经切开肛门括约肌的直肠阴道瘘修补术（附4例报告）

经切开肛门括约肌的直肠阴道瘘修补术（附４例报告）中国医学科学院北京协和医院外科（１００７３０）邱辉忠直肠阴道瘘（ＲＶＦ）临床少见，以往大多采用经阴道的ＲＶＦ修补术，但术后易复发。自１９９４年以来作者连续为４例ＲＶＦ病人采取经切开肛门括约肌从直肠内行Ｒ...     

Musset术治疗直肠阴道瘘20例临床分析

直肠阴道瘘是阴道后壁与直肠前壁之间一种非正常的连接,瘘管表面以上皮覆盖。临床表现以经阴道溢气、溢粪、性生活受限为主。主要原因为产伤,亦可继发于感染、创伤及肿瘤等,或医源性因素造成。2010年9月至2013年3月期间,吉林大学中日联谊医院结直肠肛门外科对收治的20例直肠阴道瘘患者行Musset术,效果满意,现报道如下。     

直肠阴道瘘经阴道手术治疗探讨

目的探讨直肠阴道瘘（rectovaginal fistula,RVF）经阴道手术修补的方法及手术成功的关键。方法2007年2月～2013年4月,对13例RVF经阴道修补。其中4例为RVF二次修补术,3例有2个瘘孔。均于瘘口形成半年后手术,术中不切除瘘管,采用“向心性”分离,充分利用瘘口周围的组织填补加固创面。结果13例瘘口均顺利愈合,无须行结肠造瘘术。手术时间25～55rain,（35±15）min。随访0．5～7年,平均2．5年,无复发。结论直肠阴道瘘经阴道修补简单易行,术中无需切除瘘管,手术时机、术前准备、术式的选择、术后管理是直肠阴道瘘治疗成功的关键。     

腹腔镜辅助经肛门直肠内拖出术治疗小儿先天性巨结肠165例中长期随访报告

目的总结腹腔镜辅助经肛门直肠内拖出术（laparoscopic-assisted transanal endorectal pull-through,LATEP）治疗先天性巨结肠（Hirschsprung’s disease,HD）的中长期随访疗效。方法回顾性分析2000年1月～2010年1月我中心单个手术小组完成的随访资料完整的165例LATEP。术前行钡剂灌肠、直肠肛门测压和直肠黏膜活检确诊。LATEP应用3个trocar;腹腔探查找到移行和扩张的肠段;多处浆肌层活检确定诊断和病变肠段范围;腹腔镜辅助彻底游离巨结肠,经肛门直肠内拖出彻底切除,近端与肛门吻合。临床问卷式调查随访患儿肛门功能评分、生长发育和生活质量评分。结果术后7 d吻合口感染1例。165例随访10个月～9年,（60.2±2.0）月,其中〈1年1例,1～3年15例,〉3～5年50例,〉5年99例。采用李正等肛门功能临床评分标准评定：术后3个月、1年和3年肛门排便优良率分别为59.4%（98/165）、92.1%（151/164）和97.3%（145/149）。术后3个月、1年和3年肛门静息压力依次为（20.2±6.4）、（23.8±10.4）、（26.8±9.0）mm Hg,与同年龄组20例儿童志愿者肛门静息压力（27.9±9.6）mm Hg比较,术后3个月肛门静息压力明显降低（t=-4.781,P=0.000）,术后1、3年肛门静息压力与对照组比较无明显差异性（t=-1.677,P=0.095;t=0.509,P=0.611）。术后1年146例（89.0%）患儿钡剂结肠造影示结肠扩张和痉挛段消失,肛管直肠角正常。患儿均生长发育正常。结论 LATEP是一种安全、有效、更为全面的治疗HD手术方式,术后肠功能恢复快,中长期随访肛门功能和生活质量良好。     

