儿童盆底失弛缓综合征的诊断与治疗

目的探讨儿童盆底失弛缓综合征的诊断与治疗。方法对2001年11月至2004年11月间29例便秘患儿经结肠造影和直肠肛门测压诊断为盆底失弛缓综合征的临床资料进行回顾性分析。结果本组男13例,女16例,年龄(6．7±4．0)岁。所有病例经过结肠造影和直肠肛门抑制反射(RAIR)检查均排除先天性巨结肠症。29例患儿排便弛缓反射均为上升相(正常为下降相),RAIR正常(注气5～10 m1)21例,RAIR减弱(注气15～30 ml)8例；20例直肠初始感觉和最大耐受量均正常。明确诊断后采用排便诱导训练法,配合饮食调节、乳果糖或福松等缓泻剂软化大便等治疗1-2个月,痊愈4例,好转5例,有效率31．0%；开塞露依赖20例。有4例病史在1年以上、长期依赖开塞露的学龄期患儿做了肛门内括约肌和直肠平滑肌部分切除术(Lynn术),术后随访5—24个月,平均每1-2日自行排便1次,疗效满意；其中2例术后复查直肠肛门测压、肛管静息压及括约肌功能长度均较术前下降,排便弛缓反射仍为上升相。结论儿童盆底失弛缓综合征的诊断主要依据便秘病史、结合直肠肛门测压和结肠造影；排便诱导训练法等治疗不满意者可选择Lynn术。     

全结肠气钡双重排粪造影的临床应用

目的评价全结肠气钡双重排粪造影能否作为综合诊断便秘患者有价值的影像参考依据。方法利用数字x线胃肠机对260便秘患者进行全结肠气钡双重排粪造影。结果全结肠气钡双重排粪造影诊断出升结肠冗长12例，横结肠冗长8例，降结肠冗长16例，乙状结肠冗长62例，直肠前突59例。其中，结肠冗长合并乙状结肠癌3例，结肠冗长合并降结肠癌2例，结肠冗长合并横结肠癌2例，结肠冗长合并升结肠癌1例。结论全结肠气钡双重排粪造影可一次性了解结肠病变和排粪障碍现状，是一个综合性诊断顽固性便秘的合理方法。     

手术对儿童非结肠无神经节细胞症和肛门直肠畸形所致顽固性便秘是否有意义?

作者回顾分析了匹兹堡儿童医院 1 996- 2 0 0 1年间 1 37例结肠和直肠动力学检查便秘患儿的病历 ,所有患儿均做了直肠活检、脊柱磁共振、结肠造影等检查 ,排除了解剖学异常及神经系统发育缺陷性疾病所致的顽固性便秘。其中 1 9例经内科治疗或顺行结肠灌肠法 ( Malond手术 ,3例 )不能缓解 (女 1 0例 ,7.6± 3.9岁 ) ,经结肠和肛门直肠测压评估异常者行手术治疗。结肠动力学异常分布及手术方法 :近端结肠异常行次全结肠切除一期吻合 2例 ;全结肠异常行全结肠切除术 2例 ;远端及乙状结肠异常 1 3例 ,其中行拖出式手术 5例 ,次全结肠切除并造口…     

直肠肌部分切除在便秘治疗中的探讨

目的：探讨直肠肌部分切除治疗顽固性便秘的适应证，手术方法及疗效。方法：经肛门直肠肌部分切除术，治疗便秘患儿64例。其中先天性短段型巨结肠（HD）36例；HD根治术后便秘复发10例；乙状结肠冗长症7例；特发性便秘11例。结果：随访38例（60％），随访时间最长7．5年，最短2个月，平均26．4个月。疗效满意，能自行排便32例（88％）；欠满意，偶而需要辅助方法排便2例（5．2％）；疗效差，便秘复发4例（10．5％）。结论：本手术方法简单，容易掌握，损伤小，并发症少，效果好。     

成人先天性巨结肠症的诊断和外科治疗

目的 探讨成人先天性巨结肠症的诊断和外科治疗。方法 回顾性分析1985年5月至2005年5月收治的成人先天性巨结肠症10例患者的临床资料。结果 男性7例，女性3例。年龄14．40岁。10例均有便秘史，均经钡灌肠检查确诊，5例肛门直肠测压均未引出直肠肛门抑制反射。无神经节细胞段在乙状结肠远端和直肠2例，直肠7例，未明1例。手术方法：乙状结肠造口1例，Ikeda法6例，Rehbein法2例，改良Swenson法1例。根治手术后排便功能：优7例，良1例，差1例。结论 成人先天性巨结肠症的诊断主要依据便秘史、钡灌肠检查和／或肛门直肠测压。拖出型手术是有效的手术治疗方法，手术方式应个性化。     

