Analiza prediktivnih faktora ishoda lečenja hipertrofične stenoze pilorusa primenom rastvora atropin sulfata

Abstract

Hipertrofična stenoza pilorusa (HSP) je najčešći razlog za hiruršku intervenciju u uzrastu novorođenčeta i mladog odojčeta. Ekstramukozna piloromiotomija je zlatni standard u lečenju HSP, a medikamentozni tretman primenom atropin sulfata je jedina neoperativna metoda kojom se postiže visok procenat izlečenja, pa je u nekim zemljama i uvedena kao prva linija terapije. Suštinski značaj neoperativnog tretmana je neizlaganje novorođenog deteta stresu uzrokovanim hirurškom intervencijom i opštom anestezijom. Ovom studijom je urađena procena uticaja različitih režima oralne primene atropina na njegovu efikasnost u lečenju HSP, uz definisanje prediktivnih faktora i analizu njihovog uticaja na ishod medikamentoznog tretmana. Urađeno je i poređenje efikasnosti konzervativnog tertmana sa operativnim. Metode. Studijom je obuhvaćeno 100 bolesnika lečenih zbog HSP na Univerzitetskoj dečjoj klinici (UDK) u Beogradu, u periodu od 2006 - 2016. godine. Klinički pregled, laboratorijske analize i ehosonografija abdomena, urađeni su kod svih ispitanika na prijemu. Njih 55 (55%), operisano je odmah nakon postavljanja dijagnoze. Kod preostalih 45 (45%) ispitanika lečenih konzervativno, atropin sulfatom, analizirana je efikasnost konzervativnog tretmana, s posebnim naglaskom na efekat doziranja leka i uz definisanje potencijalnih prediktivnih faktora negativnog ishoda. Procena uspešnosti lečenja analizirana je upotrebom deskriptivnih statističkih metoda uz korišćenje modela multivarijantne logističke regresije. Rezultati. Grupa ispitanika lečenih medikamentozno, obuhvata 45 bolesnika, od kojih je 36 (80%, p= 0.0008) uspešno izlečeno, bez potrebe za hirurškom intervencijom i bez komplikacija. Od opserviranih parametara, pokazalo se da u pogledu polne zastupljenosti, uzrasta, porođajne telesne mase, telesne težine na prijemu, trajanja simptoma, kao i dužine i debljine pilorusnog mišića nema statistički značajnog pojedinačnog uticaja na uspeh medikamentoznog lečenja. Ispitanici kod kojih je primenjeno progresivno povećanje doze atropina imaju 18 puta veci rizik da će biti operisani. Ispitanici koji su na prijemu imali hipohloremijsku alkalozu imaju 15 puta veći rizik, dok ispitanici koji su imali više od 5 povraćanja u prva tri dana od početka primene atropina imaju 9 puta veći rizik da će biti operisani. Preostalih 55 pacijenata uspešno je izlečeno hirurškom intervencijom (100%) uz 6,3% postoperativnih komplikacija od kojih se u 3,2% radilo o insuficijentnoj piloromiotomiji, a, koje su takođe uspešno izlečene peroralnom administracijom atropina, tako da reintervencije nisu bile potrebne...

Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause for surgery in the newborn and young infant. Extramucosal pyloromyotomy is the gold standard treatment of IHSP, but treatment with atropine sulphate has also leeds to a successful outcome and in some countries it was introduced as the first line of therapy. Conservative treatment of IHPS is of great importance because it saves a newborn from stress caused by surgery and general anesthesia. This study evaluates the impact of various oral administration regimens of atropine on its efficacy in treating IHPS with defining predictive factors and analyzing their impact on the outcome of atropine treatment. A comparison of the efficiency of the conservative tertment with the pyloromyotomy was also performed. Methods. The study included 100 patients treated for IHSP at the University Chidren´s Hospital in Belgrade in the period from 2006 - 2016. Clinical examination, laboratory analysis and ultrasonography were performed in all patients on admission. Fifty-five of them (55%) underwent surgery immediately after diagnosis was set. The remaining 45 (45%) patients were treated conservatively by atropine sulfate. We analyzed the efficacy of that treatment, with different drug dosage regimens and with definition of potential predictive factors of the negative outcome. Evaluation of the treatment was also analyzed by descriptive statistical methods and multivariate logistic regression model. Results. Group of patients, conservatively treated, included 45 patients, of whom 36 (80%, p=0,0008) were successfully cured, without the need for surgery and without complications. It has been shown that in terms of sex prevalence, age, birth weight, body weight on admission, duration of symptoms, pyloric muscle thickness and length, there is no statistically significant individual effect on the success of atropine treatment. Patients who received progressively increased dose of atropine have an 18 times higher risk of surgery, patients who have hypochloremic alkalosis have a 15 times higher risk, while others, who vomited more than 5 times within the first three days of therapy are 9 times more likely to be surgically treated. The remaining 55 patients were successfully treated by surgical intervention (100%) with 6.3% of postoperative complications, of which 3.2% were insufficient pyloromyotomy. They were successfully treated by orally administered atropine, so reintervention was not necessary...