经肛门巨结肠根治手术方式的改进

目的 探讨改良经肛门巨结肠根治术的的临床疗效及安全性. 方法 回顾性分析本院自2006-2010年采用改良经肛门巨结肠根治术治疗的68例患儿临床资料. 结果 66例患儿顽固性便秘消失,营养改善,近期无吻合口漏,无腹腔及伤口感染,远期随访无便秘复发及直肠回缩,无吻合口狭窄、污裤及便失禁,2例再发便秘,病理检查确认为巨结肠类缘性疾病,3例有小肠结肠炎. 结论 改良经肛门先天性巨结肠根治术效果满意,术后并发症少,具有较高的临床实用性和安全性.     

经肛门改良Swenson手术治疗先天性巨结肠541例

目的：总结经肛门改良 Swenson 手术治疗先天性巨结肠（HD）的临床经验。方法2000年4月至2013年12月我们确诊并行经肛门改良Swenson手术治疗HD患儿541例。收集其临床资料、术中情况及随访信息进行评估,均经直肠肛管测压、肛门指诊等评价患儿术后情况。结果541例患儿中,387例（71.5％）获随访,平均手术时间70 min,平均出血量5 mL,术后平均住院时间7 d,发生并发症20例（20/387,5.17％）,其中污粪4例（1.03％）,失禁1例（0.26％）,吻合口狭窄2例（0.52％）,小肠结肠炎7例（1.81％）,便秘复发6例（1.55％）。结论经肛门改良Swenson手术设计符合生理,安全可靠,适合临床推广使用。     

儿童腹腔镜下巨结肠根治、结直肠钉合吻合术的应用

目的评价腹腔镜辅助下结直肠切除、结直肠钉合吻合术治疗儿童先天性巨结肠的疗效。方法2010年2月至2012年2月我们对12例4—14岁常见型先天性巨结肠患儿,采取腹腔镜辅助下病变肠段游离经肛门拖出切除（改良Swenson手术）、结直肠采用吻合器完成钉合吻合术,统计手术时间、出血量、住院时间、住院期间排便情况和近期并发症。结果12例患儿均在腹腔镜辅助下顺利完成改良Swenson手术、结直肠钉合吻合术,手术时间1．5～2．0h;术中出血3～5mL;无术中并发症及术后伤口感染。2例术后出现排便时肛门疼痛;2例出现吻合口瘘,1例保守治疗30d瘘口愈合;1例行横结肠造瘘,术后4个月出现结直肠吻合口狭窄,经肛门纵行切开横行缝合后扩肛缓解;1例出现肠炎症状给予对症治疗痊愈。7例获随访患儿均无污粪、便秘情况存在,每日排便1～3次。所有患儿小便正常。结论腹腔镜辅助巨结肠根治、结直肠吻合器钉合方法可行,手术时间明显缩短,出血少,创伤小,术后恢复快,短期随访疗效满意,适合儿童巨结肠手术,但婴幼儿不适合此法。     

改良Soave术治疗先天性直肠肛管狭窄的疗效分析

目的总结分析改良Soave术治疗先天性直肠肛管狭窄的临床疗效,探讨准确诊断和一期治愈的手术方法。方法回顾性分析郑州大学第一附属医院2015年1月至2018年1月采用改良Soave术治疗5例先天性直肠肛管狭窄患儿的疗效。其中男3例,女2例,年龄4个月至6岁,病程1个月至6年,均足月出生,5例大肠气钡双重造影提示均合并继发性巨结肠,临床表现可排细条状大便。结果5例患儿术后手术切口一期愈合,排便通畅,术后1个月无小肠结肠炎、吻合口出血、吻合口漏、肌鞘感染、泌尿系统感染、腹膜炎;随访12~37个月,远期无便秘,无梗阻综合征、吻合口狭窄,无二次入院。其中1例远期出现Ⅰ°直肠脱垂,随访该患儿停止扩肛3个月后直肠黏膜脱垂频率较扩肛期间逐渐减少,截至术后15个月时已无直肠黏膜脱垂,排便正常,平均1次/d。1例远期夜间偶有污便,随访该患儿术后1年夜间偶有污便,日间控便正常,可保证生活质量。结论小儿先天性直肠肛管狭窄治疗方法尚无统一标准,常合并继发性巨结肠,改良Soave术为一期手术治愈先天性直肠肛管狭窄提供可能。准确诊断主要依据大肠气钡双重造影,狭窄段主要位于耻尾线(PC线)与I线之间。     

