腹腔镜辅助下经肛门逐层梯度切除直肠肌鞘改良Soave术治疗小婴儿先天性巨结肠的疗效分析  

Laparoscopically assisted transanal gradient ablation of rectal muscle sheath for congenital megacolon in infants

作　　者：高明娟 刘远梅 祝代威 Gao Mingjuan;Liu Yuanmei;Zhu Daiwei(Department of Pediatric General,Thoracic & Urological Surgery,Affiliated Hospital of Zunyi Medical College,Zunyi 563000,China)

机构地区：[1]贵州省遵义医科大学附属医院小儿普胸泌外科

出　　处：《临床小儿外科杂志》2019年第10期839-843,共5页Journal of Clinical Pediatric Surgery

基　　金：国家自然科学基金项目(编号:81650029);国家自然科学基金项目(编号:81360067)

摘　　要：目的探讨腹腔镜辅助经肛门逐层梯度切除直肠肌鞘改良Soave术治疗小婴儿(3个月以内)先天性巨结肠(Hirschsprung disease,HD)的疗效。 方法回顾性分析2013年10月至2018年8月遵义医科大学附属医院收治并通过手术确诊56例小婴儿巨结肠患儿的临床资料,其中常见型(病变肠段在直肠乙状结肠交界处以下,为HD最常见的一种类型)42例,长段型(病变累及降结肠甚至横结肠)14例(56例中5例术前因小肠结肠炎反复发作行回肠末端造瘘术,未纳入本研究,故实际研究样本量为51例);接受手术时患儿平均日龄(42±17)d,术前根据临床表现、钡灌肠、肛门直肠测压及直肠黏膜及肌层活检等结果确诊。51例均采用腹腔镜辅助经肛门逐层梯度切除直肠肌鞘改良Soave术进行治疗,术后随访采用Wingspread评分系统评估肛门功能。 结果51例患儿均一期完成巨结肠根治术,无一例中转开腹,42例常见型切除肠管平均长度为(10±2)cm,长段型切除肠管平均长度为(27± 7)cm ,术中失血量(15±5)mL,手术时间(96±12)min,术中、术后均无一例发生死亡或麻醉意外,其中9例拔除肛管后出现肛周皮肤糜烂,住院期间无吻合口瘘及肠梗阻发生。51例均获随访,随访时间(16±9)个月,术后发生小肠结肠炎4例,污粪7例,拖出“新直肠”隧道狭窄2例,无一例便秘复发,肛门功能Wingspread评分优良率为92.15%(47/51)。 结论小婴儿巨结肠诊断明确后一期行腹腔镜辅助经肛门逐层梯度切除直肠肌鞘改良Soave术具有手术时间短、切除病变肠管的长度短、所需切除肠管的长度相对较短以及麻醉过程安全等优势,同时患儿术后可获得较好的排便功能。Objective To evaluate the efficacy of laparoscopic assisted transanal gradient resection of rectal muscle sheath for Hirschsprung disease (HD) in infants. Methods Retrospective analysis was performed for the clinical data of 56 HD infants from October 2013 to February 2018.The clinical types were common ( n =42) and long-segment ( n =14).The average operative age was (42±17) days.According to clinical manifestations,barium enema examination,anorectal manometry and rectal mucosa & muscle layer biopsy were performed for making a definite diagnosis.Among them,5 patients were excluded for observations because of recurrent enterocolitis leading to the first-stage leakage of terminal ileum.Modified Soave procedure was performed by laparoscopic assisted transanal gradient ablation of rectal muscle sheath.The Wingspread score was utilized for evaluating anal functions. Results All 51 HD infants underwent laparoscopy without a conversion into laparotomy.For common type,the average colectomic length was (10±2) cm;For long-segment type,(27±7) cm.The volume of intraoperative blood loss (15±5)mL and the operative duration (96±12) min.There was neither perioperative mortality nor severe anesthetic accident.Nine cases developed immediate perianal skin erosion after an extraction of anal canal.There was no occurrence of anastomotic fistula or intestinal obstruction during hospitalization.During a follow-up period of (16±9)months,there were enterocolitis ( n =4),soiling ( n =7) and neo-rectal tunnel stenosis ( n =2).No constipation recurred and the excellent rate of anal function Wingspread score was 92.15%(47/51). Conclusion After a definite diagnosis of HD,phaseⅠcurative modified Soave of laparoscopic assisted transanal layer-by-layer gradient resection of rectal muscle sheath offers the advantages of a shorter operative duration,greater anesthetic safety,shorter length of intestinal resection and better defecating functions.

关 键 词：腹腔镜检查 先天性巨结肠 外科手术 治疗结果 婴儿 

分 类 号：R726.1[医药卫生—儿科] R574[医药卫生—临床医学]