经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术在全结肠型巨结肠症治疗中的应用

目的探讨经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术在先天性全结肠型巨结肠症患儿治疗中的应用价值,并对患儿术后排便功能进行评价。方法回顾性分析2014年6月至2017年6月间河北医科大学第二医院小儿外科收治的15例先天性全结肠型巨结肠症患儿的诊治及术后随访资料,其中男11例,女4例,月龄(5.11±2.67)个月,所有患儿Ⅰ期行回肠末端造瘘术,Ⅱ期行腹腔镜辅助Martin-Duhamel手术。术后随访2年,采用李正肛门功能临床评分法进行排便功能评分。定期肛管直肠测压,记录和比较患儿排便频率、性状及近远期并发症情况。结果15例均顺利完成手术,无中转开腹和死亡病例。手术时间(184.43±30.46)min,出血量(27.57±10.63)mL,肠功能恢复时间(3.29±0.91)d,术后住院时间(7.86±1.77)d。术后1~3个月排便频率为8~20次/日,术后6~9个月排便频率为4~8次/日,术后1~2年排便频率为2~4次/日(接近正常水平)。术后3个月和术后6个月排便评分无显著性差异(P=0.115),术后6个月和术后1年排便评分有显著性差异(P=0.040),术后1年和术后2年排便评分无显著性差异(P=0.542)。肛管直肠测压从术后6个月开始逐渐恢复至正常范围,与术前比较有显著性差异(肛管反射舒张压P=0.027;肛管静息压P=0.010;直肠静息压P=0.034)。术后6个月内因排便次数多致肛周湿疹、皮肤破溃6例,予以造口粉、氧化锌或芦荟软膏涂抹后恢复;小肠结肠炎1例,经保守治疗后缓解;无便秘等其他并发症发生。结论经Ⅰ期造瘘口单部位腹腔镜辅助Martin-Duhamel术治疗全结肠型巨结肠症患儿安全可行;排便功能可在术后6个月至1年逐渐恢复至接近正常儿童的水平。

Single-site laparoscopic-assisted Martin-Duhamel procedure in the treatment of total colonic aganglionosis with stage Ⅰ stoma and evaluation of postoperative defecation function

Objective To explore the value of single-site laparoscopic-assisted Martin-Duhamel procedure in the treatment of children with total colonic aganglionosis with stageⅠstoma and evaluate their postoperative defecation functions.Methods A retrospective analysis was performed for the data of diagnosis,treatment and postoperative follow-ups of 15 hospitalized cases of total colonic aganglionosis with stage I stoma from June 2014 to June 2017.There were 11 boys and 4 girls with an average age of(5.11±2.67)months.All of them underwent stageⅠterminal ileostomy and stageⅡlaparoscopic assisted Martin-Duhamel operation.They were postoperatively followed up and defecation scores were assessed for 2 years.Anorectal pressures were measured regularly and frequency,characteristics of defecation and complications recorded and compared.Results All 15 laparoscopic-assisted Martin-Duhamel procedures were performed successfully.There was neither mortality nor conversion into laparotomy.The operative duration was(184.43±30.46)min,the bleeding volume(27.57±10.63)milliliters,the recovery time of intestinal function(3.29±0.91)days and the postoperative hospital stay(7.86±1.77)days.During postoperative follow-ups,the results showed 8 to 20 times of defecation per day at 1 to 3 months,4 to 8 times of defecation per day at 6 to 9 months and 2 to 4 times of defecation per day at 1 to 2 years.No significant postoperative differences existed in defecation scores between 3 and 6 months(P=0.115)or 1 and 2 years(P=0.542).However,significant postoperative differences existed between 6 months and 1 year(P=0.040).The postoperative measurements of anorectal pressure gradually normalized at 6 months.And it was significantly different from that of preoperation(anal reflex diastolic pressure,P=0.027;anal canal resting pressure,P=0.010;rectal resting pressure,P=0.034).Six cases of perianal eczema and skin erosion were caused by frequent defecation at 6 months.One case of enterocolitis was relieved after conservative measures.No constipation occurred.Conclusion Single-site laparoscopic-assisted Martin-Duhamel procedure is both safe and feasible in the treatment of total colonic aganglionosis with stage I stoma.The postoperative function of defecation gradually normalizes at 6 months to 1 year.