先天性巨结肠Swenson改良术后排便功能与生活质量研究

目的：评估先天性巨结肠Swenson改良术后排便功能和生活质量。方法：随访常见型先天性巨结肠Swenson行改良术后患儿45例（男37例，女8例），手术年龄2．5个月－6岁，平均1．6岁。术后随访8－16年，平均10．9年，评估其排便功能和生活质量。结果：术后并发症有：污染和小肠结肠炎17例（37．8％），便秘3例（6．7％），大便失禁3例（6．7％），小便失禁4例（8．9％）；吻合口狭窄2例（4．4％）和粘连性梗阻1例（2．2％）。23例（51％）表现不同程度的排便障碍，但肛门功能优良率仍达到84．4％（李正评分）和93．4％（Rintala评分），生活质量评分显示，优者18例（40％），良者21例（46．7％），差者6例（13．3％），结论：先天性巨结肠Swenson改良术后，多数患儿远期肛门功能和生活质量优良，排便功能障碍是影响生活质量的主要因素。     

经肛门Swenson术及Soave术治疗巨结肠临床效果分析

目的 探讨分析巨结肠经肛门改良Swenson术、经肛门Swenson术(即完整保留直肠肛管黏膜及肌层)及经肛门Soave术三种术式的临床效果及各种并发症的发生率.方法 结合我科巨结肠经肛门行改良Swenson术505例经验,加上统计国内外文献巨结肠经肛门Swenson术456例及经肛门Soave术1443例的大宗病例,将其各种并发症加以统计并予以分析.结果 经肛门改良Swenson术的污粪发生率为0.6％、经肛门Swenson术为3.5％、经肛门Soave术为6.4％;吻合口狭窄的发生率分别是0.4％、0、2.1％;失禁发生率为0.2％、0.4％、0.4％;结肠小肠炎发生率为1.2％、0.4％、7.2％;便秘复发率为1.2％、0.9％、4.1％.三种手术方式并发症数据进行3×2行列表x2检验,两两比较分析,经肛门Swenson术组和改良Swenson术组组间总并发症发生率差异没有统计学意义(x2=1.6546,P=0.1983);而经肛门Soave术组与经肛门Swenson术组和改良Swenson术组的组间总并发症发生率差异均有统计学意义,分别为x2=56.3752、P＜0.0001和x2=78.1408、P＜0.0001.结论 三种经肛门手术均降低了手术创伤,但经肛门改良Swenson术和经肛门Swenson术术后并发症较少,临床效果更好.     

胃肠吻合器在先天性巨结肠根治术中的应用

为了改进先天性巨结肠的手术治疗方法，解决术后吻合口狭窄、盲囊及闸门形成等并发症，并解除术后扩肛之痛苦。应用Ｄｕｈａｍｅｌ的改良术式Ｉｋｅｄａ法，并引用美国外科医疗器械公司的ＧＩＡ－８０胃肠吻合器替代矩行钳用于盆腔直肠和结肠侧侧吻合，治疗１４例５个月至１２岁的先天性巨结肠患儿，常见型１３例，短段型１例，均获得满意临床效果。该方法完成了盆腔内直肠结肠的Ⅰ期吻合，减少患儿带钳之苦，术后不需扩肛，吻合口通畅，均无盲袋及闸门形成，排便功能恢复快。     

经肛门改良Swenson和Soave术治疗先天性巨结肠比较

目的比较经肛门改良Swenson术和Soave术治疗先天性巨结肠的疗效及优缺点。方法回顾性分析经肛门手术治疗的50例先天性巨结肠患儿临床资料，其中短段型11例，普通型35例，长段型4例；行经肛门改良Swenson术21例，经肛门改良Soave术29例。比较两组患儿手术相关因素、术后并发症及排便功能情况。结果两种术式术前灌肠时间、术中出血量、术后住院天数及出院时排便情况比较，无统计学意义（P〉0．05），而手术时间比较，前者较后者短（P〈0．05）。两组术后并发症的发生率分别为19．0％和37．9％，术后6个月时排便优良率为95．2％和89．6％。结论经肛门改良Swenson术和改良Soave术创伤小，恢复快，疗效好，但经肛门Swenson术较经肛门Soave术操作更简单方便，并发症明显减少；两者手术适应证均可适当放宽。     

改良Soave术治疗婴儿和新生儿先天性巨结肠27例

目的总结改良Soave根治术治疗婴儿和新生儿先天性巨结肠的手术体会。方法对27例10d￣3个月的先天性巨结肠患儿行改良Soave根治术,其中14例常见型巨结肠经肛门直接拖出,4例因根治术前肠穿孔行结肠造瘘术。腹部不切开肠管亦不剥离肌鞘,而是转至会阴部操作,保留肌鞘后壁距齿状线0.5cm,前壁距齿状线2￣3cm。结果术后无内括约肌征候群及肌鞘感染,每月随访1次,无便秘、腹胀及失禁现象,大便控制良好。结论改良Soave根治术应用于小婴儿和新生儿先天性巨结肠,创伤小,恢复快,减轻了患儿痛苦,术后可获得良好的排便控制功能,近期疗效满意。     

