两种评价体系探讨新生儿坏死性小肠结肠炎的手术指征

Two evaluation systems for investigating operative indications of neonatal necrotizing enterocolitis

摘要:

目的：探讨改良Bell分期和七项代谢紊乱（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）适宜的手术干预时机，使治疗趋于准确。方法：回顾性分析安徽医科大学第一附属医院小儿外科及新生儿科2015年4月1日至2018年10月1日收治的209例NEC患儿临床资料，依据改良Bell分期与MD7发生频数对患儿进行分组，比较各组之间的治愈率与死亡率，分析各组保守治疗与手术治疗效果的差异性。结果：Ⅰ期以保守治疗为主；改良Bell分期为Ⅱ期时，分为ⅡA与ⅡB期，ⅡA期保守治疗与手术治疗的治愈率、死亡率比较无统计学差异，而 ⅡB期手术治愈率更高，病死率更低；Bell分期Ⅲ期手术治愈率更高，病死率更低； MD7＜4时，保守与手术的治愈率、死亡率比较无统计学差异；MD7发生频数≥4时，手术治疗效果明显高于保守治疗组；同时，Bell分期为ⅡB期及以上及MD7发生频数≥4时，手术探查肠坏死率接近100%。结论：NEC患儿，改良Bell分期为Ⅱ期患儿，ⅡB期应积极手术干预；MD7发生频数≥4时应积极手术干预。Bell分期或MD7发生频数2个评价体系的结果可以作为绝对指征气腹以外NEC手术指征的重要补充，以谋求患儿更好的远期预后。

Abstract:

Objective：To investigate the BELL staging criteria and the frequency of seven clinical metrics of metabolic derangement （MD7），so as to evaluate the appropriate surgical intervention opportunity of neonatal necrotizing enterocolitis（NEC） for improving the accuracy of treatment. Methods：Clinical data of 209 NEC patients of our hospital from April 1st，2015 to October 1st，2018 were retrospectively analyzed and patients were grouped according to BELL staging criteria and frequency of MD7. Cure rate and mortality rate between groups were compared，and differences of conservative treatment effect and operative treatment effect in each group were analyzed. Results：Stage Ⅰ was mainly received conservative treatment. Improved stage Ⅱ was divided into ⅡA stage and ⅡB stage. There was no significant difference in cure rate and mortality rate between the conservative treatment effect and the operative effect in ⅡA stage，while cure rate was higher and mortality rate was lower in ⅡB stage. Ⅲ stage had a even higher cure rate and a even lower mortality rate. When MD7 frequency was less than 4，cure rate and mortality rate between conservative treatment and operative treatment had no statistically significant difference. When MD7 frequency was more than or equal to 4，the effect of operative treatment was significantly higher than that of conservative treatment. Meanwhile，when patients had stage ⅡB or above and MD7 frequency more than or equal to 4，the intestinal necrosis rate via operative exploration was nearly 100%. Conclusion：NEC patients，with improved BELL stage of ⅡB stage，should receive operative intervention actively；NEC children，with MD7 frequency≥4，should receive operative intervention actively. The results of the two evaluation systems of BELL staging criteria and MD7 frequency can be used as an important supplement to NEC operative indications except the absolutely indicated pneumoperitoneum，so as to seek a better long-term prognosis for patients.