腹腔镜辅助结肠切除术与巨结肠根治术治疗B型肠神经元性发育异常的对比研究

发布时间：2018-02-14 15:51

本文关键词： B型肠神经元发育异常(IND) 腹腔镜辅助结肠切除巨结肠根治术排便功能　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景目的:肠神经元性发育异常(Intestinal neuronal dysplasia,IND)是以远端肠管神经节细胞质量、数量异常为特征的常见消化道发育畸形,临床表现酷似先天性巨结肠(HD)[1]。IND分为A型和B型,临床以B型为主,A型罕见[2]。IND-B可先行保守治疗,保守治疗无效或效果欠佳的患儿需行病变肠管切除。本研究从多项手术指标及效果等方面进行比较腹腔镜辅助结肠切除术与巨结肠根治术,以指导临床治疗方式的选择。从而为临床上治疗IND-B提供更好参考依据。研究方法:回顾性研究自2009—2014年山东大学第二医院小儿外科收治并获得随访的81例经术后病理确定诊断为单纯IND-B型患儿,其中42例采取巨结肠根治术,39例采取腹腔镜辅助结肠切除手术。术前均行肛门直肠测压、钡灌肠及24小时X线片复查。术后待患儿排气后方可饮水,肛管保留2天,广谱抗生素应用3天,术后3周医师指导患儿家长开始扩肛,持续扩肛半年至吻合口平整柔软为止。1.比较两种术式手术时间、术中出血量、术后肠道蠕动恢复所需时间、住院时间及各种围手术期并发症等。2.客观排便功能检测:所有手术患儿术后3个月、6个月均复查肛门直肠测压,检测直肠静息压(RRP)、肛管静息压(ARP)及直肠肛门抑制反射(RAIR)等指标;术后6个月、1年复查钡灌肠,检测结直肠运动功能。3.主观排便功能检测:根据Reding评分标准[3],对巨结肠根治术与腹腔镜辅助结肠切除术后不同时间排便控制功能进行评分分级。结果:1.腹腔镜辅助结肠切除术手术时间少于巨结肠根治术(P0.01),腹腔镜手术术中出血明显少于巨结肠根治术(P0.05);腹腔镜辅助结肠切除术的手术费用明显高于巨结肠根治术(P0.01),但两者住院总费用没有统计学差异(P0.05);腹腔镜手术肠蠕动恢复时间少于巨结肠根治术(P0.05),两种术式留置肛管时间相比无显著性差异(P0.05),两组术后住院时间具有统计学差异(P0.05)。腹腔镜辅助结肠切除术后2例患儿出现脐部感染、1例患儿出现吻合口部分裂开,1例患儿出现小肠结肠炎,经保守抗感染治疗后均获得痊愈(12.8%);巨结肠根治术12例患儿(28.57%)出现并发症,3例患儿刀口感染、3例患儿吻合口部分裂开、2例患儿小肠结肠炎经保守治疗痊愈,1例患儿吻合口瘘伴腹膜炎再次手术行结肠造瘘,4例患儿出现肠梗阻,2例经理疗好转,2例保守治疗无效后再次手术行肠粘连松解术。2.术前两组患儿的直肠静息压和肛管静息压均明显高于正常,直肠顺应性明显下降,腹腔镜辅助结肠切除术前直肠肛门抑制反射(RAIR)消失或不典型25例,巨结肠根治术前直肠肛门抑制反射(RAIR)消失或不典型例26例。术后3个月直肠静息压、肛管静息压仍高于正常但明显低于术前(P0.05),直肠顺应性无明显改变,两组直肠肛管抑制反射均消失;术后6个月,两种术式患儿术后的直肠测压均无明显差异,直肠顺应性较术前明显变大。两组术前钡灌肠24小时后均有钡剂存留,腹腔镜辅助结肠切除术前钡灌肠典型巨结肠表现10例,巨结肠根治术前典型巨结肠表现10例;术后6个月复查钡灌肠示两组患儿结直肠内均无钡剂存留;术后1年复查,腹腔镜辅助结肠切除术无钡剂存留,巨结肠根治术后2例24小时后钡剂存留。3.术后1个月两组均有肛周污粪,腹腔镜辅助结肠切除术手术组Reding评分高于巨结肠根治术(P0.05);术后1～3个月两组患儿污粪较前减轻;术后3-6个月腹腔镜辅助结肠切除手术组7例污粪,巨结肠根治术组5例存在污粪,2例排便需开塞露辅助;术后1年,腹腔镜辅助结肠切除手术组2例污粪,巨结肠根治术组3例污粪、2例便秘复发。结论:1.与巨结肠根治术相比,腹腔镜辅助结肠切除术可减少手术时间及术中出血,且术后并发症少,术后住院时间相应缩短,虽然手术费用明星提高,但总的住院费用并无明显差异。2.IND-B不同于先天性巨结肠(HD),直肠肛门抑制反射(RAIR)消失并不能作为诊断IND-B的依据。3.腹腔镜辅助结肠切除术后短期内主观和客观排便情况优于巨结肠根治术。
[Abstract]:Background and objective: intestinal neuronal dysplasia (Intestinal neuronal, dysplasia, IND) is the quality of the distal intestinal ganglion cells, the number of abnormal characteristics of common digestive tract malformation. The clinical manifestations mimicking congenital megacolon (HD) [1].IND is divided into A type and B type, the bed is dominated by B type, A type rare [2].IND-B may be conservative treatment, conservative treatment is invalid or poor effect of children for lesions of bowel resection. This study comparing laparoscopic assisted colectomy with Hirschsprung's disease from a number of index of operation and effect, to guide the clinical treatment options for clinical treatment of IND-B. In order to provide better reference for the research methods.: a retrospective study from 2009 to 2014 the second hospital of Shandong University from pediatric surgery and followed up 81 cases of pathologically confirmed the diagnosis of herpes type IND-B patients, including 42 cases with giant. Intestinal resection, 39 cases by laparoscopy assisted colon surgery. All patients underwent preoperative anorectal manometry, barium enema and 24 hours after operation. X-ray examination for children with exhaust before drinking, anal canal 2 days, broad-spectrum antibiotics for 3 days, 3 weeks after surgery doctors to help parents of children with anal start, continued to expand half a year to anal anastomotic smooth and soft.1. comparison of two kinds of surgical operation time, intraoperative blood loss, postoperative intestinal peristalsis recovery time, hospitalization time and perioperative complications were.2. objective defecation function detection: 3 months after operation, all patients were reexamined 6 months, anorectal manometry, detection of rectal resting pressure (RRP), anal resting pressure (ARP) and rectoanal inhibitory reflex (RAIR) and other indicators; 6 months after surgery, 1 years barium enema examination, detection of colorectal motor function.3. subjective bowel function detection: according to the Reding standard for evaluation of [3], the root of Hirschsprung's disease Treatment of surgery and laparoscopic assisted colectomy after different time