Reoperation for Hirschsprung's disease

目的 分析先天性巨结肠根治术后再次手术的病例,分析再次手术的原因,讨论手术指征和再次手术方式的选择.方法 回顾分析1999年至2011年间先天性巨结肠根治术后再次手术19例临床资料.再次手术原因:吻合口狭窄5例,残留无神经节细胞症5例,直肠皮肤瘘6例,直肠阴道瘘1例,复杂瘘2例.再次手术方式:经腹联合后矢状入路术式7例,Soave术式7例,Duhamel术式1例,Rehbein术式3例,经腹修补直肠阴道瘘1例.随访患儿术后不同时期排便次数、粪便性状、便秘、失禁、污粪以及小肠结肠炎等内容.结果 84.2％(16/19)患儿有便意,能自行排便,2例偶有污粪,1例直肠骶部瘘未愈.结论 先天性巨结肠根治术后出现严重并发症,通过合理选择再次手术方式,可以达到满意的临床效果.     

Use of a circular stapler for the surgical treatment of Hirschsprung's disease

Thirteen patients, 10 with classical Hirschsprung's disease and 3 with total colonic aganglionosis, were operated upon by anterior resection (11 cases) or pull-through (2 cases) and the anastomosis was constructed with a circular stapler. The age at operation ranged from 9 months to 17 years (median 17 months). A very low resection was obtained, with the level of anastomosis less than 2 cm from the dentate line. The anastomosis was covered by a temporary enterostomy in all but 2 patients. One dorsal anastomotic leak was demonstrated at radiological follow-up. No further anastomotic complications were observed, and all enterostomies were closed within 10 weeks post-resection. The use of a circular stapler is recommended as a modification of the Rehbein operation or the Swenson pull-through.     

非开腹式经肛门结肠拖出术治疗小儿先天性巨结肠症

目的 报道既不用开腹,也不需腹腔镜,在微创的情况下实现对小儿先天性巨结肠症的根治术式。方法 采用经肛门斜行切断直肠（前高后低）,处理直肠、结肠系膜,拖出病变肠管并予以切除,结、直肠I期斜面吻合的方法,治疗短段型（5例）及普通型（18例）巨结肠共23例。结果 全部患者手术获得成功,术后无须扩肛,随方1～12个月,排例正常,未出现不良并发症。结论 非开腹式,经肛门拖出并切除病变结肠,是一种全新的手术路径。它不实现对巨结肠根治的同时,获得了最佳的美容效果,并降低了一定的术后并发症。     

Management of Hirschsprung's disease with the Swenson procedure with emphasis on long-term follow-up

In a 20-year period (1965–1985), 80 patients with Hirschsprung's disease were managed with the Swenson procedure. Two-thirds of the patients had disease limited to the rectosigmoid and sigmoid colon. In the remaining patients, aganglionosis extended into variable lengths of colon, including 5 instances of total colonic aganglionosis. All patients had a protective enterostomy at the time of pull-through. There was no operative mortality and 1 late death due to fulminating enterocolitis. All but 1 of the remaining patients are in good health. One patient, lost to follow-up for 10 years, has chronic enterocolitis. No patients, including 7 who had anastomotic leaks, ever had problems with rectal stricture. There are no instances of urinary dysfunction or problems with male sexual function. Sixty-one patients have had long-term follow-up. Fifty-two have completely normal rectal function, although in some instances it was not achieved for several years. Eight patients are too young to evaluate. Four patients have minor problems with occasional fecal soiling, but are expected to recover. Only 2 of 5 mentally retarded patients are becoming toilet trained. Despite the appearance of many other operations designed to cure Hirschsprung's disease, the Swenson procedure is still employed by many surgeons. Long-term follow-up is necessary for final evaluation of rectal function.     

Technical problems and complications of a transanal pull-through for Hirschsprung's disease.

BACKGROUND: The purpose of this study was to evaluate the technical difficulties and complications of a transanal pull-through for Hirschsprung's disease. MATERIAL AND METHODS: This report was based on a multicentric retrospective study of 65 cases. Pull-through procedures were transanal Swenson or Soave procedures in 26 and 39 cases, respectively. RESULTS: Evaluation of the aganglionic level, peri-rectal dissection, and anastomosis were the three steps in the procedure where surgeons encountered difficulties. Such difficulties led to serious complications in 3 cases. A patient with a colon biopsy before the pull-through procedure had a postoperative pneumoperitoneum requiring a second laparoscopy for suture and washing. Another patient had peritonitis due to anastomotic leakage. Finally, a difficult rectal dissection in a neonate led to a urethral injury requiring secondary urethral repair. Only 41 of the 65 patients had no abdominal scars (63 %). CONCLUSION: We considered the transanal pull-through for Hirschsprung's disease to be a reliable technique. Nevertheless, it requires an urethral stent, precise dissection, careful anastomosis and selected indications in order to avoid major complications.     

