小柯机器人

全球PaedSurg研究协作组对74个低收入、中等收入和高收入国家264家医院胃肠道先天畸形的死亡率进行了研究分析。相关论文于2021年7月13日发表在《柳叶刀》杂志上。

先天性畸形是全球5岁以下儿童死亡的第五大原因。许多胃肠道先天性畸形如果不能及时获得新生儿外科治疗是致命的，但在中低收入国家（LMICs）很少有关于这些疾病的研究。研究组比较了全球低收入、中等收入和高收入国家7种最常见的胃肠道先天性畸形的临床结局，并确定了与死亡率相关的因素。

研究组对16岁以下首次就诊的食道闭锁、先天性膈疝、肠闭锁、腹裂、脐疝、肛肠畸形和先天性巨结肠患者进行了一项多中心、国际前瞻性队列研究，2018年10月至2019年4月，招募1个月以上的患儿。使用REDCap平台收集患儿的人口统计数据、临床状态、干预措施和结局。患者在初次干预后随访30天，如果没有接受干预，则在入院后30天进行随访。主要结局是按国家收入状况分层的所有疾病合并的全因住院死亡率和每种疾病单独死亡率。

研究组纳入了来自74个国家264家医院（89家来自高收入国家，166家来自中等收入国家，9家来自低收入国家）的3849例患者，其中560例食道闭锁，448例先天性膈疝，681例肠闭锁，453例腹裂，325例脐疝，991例肛肠畸形，517例先天性巨结肠。3849例患者中，男性2231例（58.0%）。出生时的中位胎龄为38周，分娩时的中位体重为2.8千克。

低收入国家93例患者中37例（39.8%）死亡，中等收入国家2860例患者中583例（20.4%）死亡，高收入国家896例患者中50例（5.6%）死亡，组间差异均显著。腹裂在各收入阶层国家之间的死亡率差异最大，其中低收入国家10例中有9例（90.0%），中等收入国家304例中有97例（31.9%），高收入国家139例中有2例（1.4%）。

与所有患者高死亡率显著相关的因素包括国家收入状况（低收入国家与高收入国家的风险比为2.78，中等收入国家与高收入国家的风险比为2.11）、出现脓毒症（1.2）、初级干预时美国麻醉医师协会（ASA）评分较高（1.82）、未使用手术安全检查表（1.39）、需要时无法使用通气或肠外营养（通气1.96、肠外营养1.35）。给予肠外营养和使用外周置入中心静脉导管或经皮中心静脉导管与较低的死亡率相关。

研究结果表明，低收入、中等收入和高收入国家之间胃肠道先天性畸形的死亡率存在很大差异。改善中低收入国家获得优质新生儿外科护理的机会，对于实现可持续发展目标至关重要。

附：英文原文

Title: Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Author: Naomi Jane Wright, Andrew J.M. Leather, Niyi Ade-Ajayi, Nick Sevdalis, Justine Davies, Dan Poenaru, Emmanuel Ameh, Adesoji Ademuyiwa, Kokila Lakhoo, Emily Rose Smith, Abdel Douiri, Maria Elstad, Marcus Sim, Cristiana Riboni, Bruno Martinez-Leo, Melika Akhbari, Stephen Tabiri, Ashrarur Mitul, Dayang Anita Abdul Aziz, Camila Fachin, Alliance Niyukuri, Muhammad Arshad, Fowzia Ibrahim, Natalie Moitt, Mohamed Fahmy Doheim, Hannah Thompson, Harmony Ubhi, Isabelle Williams, Sophia Hashim, Godfrey Sama Philipo, Laura Herrera, Aayenah Yunus, Dominique Vervoort, Samuel Parker, Yousra-Imane Benaskeur, Osaid H. Alser, Nana Adofo-Ansong, Ahmad Alhamid, Hosni khairy Salem, Mahmoud Saleh, Safa Abdal Elrais, Sadi Abukhalaf, Patricia Shinondo, Ibrahim Nour, Emrah Aydin, Agota Vaitkiene, Kelly Naranjo, Andile Maqhawe Dube, Sodumisa Ngwenya, Mina A. Yacoub, Henang Kwasau, Gabriella Hyman, Shrouk Mahmoud Elghazaly, Ibrahim Al-Slaibi, Intisar Hisham, Helena Franco, Hana Arbab, Lubna Samad, Aqil Soomro, Muhammad Amjad Chaudhry, Safina Karim, Muhammad Adnan Khan Khattak, Shireen Anne Nah, Doris Mae Dimatatac, Candy SC Choo, Niveshni Maistry, Ashrarur Rahman Mitul, Samiul Hasan, Sabbir Karim, Hina Yousuf, Taimur Qureshi, Ibrahim Rabi Nour, Raed Nael Al-Taher, Osama Abdul Kareem Sarhan, Luis Garcia-Aparicio, Jordi Prat, Eva Blazquez-Gomez, Xavier Tarrado, Martí Iriondo, Paolo Bragagnini, Segundo Rite, Lars Hagander, Emma Svensson, Sheila Owusu, Alhassan Abdul-Mumin, Dominic Bagbio, Vijay Anand Ismavel, Ann Miriam, Shajin T, Marlene Anaya Dominguez, Monica Ivanov, Andreea Madalina Serban, Miliard Derbew, Mahmoud Elfiky, Maricarmen Olivos Perez, Marcia Abrunhosa Matias, Alexis P Arnaud, Ahmed Negida, Sebastian King, Mohamad Rafi Fazli, Nadia Hamidi, Souhem Touabti, Rossana Francisco Chipalavela, Pablo Lobos, Brendan Jones, Damir Ljuhar, Georg Singer, Samiul Hasan, Annelien Cordonnier, Lorena Jáuregui, Zlatan Zvizdic, Janice Wong, Etienne St-Louis, Qiang Shu, Yang Lui, Catalina Correa, Lucie Pos, Elvyn Alcántara, Erick Féliz, Luis Enrique Zea-Salazar, Liza Ali, Matthieu Peycelon, Nzanzu Kipata Anatole, Cherno S. Jallow, Judith Lindert, Dhruv Ghosh, Cathline Freya Adhiwidjaja, Ahmad Khaleghnejad Tabari, Saran Lotfollahzadeh, Haidar Mohammad Mussein, Fabrizio Vatta, Noemi Pasqua, David Kihiko, Hetal Gohil, Ibrahim R. Nour, Muhammed Elhadi, Suad Ahmed Almada, Gilvydas Verkauskas, Toni Risteski, Alejandro Pearrieta Daher, Oumaima Outani, James Hamill, Taiwo Lawal, Jack Mulu, Benjamin Yapo, Lily Saldaa, Beda Espineda, Krystian Toczewski, Eugene Tuyishime

Issue&Volume: 2021-07-13

Abstract:

Background

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

Methods

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

Findings

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality.

Interpretation

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

DOI: 10.1016/S0140-6736(21)00767-4

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00767-4/fulltext

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