Metaphase clinical outcome of transanal endorectal pull-through colorectal resection and oblique anastomosis for Hirschsprung' s disease

[目的]观察经肛门直肠结肠切除斜型吻合术治疗肠无神经节细胞症的中期疗效.[方法]对105例肠无神经节细胞症患儿施行经肛门直肠结肠切除斜型吻合术,术后定期对排便功能进行随访.[结果]105例无1例死亡,无术中输血、术中并发症,0～3个月平均手术时间74.6min,术中平均出血量12.5ml;3个月至1岁平均手术时间71.6min,术中平均出血量16ml；1～3岁平均手术时间77.9min,术中平均出血量20ml；＞3岁平均手术时间112.5min,术中平均出血量40ml.术后无感染、吻合口瘘、吻合口裂开.60例随访6～40个月,5例患儿出现轻度污便,小便均正常,均未出现腹胀、便秘、神经性膀胱、肛门狭窄；其中男性52例,均有阴茎勃起.4例术后2个月左右出现小肠结肠炎.28例行肛门直肠测压检查,4例存在RAIR反射,1例存在接近于正常的RAIR反射.[结论]经肛门直肠结肠切除斜型吻合术术后可获得良好的排便功能,具有创伤小、手术时间短、保留直肠感受器、恢复快、并发症少等优点,中期疗效满意.     

192例0～3个月先天性肠无神经节细胞症婴儿临床分析

目的：探讨钙视网膜蛋白在3个月内婴儿先天性肠无神经节细胞症（HD）的临床诊断价值;对采用经肛门直肠结肠斜形切除吻合术治疗3个月内婴儿HD进行随访及疗效评价。方法2008年1月至2014年10月该院确诊并行了经肛门直肠结肠切除斜形吻合术或肠造瘘术治疗3个月内婴儿HD 192例,收集其病案资料,并行根治术中期随访,评价其肛直肠功能及生活质量。结果192例 HD患儿中,139例行经肛门直肠结肠切除斜形吻合术,53例行肠造瘘术。术前诊断依据典型病史、体格检查及辅助检查,包括钡剂灌肠、直肠肛管测压和直肠吸引活检钙视网膜蛋白免疫组织化学染色,阳性率分别为80．1％、92．1％、97．9％。66例（60．5％）获中期随访,小肠结肠炎2例（3．0％）,污粪2例（3．0％）,无便秘复发、大小便失禁、肛门狭窄,男性患儿均有阴茎勃起现象,生长发育与正常婴幼儿相当。门诊随访25例,生化检查均在正常范围,15例钡剂灌肠检查显示肠道形态恢复良好;直肠肛管测压11例,10例（90．9％）肛门松弛反射恢复正常,1例未见松弛反射。结论钙视网膜蛋白免疫组织化学染色检查可作为3月内婴儿 HD术前诊断的金标准;经肛门直肠结肠斜形切除吻合术设计符合生理,并发症少,中期疗效满意,适合0～3个月小婴儿根治术。     

改良Soave术治疗婴儿先天性巨结肠13例观察

目的探讨改良Soave术治疗婴儿先天性巨结肠的疗效。方法对13例婴儿先天性巨结肠采用改良Soave术治疗。结果所有患儿术中顺利,手术平均时间为125min,出血量约50ml,术中切除结肠5—45cm,平均18cm,无手术死亡病例,术后随访6个月-1年,排便功能正常,无便秘复发,无污粪无肛门狭窄等并发症发生。结论该手术方法具有损伤小,术后恢复快、并发症少等优点。改良Soave术是一种安全有效的治疗婴儿先天性巨结肠的手术。     

