再次手术治疗先天性巨结肠初次根治术后中远期并发症的临床研究  

Redo pull-through for late postoperative complications of Hirschsprung's disease

作　　者：李颀[1] 张震[1] 肖萍[1] 马亚 闫淯淳 姜茜[1] 李龙[1] Li Qi;Zhang Zhen;Xiao Ping;Ma Ya;Yan Yunchun;Jiang Qian;Li Long(Department of General Surgery,Capital Institute of Pediatrics,Beijing 100020,China)

机构地区：[1]首都儿科研究所附属儿童医院普通外科,北京100020

出　　处：《中华小儿外科杂志》2021年第7期639-645,共7页Chinese Journal of Pediatric Surgery

基　　金：北京市属医院科研培育项目(PX2020054)。

摘　　要：目的评估先天性巨结肠初次根治术后因中远期并发症而再次手术的原因,总结手术方法并评估其预后。方法收集2016年1月至2020年1月收治于首都儿科研究所附属儿童医院普通外科的37例因先天性巨结肠初次根治术后发生中远期并发症而再次接受手术治疗的患儿。其中,男29例,女8例,男女比为3.625∶1;再次手术年龄为(3.8±2.4)岁,范围为9个月至12岁;初次根治手术年龄范围为4 d至6岁(本院4例,外院33例)。初次手术采用单纯经肛门根治术6例,腹腔镜辅助根治术16例,开腹手术15例。肛门直肠手术技术:外院患儿中,32例采用Soave-like技术,1例采用心形吻合技术;本院4例均采用内括约肌部分切除术(transanal rectal mucosectomy and partial internal anal sphincterectomy,TRM-PIAS)。再次手术原因:病变段残留19例,吻合口瘢痕狭窄5例,各种瘘管形成8例(直肠阴道瘘2例,高位复杂肛瘘4例,直肠舟状窝瘘1例,直肠尿道瘘1例),拖出肠管扭转3例,回盲部卡压梗阻1例,过长的肌鞘狭窄1例。再手术所采用的手术方式:采用腹腔镜或开腹辅助经肛门巨结肠根治术,肛门直肠手术技术采用经肛门直肠黏膜切除、TRM-PIAS法。本研究将术后随访时间满1年的24例患儿分为两组,其中将12例结肠肛管吻合患儿作为组一,将12例回肠肛管吻合患儿作为组二;同样选取两组患儿作为对照组,其中将既往经一次腹腔镜辅助根治手术的常见型和短段型的37例先天性巨结肠患儿作为对照组一,将既往经一次根治手术的33例全结肠型巨结肠患儿作为对照组二。将组一和对照组一,组二和对照组二,分别进行对比以评估预后。结果所有患儿均顺利完成手术,一期根治手术34例(结肠肛管吻合20例,回肠肛管吻合12例,结肠肛管吻合+回肠瘘口还纳2例);分期手术3例(根治术后3~6个月关瘘)。其中腹腔镜手术12例;腹腔镜松解直肠后转开腹手术14例;开腹手术11例�Objective To evaluate the causes of reoperation due to medium/long-term complications after primary radical resection of Hirschsprung's disease,to summarize the surgical approaches and to evaluate its prognosis.Methods From January 2016 to January 2020,37 children with Hirschsprung's disease underwent reoperation due to medium/long-term complications after initial radical resection.There were 29 boys and 8 females with a male-to-female ratio of 3.625:1.The operative age was(3.8±2.4)(0.75-12)years and the age of initial radical surgery 4 days to 6 years(4 at our hospitals and 33 at other hospital).Primary procedures included total transanal radical resection(n=6),laparoscopic-assisted radical resection(n=16)and laparotomy(n=15).Anorectal techniques included Soave-like(n=32),heart-shaped anastomosis(n=1)and transanal rectal mucosal resection&partial internal sphincterectomy(TRM-PIAS)(n=4).The causes of reoperation were residual lesion segment(n=19),anastomotic scar stenosis(n=5)and various fistula formations(n=8),pull-through bowel torsion(n=3),ileocecal entrapment obstruction(n=1)and long myometrial stricture(n=1).The fistulas included rectovaginal fistula(n=2),high complex anal fistula(n=4),scaphoid fossa fistula(n=1)and rectourethral fistula(n=1).Laparoscopic or laparotomy-assisted transanal radical resection of megacolon and TRM-PIAS were employed.At Year 1 postoperatively,24 children were divided into two groups of coloanal anastomosis and ileoanal anastomosis(n=12 each).Two control groups were also selected.And 37 children with common/short type of Hirschsprung's disease previously undergoing laparoscopic-assisted radical surgery were selected as control group 1 while another 33 children with total Hirschsprung's disease previously undergoing radical surgery control group 2.Four groups were compared to evaluate the prognosis.Results All operations were successfully completed.Among 34 cases of one-stage radical surgery,there were coloanal anastomosis(n=20),ileoanal anastomosis(n=12),coloanal anastomosis plus

关 键 词：巨结肠 先天性 并发症 再次手术 

分 类 号：R726.5[医药卫生—儿科]