经肛门逐层梯度切除直肠肌鞘治疗婴幼儿巨结肠的疗效分析

发布时间：2018-09-19 06:00

【摘要】：目的:探讨经肛门逐层梯度切除直肠肌鞘治疗婴幼儿先天性巨结肠的疗效。方法:回顾性分析遵义医学院附属医院小儿普胸泌外科2010年1月~2016年12月明确诊断并行逐层梯度切除直肠肌鞘的改良Soave术治疗婴幼儿巨结肠共77例,年龄2天-3岁,其中常见型45例,长段型24例,短段型3例,全结肠型5例,由于短段型和全结肠型病例数较少未纳入研究范畴。随访69例,死亡2例(均于家中因腹胀、高热死亡,考虑小肠结肠炎),5例失访,随访资料完整有62例,男患46例,女患16例(男:女=2.9:1),手术年龄17天~3岁,一期根治术48例,普通型39例,长段型9例,其中腹腔镜辅助35例,单纯经肛手术8例,腹会阴术5例;新生儿期造瘘二期根治14例,二期根治手术在造瘘术后6月-9月,普通型1例,长段型13例,其中腹腔镜辅助12例,腹会阴术2例。随访时间1月-6年,根据病变范围(普通型和长段型)和随访时间进行分组(A组:术后1-6月,B组:术后6月-2年,C组:术后2年-6年);随访内容:(1)术后并发症(肛周皮炎、肠梗阻、小肠结肠炎、吻合口狭窄、污粪、大便失禁、便秘复发);(2)排便功能评估:主观指标应用Heikkinen评分,客观指标采用直肠肛门测压以及钡灌肠检查。结果:62例患儿中发生术后并发症20例(肛周皮炎13例,肠梗阻3例,小肠结肠炎12例,吻合口狭窄4例,污粪11例,大便失禁3例,便秘复发6例),发生率为32.3%,其中普通型8例,长段型12例,两组比较有统计学差异(P0.05);术后排便功能优良率:术后1-6月普通型80%,长段型59.1%,术后6月-2年普通型89.7%,长段型68.8%,术后2年-6年普通型94.7%,长段型81.3%,三个时间段普通型和长段型比较,P0.05,均有统计学意义;三组患儿排便功能总的优良率:A组71.0%,B组83.6%,C组90.7%,A组与B组、C组比较均有统计学意义(P0.05)。术后6月行肛门直肠测压检查46例,普通型32例,长段型14例,RAIR恢复19例,其中普通型14例,长段型5例,两组比较无统计学意义(P0.05);普通型肛管静息压较长段型高,两组比较有差异(P0.05)。术后6月复查钡剂灌肠50例,普通型33例,长段型17例,结果显示:拖下结肠形态正常,未见明显狭窄段和扩张段,24h复查钡剂排空26例(普通型19例,长段型7例),未排空24例(普通型14例,长段型10例)。结论:1.经肛门逐层梯度切除直肠肌鞘的改良Soave术治疗婴幼儿先天性巨结肠可获得较好的排便功能;2.普通型巨结肠术后排便功能优良率明显优于长段型巨结肠,病变范围越长,术后排便功能恢复越慢,长段型巨结肠患儿随着术后时间延长绝大多数可获得较好的效果。
[Abstract]:Objective: to investigate the effect of transanal gradient resection of rectal muscle sheath in the treatment of congenital Hirschsprung's disease (Hirschsprung's disease) in infants. Methods: a retrospective analysis of 77 cases of Hirschsprung's disease in infants, aged 2 days, was performed in 77 cases of Hirschsprung's disease (n = 77, age 2 days), who were treated with modified Soave procedure combined with graded resection of rectum muscle sheath from January 2010 to December 2016 in the Department of General Thoracic surgery in affiliated Hospital of Zunyi Medical College. Among them, there were 45 cases of common type, 24 cases of long segment type, 3 cases of short segment type and 5 cases of total colonic type. 69 cases were followed up, 2 cases died (all died of abdominal distension, high fever, considering enterocolitis) in 5 cases. The follow-up data were complete in 62 cases, 46 males and 16 females (male: female 2.9: 1). The age of operation was 17 days and 3 years old, and 48 patients underwent one stage radical operation. There were 39 cases of common type, 9 cases of long segment type, 35 cases of laparoscope assisted operation, 8 cases of simple transanal operation, 5 cases of abdominal perineum operation, 14 cases of second stage radical operation of neonatal fistula, 1 case of common type of secondary radical operation from 6 months to 9 months after operation. There were 13 cases of long segment type, of which 12 cases were laparoscopically assisted, 2 cases were abdominal perineum operation. The patients were followed up for 1 month to 6 years, according to the range of lesions (common type and long segment type) and follow-up time (group A: 1-6 months after operation: group B: 6 months to 2 years after operation: group C: 2 years to 6 years after operation), and follow up: (1) postoperative complications (perianal dermatitis, 2 years and 6 years after operation), (1) postoperative complications (perianal dermatitis), Bowel obstruction, enterocolitis, anastomotic stricture, feces, fecal incontinence, constipation recurrence (); (_ 2) were evaluated: Heikkinen score was used as subjective index, rectal and anal manometry and barium enema were used as objective index. Results postoperative complications occurred in 20 cases (13 cases of perianal dermatitis, 3 cases of intestinal obstruction, 12 cases of enterocolitis, 4 cases of anastomotic stenosis, 11 cases of feces, 3 cases of fecal incontinence). The incidence of constipation was 32.3%, including 8 cases of common type, 12 cases of long segment type, 6 cases of constipation recurrence. There was significant difference between the two groups (P0.05), the excellent and good rate of postoperative defecation function: normal type 80%, long segment 59.1%, common type 89.778, long segment 68.8%, common type 94.7 7, long segment 81.3%, common type 81.3% after operation 1 to 6 months after operation. The comparison of long segment type (P0.05) was statistically significant. The total excellent and good rate of defecation function in group A was 71.0% and 83.6% in group B was significantly higher than that in group A (P 0.05). Six months after operation, 46 cases of anorectal manometry, 32 cases of common type, 19 cases of long segment type, 14 cases of common type, 5 cases of long segment type, had no significant difference between the two groups (P0.05), the rest pressure of common anal canal was higher than that of long segment type. There was a difference between the two groups (P0.05). Six months after operation, 50 cases of barium enema, 33 cases of common type and 17 cases of long segment type were reexamined. The results showed that the shape of dragging down colon was normal, 26 cases of barium emptying were found in 24 hours without obvious stenosis and dilated segment (19 cases of common type). There were 7 cases of long segment type and 24 cases of non-emptying (14 cases of common type and 10 cases of long segment type). Conclusion 1. The improved Soave procedure for the treatment of congenital Hirschsprung's disease can obtain better defecation function in the treatment of infants with Hirschsprung's disease (Hirschsprung's disease). The excellent and good rate of defecation function in general Hirschsprung's colon was obviously better than that in long Hirschsprung's colon. The longer the lesion range, the slower the postoperative defecation function was recovered. Most of the children with long Hirschsprung's colon could get better results with the extension of postoperative time.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5

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