直肠肛门反射及其对特发性便秘的诊断价值

目的研究直肠肛门反射(RAR)对特发性便秘(CIC)的诊断意义。方法用直肠肛管测压法检测30位正常人和32例特发性便秘患者直肠肛门反射曲线的肛门外括约肌收缩压(EASCP)、肛门内括约肌舒张压(IASDP)、肛门外括约肌收缩压与肛门内括约肌舒张压的压力差(PD)、反射时间(RT)包括直肠肛门收缩反射时间(RACRT)和直肠肛门抑制反射时间(RAIRT)6项技术指标。结果30位正常人均能导引直肠肛门反射,32例特发性便秘患者的EASCP、IASDP、PD、RAIRT和直肠肛门反射时间(RART)均明显小于正常组,两组间差异有非常显著性意义(P<0.01)。结论特发性便秘患者的直肠肛门反射、直肠肛门收缩反射、直肠肛门抑制反射均比正常人明显减弱,与直肠肛管压力变化高度相关,以肛门内括约肌舒张功能失调为主要病理改变。     

成人结肠冗长症的诊断与外科治疗82例报告

目的总结成人结肠冗长症的诊断与外科治疗经验。方法对82例成人结肠冗长症极其主要合并症——顽固性便秘的临床资料进行回顾性分析。结果82例中66例（80％）有顽固性便秘，28例（34％）有腹痛、腹胀，16例（19％）便秘与腹泻交替出现。82例中74例经x线钡剂灌肠透视，8例于急诊术中确诊。35例为结肠冗长症Ⅰ型；19例为Ⅱ型；28例为Ⅲ型（其中包括4个节段结肠冗长即全结肠冗长18例）。82例中行乙状结肠切除32例，右半结肠切除术3例，右半结肠及横结肠切除4例，横结肠左半及脾曲切除4例，降结肠及乙状结肠切除、将脾曲结肠向下游离与直肠上端吻合15例，横结肠、降结肠、乙状结肠切除、再将肝曲结肠向下游离与直肠上端吻合6例，全结肠切除、回肠末端与直肠上端吻合18例。82例术后无肠吻合口漏等严重并发症。术后随访3个月至4年，随访率为88％（72／82），疗效满意。结论根据顽固性便秘病史和x线钡剂灌肠透视可确诊成人结肠冗长症，外科手术是治疗成人结肠冗长致顽固性便秘的有效措施。     

慢传输型便秘合并成人巨结肠32例临床诊治

目的总结慢传输型便秘合并成人巨结肠的诊断和治疗经验。方法回顾性分析2007年10月至2011年6月收治的32例慢传输型便秘合并成人巨结肠患者的临床资料。结果32例患者中男15例,女17例,年龄18～56岁,均符合罗马Ⅲ便秘诊断标准。结肠传输试验提示结肠传输缓慢;钡灌肠及排粪造影提示肠管狭窄段位于横结肠3例,降结肠4例．直肠20例,横结肠或降结肠与直肠同时存在狭窄段5例;肛门直肠测压显示23例直肠肛门抑制反射消失,另9例未见异常。手术治疗行巨结肠切除、结肠部分切除、结肠结肠侧侧吻合术7例;巨结肠切除、结肠次全切除、结肠直肠下端改良Duhamel吻合术16例：结肠全切除、回肠储袋J-Poueh与直肠下端改良Duhamel吻合术9例。术后无并发症发生,随访3～47个月,18例患者排粪功能优,9例良,5例～般。结论慢传输型便秘临床诊治中应警惕合并成人巨结肠：详细询问病史和对辅助检查的综合分析是减少漏诊和误诊的关键。手术切除范围应包括病变的巨结肠和有慢传输的结肠．并按巨结肠根治术方式进行吻合。     

腹腔镜辅助经肛门拖出术治疗成人巨结肠一例

患者女 ,2 8岁。腹胀、便秘、腹痛 2 0余年。排便后症状缓解。经常大量服用泻剂 ,明显消瘦 ,体重 4 4kg。体格检查示腹部平软 ,肠鸣音活跃。钡灌肠显示乙状结肠、降结肠远端明显扩张 ,乙状结肠冗长。入院诊断 :先天性巨结肠 ,乙状结肠冗长症不能排除。小儿外科与普外科合作 ,行腹腔镜辅助经肛门拖出术 ,切除直肠黏膜及乙状结肠。硬膜外麻醉下 ,膀胱截石位 ,插尿管 ,肛门扩张后缝牵引线四针。直肠后壁齿状线上 3cm取全层活检 ,送快速冰冻 ,病理报告未见神经节细胞 ,符合先天性巨结肠。于齿状线上0 4cm处环行切开直肠黏膜 ,向近端剥离 ,针状…     

经脐和肛门自然腔道联合腹腔镜结肠次全切除一例

患儿,男,6个月.因生后腹胀、便秘而入住河北医科大学第二医院,术前经钡灌肠及肛管直肠测压诊断为先天性长段巨结肠症.X线造影显示其移行段达结肠脾曲,结肠继发扩张已达结肠肝曲.行腹腔镜监视下经肛门自然腔道直肠内拖出结肠次全切除术.     

