高位和中间位肛管直肠畸形的治疗选择

目的 评价新生儿期后矢状路肛门直肠成形术（PSARP）治疗高位和中间位肛管直肠畸形的安全性、可行性及长期效果。方法随访113例高位和中间位肛管直肠畸形患儿,其中48例手术分Ⅲ期（结肠造瘘-后矢状路肛门直肠成形术关瘘,A组）,65例新生儿期行后矢状路肛门直肠成形术（B组）。根据改良Wingspread评分方法,肛管直肠功能分为“优”、“良”、“一般”和“差”。根据钡灌肠,肛管直肠角分为“清晰”、“模糊”、“无”;同时观察钡剂向外泄漏情况。肛管直肠测压测定肛管静息压,肛管收缩压及肛管直肠反射。结果A组,58．3％（28／48）的病例表现“优”或“良”;钡灌肠,85．4％（41／48）的病例显示肛管直肠角“清晰”,10．4％（5／48）的病例有钡剂外泄。B组,53．8％（35／65）的病例表现“优”或“良”;83．1％的病例显示肛管直肠角“清晰”,7．7％（5／65）的病例有钡剂外泄。早期手术并发症,A组为56．3％（27／48）,其中39．6％（19／48）与结肠造瘘有关;B组为29．2％（19／65）。A组与B组便秘发生率分别为47．9％（23／48）和44．6％（29／65）,污粪为47．9％（23／48）和50．8％（33／65）。结论新生儿期后矢状路肛门直肠成形术（PSARP）治疗高位和中间位肛管直肠畸形是安全可行的,且长期效果与Ⅲ期PSARP手术相同。

The treatment of high and intermediate anorectal malformations

Objective The aim of this study was to examine the safety,the feasibility and the long-term outcome of onestage repair of high and intermediate anorectal malformation using posterior sagittal anorectoplasty(PSARP) in neonates.Methods One hundred and thirteen patients with high-and intermediate-type anorectal malformations(ARM) were followed-up.Of 113 cases,48 had divided colostomy,definitive operation,followed by colostomy closure(groupA);the remaining 65 cases underwent one-stage PSARP operation during neonatal stage(groupB).Anorectal function was measured by the modified Wingspread scoring,including "excellent," "good," fair,and "poor." In barium enema studies,anorectal angulation was judged as "clear," "unclear" and "not present" and leakage of barium was also recorded.For anorectal manometric studies,anal resting pressure(ARP),anal squeezing pressure(ASP) and positive anorectal reflex(PAR) were measured.Results In group A,the rate of "excellent" and "good" scores was(58.3%)(28/48). Barium enema examination: (85.4%)(41/48) was "clear" and(14.6%)(7/48) "unclear" or "not present." The rate of barium leakage was(10.4%)(5/48).In group B,the rate of "excellent" and "good" was(53.8%)(35/65).Anorectal angulations were "clear" in(83.1%) of patients(54/65). Barium leakage happened in(7.7%) of patients(5/65).Early operative complications occurred in(56.3%)(27/48) of patients in groupA and(29.2%)(19/65) in group B.The incidence of colostomy complications in group A was(39.6%)(19/48).Soiling and constipation were the major complications after the PSARP operation.The respective rates of constipation in the two groups were(47.9%)(23/48) and(44.6%)(29/65);and soiling(47.9%)(23/48) and(50.8%)(33/65).There was no statistically significant difference in the mean ARP between the two groups.Conclusions The one-stage PSARP procedure in neonates not only achieves the same long-term outcome as the conventional PSARP procedures but also results in less short-term complications.Complete one-stage repair using the PSARP to treat high-type and intermediate-type anorectal malformations is safe and feasible.