先天性巨结肠根治术后再次手术的原因分析及处理策略

发布时间：2018-01-06 11:29

  本文关键词：先天性巨结肠根治术后再次手术的原因分析及处理策略　出处：《广西医科大学》2016年硕士论文　论文类型：学位论文

  更多相关文章： 先天性巨结肠 再次手术 原因分析 处理

【摘要】：目的：通过对先天性巨结肠根治术后再次手术的原因进行分析,探讨其处理策略,以提高手术疗效。方法：回顾性分析广西医科大学第一附属医院小儿外科2005年1月至2015年10月期间我院收治的先天性巨结肠病例术后因各种原因再次手术病例共60例,其中首次在我院行巨结肠根治术有42例(42/416,10.1%),另外18例由外院转入。本组男性56例,女性4例,首次手术年龄最小为1月,最大为12岁,其中1岁以下26例,1～3岁19例,3岁以上15例,平均年龄28.6个月,中位年龄12个月。本组病例行巨结肠根治术后再次经历1次手术有34例,2次手术有23例,3次及3次以上手术3例。统计并分析再次手术病例的原因,结合临床分型、首次根治术式、再次手术方式的选择、再次手术与既往手术病理结果等相关资料,进行统计学分析。结果：首次手术年龄与术后便秘复发关系无统计学意义(P0.05),首次手术年龄与术后吻合口漏关系有统计学意义(P0.05),年龄超过1岁患儿,术后发生吻合口漏率较年龄小于1岁患儿高。术前巨结肠临床分型：短段型4例,常见型38例,长段型10例,全结肠型3例,结果显示巨结肠术前临床分型与再次手术关系无统计学意义(P0.05)。既往手术方式：经肛门改良Swenson术32例,再次手术例数2例；Duhamel术43例,再次手术例数2例；改良Rehbein术50例,再次手术例数7例；经肛门改良Soave术282例(单纯肛门拖出74例,开腹辅助166例,腔镜辅助42例),再次手术例数40例。9例病人外院转入,首次根治手术方式不详或不能确定,结果显示首次巨结肠根治术与再次手术关系无统计学差异(P0.05)。再次手术的原因有：术后便秘复发28例(46.7%),其中误诊类缘病使手术中切除肠管范围不足5例,病变肠管切除不全21例,吻合口狭窄及内括约肌痉挛2例；吻合口漏20例(33.3%),其中有2例术后肛门吻合口回缩(3.3%)；术后粘连性肠梗阻10例(16.7%),其中有1例吻合口肠扭转；术后切口愈合不良或裂开4例(6.7%)；术后盆腔脓肿2例(3.3%)；术后出血1例(1.7%)；副损伤性瘘3例(5%)：直肠尿道瘘1例(1.7%)、直肠阴道瘘1例(1.7%)、肛瘘1例(1.7%),其中有8例病人同时合并有2种或2种以上并发症。28例术后便秘复发病例中,再次手术病理结果与首次病理结果相符有21例,有5例病例首次诊断巨结肠,再次手术术后病例诊断巨结肠类缘病,手术范围切除不恰当有2例,术中切除了扩张段肠管,狭窄段未做切除。获得随访例数48例(80%),失访例数11例(18.3%),死亡1例(1.6%)。在访病人中：41例病人均能自主排便,排便控制良好,大便次数1-3次/天,大便成形,偶有稀便,生长发育与同龄儿童无明显差异；4例病人有少量肛周污粪,不影响日常生活；3例近期出院的病人间断发生小肠结肠炎。结论：先天性巨结肠根治术后吻合口漏与手术年龄相关,年龄越大,术后吻合口漏发生率会越高,其临床分型、首次手术方式与再次手术率无明显相关。对于吻合口漏及副损伤性瘘等围手术期并发症：保守治疗无效时,强调当机立断手术探查,特别是吻合口漏,应果断造瘘,充分引流。便秘复发强调术前全面了解既往诊疗过程,充分准备,必须了解吻合口及结肠形态功能做到术前诊断证据充分,强调以术前或术中病理检查作为手术依据。再次根治术应在可靠的病理诊断基础上实施,尤其是便秘复发及既往造瘘术后的病例。盆腔的精准解剖是完成手术的关键。
[Abstract]:Objective: to analyze the cause of reoperation for congenital megacolon radical operation, to explore its treatment strategies, in order to improve the curative effect. Methods: retrospective analysis of the First Affiliated Hospital of Guangxi Medical University from January 2005 to October 2015 in pediatric surgery of congenital megacolon patients admitted to our hospital due to various reasons of reoperation in 60 cases, among them for the first time in our hospital 42 cases of Hirschsprung's disease (42/416,10.1%), the other 18 cases from outside the hospital into. 56 patients were male and 4 female patients, the youngest was the first operation in January, the maximum of 12 years, under the age of 1 in 26 cases, 19 cases of 1 ~ 3 years old, 3 years old in 15 cases, the average age of 28.6 months, the median age was 12 months. The patients underwent megacolon radical operation again after 1 operations in 34 cases, 2 surgeries in 23 cases, 3 cases were 3 times and 3 times more surgery. Statistics and analysis the cause of reoperation cases, according to the clinical Bed type for the first time, radical surgery again, the choice of surgical method, reoperation and previous surgical pathologic results and other relevant information, for statistical analysis. Results: the relationship between recurrent constipation first surgery and postoperative age had no statistical significance (P0.05) for the first time, age at surgery and postoperative anastomotic leakage was statistically significant relationship (P0.05) over 1 years of age, children, anastomotic leakage rate is less than 1 years of age in children with megacolon after surgery. Preoperative clinical classification: 4 cases of short segment type, common type in 38 cases, 10 cases of long segment type, 3 cases of total colonic type, showed megacolon preoperative clinical classification and surgery again the relationship was not statistically significant (P0.05). Methods: 32 cases with previous surgery anal modified Swenson procedure, 2 cases of reoperation cases; 43 cases of Duhamel patients, 2 cases of reoperation cases; 50 cases of modified Rehbein surgery, reoperation and 7 cases; 282 cases with modified Soave operation (simple anal anal 鎷栧嚭74渚，

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