Antegrade enemas for defecation disorders: do they improve the colonic motility?

Purpose

The aim of the study was to describe the changes in colonic motility occurring after chronic antegrade enema use in children and young adults.

Methods

Colonic manometry tracings of patients who had used antegrade enemas for at least 6 months and were being evaluated for possible discontinuation of this treatment were retrospective reviewed.

Results

Seven patients (median age of 12 years, range 3-15 years) met our inclusion criteria. Four patients had idiopathic constipation, 2 had tethered cord, and 1 had Hirschsprung disease. Colonic manometry before the use of antegrade enemas showed dysmotility in 6 (86%) children, mostly in the distal colon. None of the patients underwent colonic resection between the 2 studies. All the patients had colonic manometry repeated between 14 and 46 months after the creation of the cecostomy. All patients with abnormal colonic manometry improved with the use of antegrade enema with a complete normalization of colonic motility in 5 (83%) patients.

Conclusion

Use of antegrade enema alone, without diversion or resection, may improve colonic motility.     

Chronic idiopathic intestinal pseudo-obstruction caused by acquired visceral neuropathy localised in the left colon: Report of two cases

Two cases of chronic idiopathic intestinal pseudo-obstruction (CIIP) are reported. One is a 51-year-old man, and the other is a 47-year-old woman. Both patients presented with severe constipation and barium enema showed a marked dilation of the right colon, and a narrowing in the left colon. Studies done on the motility of the colon and anorectum revealed normal resting pressure profiles of the anorectom, a normal recto-anal reflex, and a normal resting tone of the collapsed colon. Administration of methacholine chloride, however, provoked large, non-propulsive movements in the collapsed colon, which were inhibited by the administration of atropin sulfate. Histologic examination disclosed a marked decrease in neurons and an increase of Schwann cells in the myenteric plexus of the collapsed colon. CIIP due to acquired visceral neuropathy localised in the left colon, was diagnosed as a result of manometric and histologic findings. One case was cured surgically, by a left hemi-colectomy, and the other was cured medically using choline antagonists and laxatives.     

Chronic idiopathic intestinal pseudo-obstruction caused by acquired visceral neuropathy localised in the left colon: report of two cases

Two cases of chronic idiopathic intestinal pseudo-obstruction (CIIP) are reported. One is a 51-year-old man, and the other is a 47-year-old woman. Both patients presented with severe constipation and barium enema showed a marked dilation of the right colon, and a narrowing in the left colon. Studies done on the motility of the colon and anorectum revealed normal resting pressure profiles of the anorectom, a normal recto-anal reflex, and a normal resting tone of the collapsed colon. Administration of methacholine chloride, however, provoked large, non-propulsive movements in the collapsed colon, which were inhibited by the administration of atropin sulfate. Histologic examination disclosed a marked decrease in neurons and an increase of Schwann cells in the myenteric plexus of the collapsed colon. CIIP due to acquired visceral neuropathy localised in the left colon, was diagnosed as a result of manometric and histologic findings. One case was cured surgically, by a left hemi-colectomy, and the other was cured medically using choline antagonists and laxatives.     

直肠肛管纵切心型吻合术治疗先天性巨结肠远期疗效观察

目的 评定经直肠肛管纵切心型吻合术式治疗5年以上先天性巨结肠68例疗效。方法 随访收集1992至1996年间采用心型吻合术式根治的先天性巨结肠68例的临床资料。男40例,女28例,手术时年龄<6个月22例(32％),其中新生儿10例(15％),6个月～3岁27例(40％),>3岁19例(28％);常见型46例(67％),长段型10例(15％),短段型12例(18％)。本组患儿均来院复查。通过①临床观察排便功能检查:每日排便次数、性状、有无便意、便秘、失禁及污粪,是否使用泻药,是否影响日常群体生活等。同时常规做肛诊检查。②客观排便功能测定:钡灌肠造影检查、直肠肛门测压。结果 肛门功能异常者13例(19％),主观检查以污粪为多7例(10％),其中术后6年以上1例(1.4％),4～6年6例(8.8％),便秘2例(3％),失禁4例(6％);钡灌肠造影检查:肛管直肠角68例均在正常范围,钡剂外溢7例(10％),24 h钡剂潴留2例(3％)。直肠肛门测压:直肠肛管抑制反射阳性36例(52.94％),肛管直肠压差和肛管高压区长度均低于正常参考值。结论 直肠肛管纵切心型吻合术适用于各年龄组及各种类型的巨结肠,其远期肛门直肠功能受无神经节细胞肠管长度影响,但症状随年龄增长而逐渐改善,可望通过生物反馈训练加快功能恢复。     