Transanal one-stage endorectal pull-through for Hirschsprung’s disease: a comparison with the staged procedures

Transanal one-stage endorectal pull-through (TOSEPT) has been presented as the most recent progression in treatment of Hirschsprung's disease (HD), which may be able to replace various previous techniques. This prospective study was designed to compare the efficacy and probable complications of the commonly used open surgery with those of TOSEPT technique in management of HD. Forty-two children (35 boys and 7 girls) between 3 days and 12 years of age underwent surgical treatment for HD-all after being diagnosed by barium enema over an 18-month period. In a manner of systematic random selection, 21 patients were operated by TOSEPT and the other 21 by Swenson procedures. All patients were followed-up at least for 12 months after hospital discharge. The necessary data containing age, sex, length of the resected aganglionic segment, intraoperative details, duration of hospital stay and postoperative functional results or complications were collected during hospitalization and follow-up period. There was no significant difference in age at the first operation, sex distribution and length of resected bowel between the two groups. Rate of postoperative complications were significantly higher in Swenson procedure group (P < 0.01). Narcotics were needed in all patients of Swenson procedure group but only in two patients operated by TOSEPT also required laparotomy (P < 0.001). The hospitalization period of TOSEPT group was also less than that of Swenson group (P < 0.001). The total cost of treatment by Swenson procedure is considerably higher than by TOSEPT. TOSEPT can significantly diminish postoperative pain, surgical complications, hospital stay and cost burden caused by Hirschsprung's disease. Besides, this procedure is cosmetically preferable because no visible scar remains.     

Endorectal pull-through for Hirschsprung's disease

From 1 July 1974 to 30 June 1987, 78 patients with Hirschsprung's disease underwent Soave's endorectal pull-through at the Hadassah University Medical Center in Jerusalem; 12 patients treated by Swenson or modified Duhamel procedures are not included in this report. All the patients were initially diagnosed and treated at our institution. Sixty-three (80%) had standard rectosigmoid disease; 15 (20%) had longer aganglionic segments; and 1 had total colonic aganglionosis. The diagnosis was made in 45 neonates (58%) and 28 infants (36%). Only 5 children were older than 1 year at diagnosis. Seventy-five patients (96%) underwent initial colostomy performed closely proximal to the transition zone. The definitive Soave endorectal pull-through was performed in the majority of the patients before the age of 1 year. There was no mortality. A relatively low morbidity was encountered and all the patients are continent after follow-up periods of 1 to 13 years. In view of its gratifying results, Soave's endorectal pull-through is our preferred definitive procedure for Hirschsprung's disease in infants and young children. Offprint requests to: M. Schiller     

Laparoscopic-assisted approaches for the definitive surgery for Hirschsprung's disease

The surgical management of Hirschsprung's disease has progressed from a two- or three-stage procedure to a primary operation over the last 25 years. More recently, definitive surgery for Hirschsprung's disease has been performed using minimally invasive techniques. The Swenson, Duhamel and Soave endorectal pull-through procedures have all been reported using minimally invasive approaches. The endorectal dissection has become the dominant minimal access procedure because of the ease and reliability in performing this technique and the excellent results obtained. Although a transanal endorectal pull-through can be performed without laparoscopy, the laparoscopic-assisted transanal endorectal pull-through is a much more versatile technique and allows early biopsies to determine the extent of aganglionic and dysfunctional bowel before ablation of the rectum and mesocolon. The authors use a laparoscopic-assisted transanal pull-through for aganglionosis of the left and transverse colon. Total colon aganglionosis or aganglionosis of the ascending colon is managed by a laparoscopic-assisted Duhamel procedure which provides a better reservoir in patients with a short or absent colon.     

Esophageal motility in children with Hirschsprung's disease

Esophageal motility was studied in 12 children with Hirschsprung's disease to see if extracolonic motor dysfunction was present in this disorder. Manometric tracings were compared with those from eight children with idiopathic megacolon and from 10 children without esophageal disease or constipation. Amplitude of esophageal contraction waves was significantly higher in children with Hirschsprung's disease than in the other two groups. Swallows that were followed by simultaneous contractions or double-peaked waves were also more common in the group with Hirschsprung's disease (subjects with Hirschsprung's disease, subjects with megacolon, and controls; 57%, 10%, and 8%, respectively). Lower esophageal sphincter characteristics did not differ among the three groups. The increase in simultaneous contractions and double-peaked waves persisted in those children who were reexamined following surgery for Hirschsprung's disease, whereas wave amplitudes fell to a level similar to that observed in the other groups. These data suggest that gastrointestinal motor dysfunction in persons with Hirschsprung's disease is not restricted to the colon, and that some of the observed abnormalities in esophageal motility do not reflect nonspecific responses to megacolon or colonic obstruction.