先天性巨结肠根治术后医源性直肠阴道瘘的再手术治疗  

Redo surgery for iatrogenic rectovaginal fistula after pull-through in Hirschsprung's disease

作　　者：吴东阳[1] 陈亚军[1] 王增萌[1] 彭春辉[1] 庞文博[1] 黄心洁[1] 王凯[1] Wu Dongyang;Chen Yajun;Wang Zengmeng;Peng Chunhui;Pang Wenbo;Huang Xinjie;Wang Kai(Department of General Surgery,Beijing Children's Hospital,Capital Medical University,National Center for Children's Health,Beijing 100045,China)

机构地区：[1]国家儿童医学中心,首都医科大学附属北京儿童医院普外科,北京100045

出　　处：《临床小儿外科杂志》2022年第11期1024-1028,共5页Journal of Clinical Pediatric Surgery

摘　　要：目的分析先天性巨结肠根治术后医源性直肠阴道瘘的发生原因,探讨再次手术治疗的方法及效果。方法回顾性分析2007年12月至2020年12月首都医科大学附属北京儿童医院普外科收治的6例先天性巨结肠根治术后医源性直肠阴道瘘患儿临床资料。再次手术治疗的方式包括经腹经肛Soave术、经会阴或经肛门修补手术。分析发生直肠阴道瘘的原因,总结手术经验,随访预后情况。结果6例患儿临床表现均为自阴道内漏出粪便,其中4例出现在初次手术后,2例出现在再次手术后;行再次手术的原因分别为手术后腹腔出血、存在肠无神经节细胞段残留。4例合并吻合口回缩、狭窄,采用经腹经肛Soave术治疗直肠阴道瘘及吻合口回缩、狭窄,均经单次修复获成功;2例仅单纯局部修补直肠阴道瘘,其中1例经肛门修补2次后瘘管闭合,1例经会阴/经肛门局部修补5次后瘘管仍未闭合。结论先天性巨结肠根治术后直肠阴道瘘是一种较为严重的医源性损伤,在进行先天性巨结肠拖出手术时应紧贴直肠黏膜下层或直肠壁分离,以避免损伤阴道。经腹经肛Soave手术修复直肠阴道瘘成功率高,可同时处理吻合口回缩、狭窄。Objective To explore the causes of iatrogenic rectovaginal fistula after pull-through in Hirschsprung's disease(HD)and summarize the experiences and efficacies of reoperation.Methods From December 2007 to December 2020,retrospective review was conducted for clinical data of 6 HD children with iatrogenic rectovaginal fistula after pull-through.The surgical procedures for repairing rectovaginal fistula included transabdominal and transanal Soave,transperineal or transanal surgery.Results A total of six girls were included.Clinical manifestation was vaginal excretion.Injuries occurred in initial surgery(n=4)and during redo pull-through(n=2).The reasons for re-operation were postoperative abdominal hemorrhage and aganglionic segment residue.Rectovaginal fistula with anastomotic retraction and stenosis were successfully repaired by transabdominal and transanal Soave procedure in single time(n=4).The remaining two cases underwent simple local repair of rectovaginal fistula,including fistula closure after anal repair twice(n=1)and failed closure after five local(perineal/anal)repairs(n=1).Conclusion Rectovaginal fistula after pull-through in HD is a serious iatrogenic injury.It should be separated close to rectal submucosa/rectal wall to avoid vaginal injury.Transabdominal and transanal Soave procedure has a high success rate for repairing rectovaginal fistula and managing anastomotic retraction and stenosis.

关 键 词：巨结肠 先天性巨结肠病 直肠阴道瘘 腹腔镜 外科手术 

分 类 号：R73[医药卫生—肿瘤]