Routine double contrast barium enema and fiberoptic colonoscopy in the diagnosis of colorectal carcinoma

The diagnostic efficacy of routine double-contrast barium enema and fiberoptic coloscopy for detection of cancer was retrospectively studied in 303 patients consecutively operated for colorectal adenocarcinoma in a 52-month period from January 1980. Double-contrast barium enema was performed in 180 patients with 184 carcinomas, 157 (85%) of which were revealed by this examination. The detection rate of carcinoma according to site was 89% between cecum and descending colon, 92% in sigmoid colon and 71% in rectum. Fiberoptic colonoscopy was done in 176 patients with 181 carcinomas, 163 (90%) of which were detected by the endoscopical examination. The detection rate of carcinoma according to site was 86% between cecum and descending colon, 90% in sigmoid colon and 95% in rectum. The two methods were equally effective in detecting carcinoma of the colon. Colonoscopy was superior to barium enema in detection of rectal carcinoma.     

肛门直肠局部注射肉毒毒素A治疗先天性巨结肠症

目的探讨局部注射肉毒毒素A治疗短段型先天性巨结肠症的可行性。方法对8例经病理组织学和钡灌肠诊断证实为短段型先天性巨结肠患儿,在截石位3、6、9钟位,将肉毒毒素A注射入肛门内括约肌和直肠肌层内,总剂量1.5U/kg。治疗前及治疗后1个月、1年分别作肛门直肠测压,治疗后3～6个月复查钡灌肠,以后每年钡灌肠复查1次。结果所有患儿治疗后均恢复良好,无术中和术后并发症。1年内所有患儿均能自主排便,未发现腹胀、便秘。有3例1年后再次出现便秘(3～5d排便1次)和轻度腹胀症状,但经扩肛后均迅速缓解。随访1个月时,肛门直肠静息压8例均较术前降低,1年后复查6例仍低于术前。术后3～6个月复查钡灌肠,8例扩张结肠均较术前明显缩小。结论肉毒毒素A注射治疗短段型巨结肠症是一种安全、可靠的新方法,其损伤小,近期疗效良好;但作用机制和远期疗效有待进一步研究。     

腹腔镜手术治疗成人结肠冗长症疗效分析

目的:探讨腹腔镜全结肠切除术治疗成人结肠冗长症的临床效果。方法:回顾分析2011年4月至2013年4月为7例结肠冗长症患者行腹腔镜手术治疗的临床资料。5例伴有顽固性便秘,2例伴便秘与腹泻交替症状,且经X线钡剂灌肠确诊为全结肠冗长症。结果:7例均顺利完成结肠切除术,最后以回肠末端同直肠上端直接吻合。术后未发生严重并发症。术后住院6~9 d,平均(7.8±1.5)d。随访9~24个月,平均(15.0±4.5)个月,疗效均满意,生活质量明显改善,未出现长期腹泻及肠梗阻、便秘复发等远期并发症。结论:X线钡剂造影检查结合长期的顽固性便秘病史是现阶段结肠冗长症诊断的理想方式。应用腹腔镜全结肠切除术治疗成人结肠冗长症疗效确切,具有患者创伤小、康复快、安全有效等优点,但应严格掌握手术适应证。     

Large bowel volvulus in childhood

BACKGROUND: Large bowel volvulus is extremely uncommon in children. The probable pathogenesis, predisposing factors and management of large bowel volvulus in children are debatable. METHODS: Seven consecutive cases of large bowel volvulus occurring over a 6-year period are reported. RESULTS: Two patients with caecal volvulus, one with transverse and subsequent sigmoid volvulus, one with transverse colon volvulus and three children with sigmoid volvulus are reported. Four girls and one boy with cerebral palsy, one female with Moya Moya disease and spastic paraplegia and an otherwise healthy boy presented at a mean age of 8.3 years (range: 3-15 years). The common presentation was abdominal distension (n = 6), tenderness (n = 6), constipation (n = 7) and bloody mucoid discharge per rectum (n = 6). Plain abdominal X-ray and barium enema were diagnostic. Resection with primary ileocolic, colocolic or colorectal anastomosis was performed in all cases. The mean follow-up was 3.4 years (range: 1-6 years) and there was no mortality. CONCLUSIONS: Large bowel volvulus in children may be due to congenital anomalous or absent ligamentous fixation of the large bowel, and abnormal mesocolon or a common ileocolo-mesentery. Large bowel obstruction due to volvulus must be considered in the differential diagnosis in a child presenting with constipation associated with bloody mucoid discharge per rectum. Resection of the involved segment and primary anastomosis is the definitive treatment for large bowel volvulus in children.