腹腔镜全结肠直肠切除治疗家族性息肉病八例

目的探讨腹腔镜全结肠、直肠切除治疗家族性息肉病的有效性和优越性。方法我们应用腹腔镜对8例家族性息肉患者行全结肠直肠切除,回肠储袋肛管吻合。观察手术安全性、术后恢复情况以及随访结果并与2001年以前开腹全结肠切除的6例患者作为对照比较。结果8例患者均顺利行腹腔镜全结肠切除术,无中转开腹手术,平均手术时间为178min（165～210min）,与开腹组比,差异无统计学意义（P〉0．05）;平均出血量110ml（70～200m1）,肛门排气时间1．2d（1～3d）,住院时间12．5d（10～18d）,与开腹组相比差异有统计学意义（P〉0．05）。术后无严重并发症发生。随访32～58个月,平均46．8个月,腹腔镜组无局部复发,开腹组1例患者术后25个月直肠复发并癌变。术后1个月内控便困难,每天排便9～10次,有便意;术后3个月每天排便4～8次,能控制成形大便,但水样便及气体控制困难;术后6个月每天排便3～5次,能控制成形大便,基本能控制水样便及气体;术后9个月后每天排便2～3次,能随意控制成形大便、水样便及气体。结论腹腔镜行全结肠、直肠切除治疗家族性息肉病具有安全、有效、微创、术后疼痛小、住院时间短等优点。熟练的腹腔镜技术是手术成功的保证。     

低位直肠癌切除经肛门行结肠直肠粘膜吻合术36例报告

目的探讨直肠中下段癌保留肛门括约肌功能最佳治疗术式。方法对采用经腹经肛门切除中下段直肠癌又经肛门行结肠直肠粘膜吻合术36例。癌灶下缘距肛缘6～7cm24例，8～10cm12例。结果全组无手术死亡，无吻合口瘘和吻合口狭窄发生。术后随访36例6～60个月，平均33个月。于术后19个月局部癌复发2例(5．56％)。本组术后8～12周时排便功能控制良好，为1～3次／d，18周时肛门排便功能基本恢复正常，排便次数为1～2次／d。结论在合理选择手术适应证的前提下，结肠直肠粘膜吻合术可作为手术治疗低位直肠癌并保留肛门的一种安全术式。     

经肛门非开腹巨结肠根治术

目的:报告经肛门非开腹先天性巨结肠根治术临床体会.方法:经该术式治疗先天性巨结肠10例.术前行直肠粘膜吸引检查以确诊和X线钡灌肠摄片确定病变范围,短段型3例,常见型7例.齿线上1 cm切开直肠粘膜1周,游离直肠粘膜管,直视下游离扩张的直肠近端和乙状结肠,妥善处理肠系膜血管,向上游离达正常结肠,拖出的结肠与直肠切缘全层间隙吻合.结果:全部患儿经肛门完成手术,切除肠管平均长度23.6 cm(12～32 cm),平均手术时间112 min(90～150 min),术中平均出血量32 ml(15～80 ml).1个月内大便成形正常,无手术并发症出现.结论:经肛门非开腹巨结肠根治术适合于新生儿和婴幼儿短段型及常见型巨结肠,手术创伤小,并发症少,效果满意.     

28例经肛门婴幼儿巨结肠根治术式的研究

目的研究经肛门巨结肠根治术的改进方式及其手术效果。方法28例经组织学检查诊断为巨结肠的患儿均行Ⅰ期经肛门巨结肠根治术,按Soave术式改为在直肠后壁齿状线上0．5cm、前壁齿状线上2．5cm,呈前高后低切开直肠粘膜,同时肌鞘后壁V形切除,拖出正常结肠与肛门斜行吻合。结果平均手术时间90min（65—120min）,平均出血60m1（40～70m1）,无术中和术后并发症,随访6～12个月,所有患儿排便1～3次／d,无污粪。结论经肛门Ⅰ期巨结肠根治术安全有效、适应证广、值得推广。     

红肛门非开腹巨结肠根治术

目的：报告经肛门非开腹先天性巨结肠根治术临床体会。方法：经该术式治疗先天性巨结肠10例。术前行直肠粘膜吸引检查以确诊和X线钡灌肠摄片确定病变范围，短段型3例，常见型7例。齿线上1cm切开直肠粘膜1周，游离直肠粘膜管，直视下游离扩张的直肠近端和乙状结肠，妥善处理肠系膜出血，向上游离达正常结肠，拖出的结肠与直肠切缘全层间隙吻合。结果：全部患儿经肛门完成手术，切除肠管平均长度23.6cm(12-32cm)，平均手术时间112min(90-150min)，术中平均出血量32ml(15-80ml)。1个月内大便成形正常，无手术并发症发现。结论：经肛门非开腹巨结肠根治术适合于新生儿和婴幼儿短段型及常见型巨结肠，手术创伤小，并发症少，效果满意。     

