multiple strictures have no effect upon postoperative recovery and outcomes.
参考文献/References:
[1] Neu J,Walker WA.Necrotizing enterocolitis[J].N Engl J Med,2011,364(3):255-264.DOI:10.1056/NEJMra1005408.
[2] Cao XC,Zhang L,Jiang SY,et al.Epidemiology of necrotizing enterocolitis in preterm infants in China:a multicenter cohort study from 2015 to 2018[J].J Pediatr Surg,2022,57(3):382-386.DOI:10.1016/j.jpedsurg.2021.05.014.
[3] Heida FH,Loos MHJ,Stolwijk L,et al.Risk factors associated with postnecrotizing enterocolitis strictures in infants[J].J Pediatr Surg,2016,51(7):1126-1130.DOI:10.1016/j.jpedsurg.2015.09.015.
[4] Phad N,Trivedi A,Todd D,et al.Intestinal strictures post-necrotising enterocolitis:clinical profile and risk factors[J].J Neonatal Surg,2014,3(4):44.
[5] Liu W,Wang Y,Zhu J,et al.Clinical features and management of post-necrotizing enterocolitis strictures in infants:a multicentre retrospective study[J].Medicine (Baltimore),2020,99(19):e20209.DOI:10.1097/MD.0000000000020209.
[6] Zhang H,Chen JP,Wang Y,et al.Predictive factors and clinical practice profile for strictures post-necrotising enterocolitis[J].Medicine (Baltimore),2017,96(10):e6273.DOI:10.1097/MD.0000000000006273.
[7] Gaudin A,Farnoux C,Bonnard A,et al.Necrotizing enterocolitis (NEC) and the risk of intestinal stricture:the value of C-reactive protein[J].PLoS One,2013,8(10):e76858.DOI:10.1371/journal.pone.0076858.
[8] Schimpl G,H?llwarth ME,Fotter R,et al.Late intestinal strictures following successful treatment of necrotizing enterocolitis[J].Acta Paediatr Suppl,1994,396:80-83.DOI:10.1111/j.1651-2227.1994.tb13251.x.
[9] Hartman GE,Drugas GT,Shochat SJ.Post-necrotizing enterocolitis strictures presenting with sepsis or perforation:risk of clinical observation[J].J Pediatr Surg,1988,23(6):562-566.DOI:10.1016/s0022-3468(88)80369-5.
[10] Bell MJ,Ternberg JL,Askin FB,et al.Intestinal stricture in necrotizing enterocolitis[J].J Pediatr Surg,1976,11(3):319-327.DOI:10.1016/s0022-3468(76)80185-6.
[11] 刘国斌,郭振华,王佚,等.79例新生儿坏死性小肠结肠炎后肠狭窄临床特点及诊疗体会[J].第三军医大学学报,2019,41(8):799-804.DOI:10.16016/j.1000-5404.201810196.Liu GB,Guo ZH,Wang Y,et al.Clinical features and managements of intestinal strictures after neonatal necrotizing enterocolitis:analysis of 79 cases[J].J Third Mil Med Univ,2019,41(8):799-804.DOI:10.16016/j.1000-5404.201810196.
[12] 陈发玲,徐伟珏,黄雄,等.一期肠切除肠吻合术治疗新生儿坏死性小肠结肠炎后肠狭窄[J].临床小儿外科杂志,2020,19(11):1016-1020.DOI:10.3969/j.issn.1671-6353.2020.11.011.Chen FL,Xu WJ,Huang X,et al.Experience of treating intestinal stenosis after one-stage intestinal resectional anastomosis for neonatal necrotizing enterocolitis[J].J Clin Ped Sur,2020,19(11):1016-1020.DOI:10.3969/j.issn.1671-6353.2020.11.011.
[13] Goettler CE,Stallion A,Grisoni ER,et al.An unusual late complication of necrotizing enterocolitis[J].J Pediatr Surg,2001,36(12):1853-1854.DOI:10.1053/jpsu.2001.28868.
[14] Houben CH,Lo AWI,Tsui SY,et al.Under pressure:a contribution to the pathogenesis of acquired ileal atresia[J].BMJ Case Rep,2013,2013:bcr2013201505.DOI:10.1136/bcr-2013-201505.
[15] 陈虎,钭金法.新生儿坏死性小肠结肠炎后肠狭窄临床特点和治疗现状[J].临床外科杂志,2017,25(12):949-951.DOI:10.3969/j.issn.1005-6483.2017.12.023.Chen H,Dou JF.Clinical features and treatments of neonatal intestinal stenosis after necrotizing enterocolitis[J].J Clin Surg,2017,25(12):949-951.DOI:10.3969/j.issn.1005-6483.2017.12.023.
[16] 夏仁鹏,李碧香,周崇高,等.新生儿坏死性小肠结肠炎后肠狭窄65例临床特点与外科治疗[J].中华新生儿科杂志,2020,35(5):352-355.DOI:10.3760/cma.j.issn.2096-2932.2020.05.007.Xia RP,Li BX,Zhou CG,et al.Clinical characteristics and surgery of intestinal stricture after necrotizing enterocolitis in neonates:a report of 65 cases[J].Chin J Neonatol,2020,35(5):352-355.DOI:10.3760/cma.j.issn.2096-2932.2020.05.007.
[17] 董晨彬,郑珊,沈淳.新生儿坏死性小肠结肠炎后肠狭窄14例诊疗体会[J].中华小儿外科杂志,2012,33(5):344-347.DOI:10.3760/cma.j.issn.0253-3006.2012.05.007.Dong CB,Zheng S,Shen C.Management of intestinal strictures after necrotizing enterocolitis:retrospective study of 14 cases[J].Chin J Pediatr Surg,2012,33(5):344-347.DOI:10.3760/cma.j.issn.0253-3006.2012.05.007.
[18] 陈虎,黄寿奖,秦琪,等.新生儿坏死性小肠结肠炎后肠狭窄的临床特点及外科治疗[J].中华小儿外科杂志,2019,40(10):916-920.DOI:10.3760/cma.j.issn.0253-3006.2019.10.010.Chen H,Huang SJ,Qin Q,et al.Clinical characteristics and surgical treatment of intestinal stenosis after necrotizing enterocolitis in neonates[J].Chin J Pediatr Surg,2019,40(10):916-920.DOI:10.3760/cma.j.issn.0253-3006.2019.10.010.
[19] 中华医学会小儿外科分会新生儿外科学组.新生儿坏死性小肠结肠炎外科手术治疗专家共识[J].中华小儿外科杂志,2016,37(10):724-728.DOI:10.3760/cma.j.issn.0253-3006.2016.10.002.Group of Neonatal surgery,Branch of Pediatric Surgery,Chinese Medical Association:Expert Consensus on Surgery for Neonatal Necrotizing Enterocolitis[J].Chin J Pediatr Surg,2016,37(10):724-728.DOI:10.3760/cma.j.issn.0253-3006.2016.10.002.
[20] Janik JS,Ein SH,Mancer K.Intestinal stricture after necrotizing enterocolitis[J].J Pediatr Surg,1981,16(4):438-443.DOI:10.1016/s0022-3468(81)80002-4.
[21] Houben CH,Chan KWE,Mou JWC,et al.Management of intestinal strictures post conservative treatment of necrotizing enterocolitis:the long term outcome[J].J Neonatal Surg,2016,5(3):28.DOI:10.21699/jns.v5i3.379.
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备注/Memo
收稿日期:2022-3-1。
基金项目:国家自然科学基金面上项目(81873849)
通讯作者:沈淳,Email:chshen0521@126.com