of defecation control function score. Results: 1. laparoscopic assisted colectomy surgery for Hirschsprung's disease (less than P0.01), the intraoperative bleeding was less than radical macrosigmoid operation (P0.05); the operation cost of laparoscopic assisted colectomy was significantly higher than that of Hirschsprung's disease radical resection (P0.01), but the total cost of hospitalization was not statistically significant (P0.05); laparoscopic surgery recovery time of intestinal peristalsis less than Hirschsprung's disease (P0.05), two kinds of operation time retention anal compared no significant difference (P0.05), two groups of postoperative hospitalization time had statistical differences (P0.05) laparoscopic. Assisted colectomy after 2 cases of umbilical infection, 1 cases of anastomotic partial dehiscence, 1 cases of enterocolitis after conservative anti infection treatment were cured (12.8%); megacolon Radical resection in 12 cases (28.57%) had complications, 3 cases of incision infection, 3 cases of anastomotic part dehiscence, 2 cases of enterocolitis cured by conservative treatment, 1 cases of anastomotic fistula with peritonitis surgery colostomy, 4 cases of intestinal obstruction, 2 cases of physical therapy improved, 2 conservative treatment had no reoperation after underwent enterolysis before.2. two groups of children with rectal resting pressure and anal resting pressure was significantly higher than that of normal, rectal compliance decreased, laparoscopic assisted colectomy before the rectoanal inhibitory reflex (RAIR) disappeared or atypical 25 cases of Hirschsprung's disease before rectum anal inhibitory reflex (RAIR) disappeared or atypical cases in 26 cases. 3 months postoperative rectal resting pressure, anal resting pressure is still higher than normal but was significantly lower than that before operation (P0.05), rectal compliance had no obvious change, two groups of rectoanal inhibitory reflex disappeared after operation; 6 months, there were no significant difference between the two kinds of surgical postoperative patients with rectal manometry, rectal compliance significantly larger. Two groups of preoperative barium enema after 24 hours of barium retention, laparoscopic assisted colectomy before barium enema typical manifestations of 10 cases of megacolon, Hirschsprung's disease before. Megacolon manifestation in 10 cases; 6 months after the treatment in two groups of children with colorectal barium enema were not barium retention; review 1 years after surgery, laparoscopic assisted colectomy without barium retention, radical macrosigmoid operation in 2 cases after 24 hours after barium retention after.3. 1 months in two groups have crissum soiling, laparoscopy assisted colectomy surgery group Reding was higher than that of Hirschsprung's disease (P0.05); 1~3 months after surgery, two groups of children with fecal pollution decreased; 3-6 months after surgery, laparoscopic assisted colectomy group 7 cases of fecal pollution, Hirschsprung's disease group 5 cases with fecal pollution, 2 cases of bowel to glycerine With assistance; 1 years after surgery assisted laparoscopic resection of colon surgery group 2 cases of fecal pollution, Hirschsprung's disease group and 3 cases of soiling, 2 cases of recurrent constipation. Conclusion: 1. compared with radical macrosigmoid operation, laparoscopic assisted colectomy can reduce bleeding and operation time, and fewer postoperative complications. Postoperative hospitalization time shortened, while the cost of surgery but no star increase, the cost of hospitalization was significantly difference in total.2.IND-B different from Hirschsprung's disease (HD), rectoanal inhibitory reflex (RAIR) disappeared and cannot be used as a diagnosis of IND-B.3. laparoscopic colon resection in a short period of time after the subjective and objective defecation is better than that of the giant radical resection of colon.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5

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