单纯经肛门先天性巨结肠根治术方法探讨

目的报告经肛门非开腹先天性巨结肠根治术临床效果。方法经该术式治疗先天性巨结肠10例。术前行直肠粘膜吸引检查以确诊和X线钡灌肠摄片确定病变范围，短段型3例，常见型7例。齿线上lcm切开直肠粘膜1周，游离直肠粘膜管，直视下游离扩张的直肠近端和乙状结肠，妥善处理肠系膜血管，向上游离达正常结肠，拖出的结肠与直肠切缘全层间隙吻合。结果全部患儿经肛门完成手术，切除肠管平均长度23．6cm(12—32cm)，平均手术时间112min(90—150min)，术中平均出血量32ml(15—80m1)。1个月内大便成形正常，无手术并发症出现。结论经肛门非开腹巨结肠根治术适合于新生儿和婴幼儿短段型及常见型巨结肠，手术创伤小，并发症少，效果满意。     

超声刀在57例腹腔镜手术中的应用

总结应用超声刀实施腹部外科腹腔镜手术的经验。其中阑尾切除术13例,肠粘连松解术6例,Dixon术8例,Miles术10例,直肠部分切除2例,左半结肠切除3例,右半结肠切除1例,LS 12例,LC 2例。手术时间45~180 min,平均出血量<100 ml,术后恢复良好。直、结肠癌患者随访2~44个月,无局部复发或转移。认为超声刀的应用有助于腹腔镜手术的实施。     

先天性巨结肠经肛门一期拖出术的评估

目的观察经肛门一期拖出术(TAS)治疗先天性巨结肠的近、中期并发症,并探讨其防治方法。方法先天性巨结肠患儿63例行TAS治疗,随访51例(81%),随访时间3月-4年结果术后1周内有肛周炎38例,小肠结肠炎5例,肛门黏膜外翻2例,吻合口狭窄2例,排便失禁2例。术后6个月,大便次数>5次/d有45例,1-3次/d有6例,随术后时间推延,大便次数逐渐减少。结论TAS的优点虽多,但仍存在小肠结肠炎、肛周炎、吻合口狭窄等并发症,长期疗效还有待于进一步随访。     

先天性巨结肠术后远期生活质量评价

目的：评价先天性巨结肠（HD）行Ikeda钉合法根治术及经肛门SoaveⅠ期拖出术术后远期生活质量。方法：对68例HD术后患儿进行随访,获随访43例,其中行Ikeda钉合法根治术者20例,经肛门SoaveⅠ期拖出术者23例。对随访病例进行问卷调查,了解其生理、心理和社会行为三方面的情况,综合后评价生活质量。结果：经肛门SoaveⅠ期拖出术组患儿与Ikeda钉合法根治术组患儿在术后远期生活质量总体评分上无显著差别;在术后生理功能方面、心理行为及社会行为方面,两种手术方式无显著差别。结论：HD不同手术方式对术后远期生活质量的影响无显著差别,术后心理问题及社会行为问题影响到了生活质量,应当引起重视。     

A new modification of transanal Soave pull-throug procedure for Hirschsprung＇s disease

Background One stage transanal Soave pull-through procedure (TSPP) is a recent popular operation in the treatment of Hirschsprung's disease (HD). W ith no visible scar and a short hospital stay, it is well accepted by surgeons and mothers. In the conventional Soave procedure, a long rectal muscular cuff left for anocolic anastomosis might increase the incidence of postoperative enterocolitis and constipation. This study presents a modified transanal Soave pull-through procedure (MTSPP) which includes an oblique mucosectomy and an oblique anastomosis with a short split muscular cuff.Methods A review of two groups of HD patients was made: 112 underwent conventional transanal Soave procedure from 1999 to 2001 (group 1) and 140 underwent modified transanal Soave procedure from 2002 to 2004 (group 2). A comparison was made between the two groups on operative data and postoperative complications. The data included: age at the operation, operating time, blood loss, time to feeds and hospital stay, occurrence of postoperative enterocolitis or constipation, need for anal dilatation, postoperative bowel function and perianal skin problems. Results There was no significant difference between two groups with respect to age, gender, length of colon resected, operating time, blood loss and hospital stay. However occurrence of postoperative enterocolitis, constipation, anastomotic stricture and time needed for anal dilatation were evidently less in group 2 (MTSPP). The m ean operating time i n group 1 was ( 106 ± 39) minutes with a range of 60 to 170 minutes; in group 2 was (101 ± 36) minutes with a range of 66 to 190 minutes. The average length of the bowel resected in group 1 was (24 ± 7) cm, range 15 to 58 cm; in group 2 was (26 ± 8) cm, range 15 to 70 cm. Two patients, one in each group, required l aparoscopic assistance because of long aganglionic colon. Another patient in group 2 required laparotomy because of total colonic aganglionosis. Postoperative complications in group 1 included: temporary perianal excoriation in 34 patients (26 were &lt;3 months of age), enterocolitis in 21, anastomotic stricture in 11, recurrent constipation in 12, cuff abscess in 1, anastomosis leak in 1, soiling in 3 and rectal prolapse in 1. In group 2 post operative complications included: transient perianal excoriation in 37 patients (30 were &lt;3 months of age), enterocolitis in 13, anastomotic stricture in 5, recurrent constipation in 6, anastomotic leak in 1, adhesive bowel obstruction in 1 and soiling in 4. Complete bowel continence was found in 97 children (86.6%) in group 1 and in 129 children (92.1%) in group 2 at one year followup after operation.Conclusions Modified transanal Soave pull-through procedure for HD with oblique mucosectomy and anastomosis and a short split muscular cuff is a safe and feasible operation with low incidence of postoperative complication. It is an encouraging improvement of the conventional transanal Soave pull-through procedure. MTSPP is a preferable choice in the surgery of HD. Chin Med J 2006; 119(1):37-42     

A new modification of transanal Soave pull-through procedure for Hirschsprung''s disease

SINGLE STAGE TRANSANAL SOAVE PULL-THROUGH PROCEDURE (TSPP) REPRESENTS AN IMPROVEMENT IN THE SENSE OF MINIMAL INVASIVE SURGERY FOR HIRSCHSPRUNG’S DISEASE (HD).1 IT HAS BEEN RAPIDLY POPULARIZED IN MANY CENTRES SINCE IT WAS PUBLISHED BY DE LA TORRE-MONDRAGON IN 1998.2 IN CONVENTIONAL SOAVE PROCEDURE, A LONG RECTAL MUSCULAR CUFF(5 TO 7 CM) WAS LEFT FOR ANOCOLIC SANASTOMOSIS, WHIC…     

Ⅰ期经肛门巨结肠根治术

目的　总结先天性巨结肠Ⅰ期经肛门根治术的手术过程、疗效及短期随访结果。方法　自 2 0 0 1年经该术式治疗 1 4例巨结肠患儿。方法为在直肠后壁齿状线上 0 .5cm ,前壁齿状线上 2cm切开直肠粘膜 ,向近端游离达腹膜返折后 ,残留肌鞘后壁“V”型切除 ,游离近端结肠 ,拖出近端结肠与肛门吻合。结果　所有手术均顺利完成 ,手术时间 90 - 1 50分钟 ,出血量极少 ,最少不足 5ml,所有病例均未输血。术后早期便次较多 ,1月后减少至 1 -3次 /天。随访 1 - 6月 ,无吻合口狭窄、污粪及肠炎。结论　经肛门巨结肠根治术安全有效、简便易行 ,近期效果良好。     

经肛门Soave Ⅰ期脱出根治术治疗婴幼儿长段型先天性巨结肠

目的回顾分析用经肛门SoaveⅠ期脱出根治术治疗长段型先天性巨结肠的手术过程、疗效及随访,探讨长段型先天性巨结肠经肛门脱出非开腹治疗的可行性和安全性。方法自2001年2月至2005年2月应用经肛门SoaveⅠ期脱出根治术治疗长段型先天性巨结肠患儿39例。年龄6个月至3岁,平均年龄1.92岁,均经钡剂灌肠、直肠测压和病理证实为先天性巨结肠。随访手术时间、出血量和并发症。结果经肛门直接脱出38例,由于痉挛段位于结肠肝区腹腔镜辅助下脱出1例;直接拖出痉挛段最长60 cm,至横结肠;平均切除结肠58 cm,最长75 cm;平均手术时间107 min;均于术后2~4 d进食,术后平均住院时间9.3 d,患儿术后1个月随访时排便2~4次/d,半年时排便1~3次/d,无粪污,无吻合口狭窄。结论对于长段型先天性巨结肠特别是痉挛段位于脾区及脾区以远的,非开腹根治术是可行的和安全的。术前充分的肠道准备,特别是洗肠是长段型先天性巨结肠非开腹根治术的基础,而彻底切除痉挛段是手术成功的关键。     

A new modification of transanal Swenson pull-through procedure for Hirschsprung’s disease

Background The one-stage pull-through procedures for Hirschsprung＇s disease （HD） have become popular because it is well accepted by surgeons and mothers with no visible scar and a short hospital stay. It represents the latest development in the concept of a minimally invasive surgery for HD. We introduce a new method of transanal one-stage pull-through for Hirschsprung＇s disease, different from the transanal Scare procedure.
Methods One hundred and thirty-four patients aged 9 days to 5 years underwent a transanal one-stage pull-through procedure. The diagnosis was definite by barium enema or rectal biopsies preoperatively. The patients were anesthetized and placed in the lithotomy position. A urinary catheter was optional. Giving anorectal dilatations for half a minute, a pull-through of the rectum above the peritoneal reflection and into the intussusception was performed. Fine silk suturing was performed circumferentially at the level of that point which was used for traction for the distal end. Another circumferential suture was performed parallel 0.5 cm distance above the original one and used for traction for the proximal intestines. The full-thickness rectal wall was truncated between the above two circumferential sutures with cautery. The proximal intestines were pulled down and the mesenteric vessels were dissected with ligation until normal intestines were accessed; the presence of ganglion cells was determined by intraoperative rapid frozen section. The distal end was dissected anteriorly 2.5-3.5 cm above the dentate line. The posterior rectal wall was split longitudinally and dissected to a point 0.5-1.0 cm above the dentate line. The segment of the lesion was resected. The length of bowel resected ranged from 12 to 50 cm （median 16.5 cm）. An oblique anastomosis was made.
Results The mean operating time was 70 minutes. Postoperative rectal dilation was not required. The patient tolerated feeding on the first postoperative day. Eighty-eight patients were followed-up. All these patients ha     

经肛门巨结肠根治术治疗126例儿童先天性巨结肠临床疗效研究

目的探讨经肛门巨结肠根治术治疗儿童先天性巨结肠临床疗效及手术技巧。方法回顾分析经肛门手术治疗126例先天性巨结肠患儿的临床资料,采用经肛改良Soave术95例,经肛改良Swenson术31例。结果除早期经肛Soave术中7例（5．6％）二期手术外,余均一期完成手术（94．4％）。辅助腹部小切口5例,腹腔镜12例。术后并发症35例,其发生率为27．8％,其中肛周糜烂15例,小肠结肠炎9例,吻合口狭窄5例,污粪2例,再手术4例,两种术式的术后并发症比较差异无统计学意义（P〉0．05）。103例获随访1—10（中位数2）年,痊愈96例（93．2％）,好转5例（4．9％）,无效2例（1．9％）,两种术式不同类型的术后排便功能优良率比较差异均无统计学意义（P〉0．05）。结论两种术式治疗先天性巨结肠临床疗效好,各有其优点,均存在一定的并发症,但经肛Swenson术较经肛Soave术操作更简单方便,术后不需扩肛。     

经肛门Ⅰ期巨结肠根治术预后因素的探讨

目的对经肛门Ⅰ期巨结肠根治术预后因素进行探讨,以期为临床治疗提供依据。方法对经肛门Ⅰ期巨结肠根治术治疗的患儿177例,将其原始资料按统一标准列表、赋值,以其根治术后便秘、术后小肠结肠炎作为自变量,将其他因素作为应变量,采用多元回归法分析其根治术预后与其他因素之间的关系。结果先天性巨结肠经肛门Ⅰ期根治术便秘可能与后鞘切除范围、黏膜剥离位置、吻合口狭窄及手术年龄有关;术后小肠结肠炎可能与后鞘切除范围、黏膜剥离位置、吻合口狭窄及术前是否存在小肠结肠炎有关。结论经肛门Ⅰ期巨结肠根治术手术后主要与术中病变肠管及后鞘切除范围、黏膜残留、手术年龄,以及正确术前诊断有关,选择合适手术时机,正确处理后鞘及黏膜是提高治愈率的关键。