经直肠内瘘修补治疗女童直肠前庭瘘

目的：探讨对女婴直肠前庭瘘的合理手术方法。以提高治愈率。方法：对我院１９９１年４月至１９９８年１２月收治的４４例病例进行回顾性分析。采用经直肠内瘘修补术，结果：随访３８例，随访率为８６．４％，最长７年，最短半年，瘘复发２例，占５．３％。结论：经直肠内瘘修补术简单易操作，疗效确实，是治疗伴正常肛门的女婴直肠前庭瘘的有效方法之一。     

直肠中下段癌经腹肛门切除后经肛门结肠直肠粘膜吻合术

目的为探讨直肠中下段癌保留肛门临床最佳治疗术式。方法对1993年～1997年收治28例中下段直肠癌经腹肛门切除后经肛门行结肠直肠粘膜吻合术。结果随访6～52个月,平均29个月。无手术死亡率,无吻合口漏和吻合口狭窄发生。仅1例于术后19个月局部癌复发(3.6%),余27例现仍无瘤生存。术后8～12周时排便控制良好,次数为2～3次/日,18周时肛门排便功能基本恢复正常,排便次数为1～2次/日。结论合理选择手术适应症,既要避免腹壁结肠造口,又要保证手术的彻底性,在提高患者生活质量的同时,还要注重远期效果。     

经肛门结肠拖出术治疗小儿先天性巨结肠--附57例报告

目的 探讨单纯经肛门结肠拖出术治疗小儿先天性巨结肠的可行性。方法 2001年7月—2002年5月，57例巨结肠患儿行经肛门结肠拖出术。结果 53例顺利完成单纯经肛门结肠拖出术，手术时间(1—2)小时，平均1．5小时，出血5m1—10m1。51例术后1天开始自行排便、进食，2例术后3天予开塞露灌肠后排便。4例长段型巨结肠，病变累及横结肠，在腹腔镜辅助下完成，手术时间(2—3．5)小时，平均3小时，术后(2—3)天开始排便、进食。随访(2—9)月，57例患儿排便功能均正常良好。结论 单纯经肛门结肠拖出巨结肠根治术治疗小儿先天性巨结肠可行，此术式损伤小、出血少、术后恢复快、住院时间短，术后排便功能恢复良好。     

小儿直肠尿道瘘的修补与肛门括约肌重建术

目的：提高经多次手术失败的直肠尿道瘘、大便失禁的手术成功率。方法：按Pickrell术式或Hartle改良方法,压榨股薄肌支配神经后移转到肛门周围固定,行肛门外括约肌成形术共18例。结果：1989－1999年共治疗3－15岁直肠尿道瘘伴大便失禁小儿18例,结果15例无漏尿,3例漏尿者也都在术后5周内消失,大便失禁亦都有改善。15例随访7个月－6年,12例大便失禁明显改善。结论：用该法解决难以处理的直肠尿道瘘成功率高,大便失禁得到改善。     

经阴道修补直肠阴道瘘的临床分析

为探讨经阴道修补治疗直肠阴道瘘的临床效果，回顾分析于我院经阴道修补治疗的5例直肠阴道瘘患者的病例资料。结果显示，5例患者均成功完成手术，其中1例术后1个月内有少量阴道排气，2个月后痊愈。随访6个月至5年，均无复发。结果表明，准确把握手术时机、适应症及全面的围手术期护理，是经阴道修补直肠阴道瘘手术成功的关键。     

复发性直肠阴道瘘治疗的新选择

复发性直肠阴道瘘仍是临床上一个较特殊和困难的问题。作者采用肛门内转移皮瓣与阴道口后外侧游离皮瓣相结合，对1例75岁的女性，曾两次行经肛门内皮瓣修复术，第二次手术并行了回肠造瘘，术后仍失败的患者行了修补术．临床效果满意，修补术后10周，对上次的回肠造瘘进行了复瘘术。术后随访两年以上证实修补无裂开和瘘复发。     

经骶部"∧"形切口一期肛门成形术治疗女婴无肛阴道瘘17例疗效分析

目的分析骶部“∧”形切口骶会阴一期肛门成形术治疗女婴无肛阴道瘘的可行性及其手术要点。方法1998年4月~2005年11月共收治17例中位及较低高位无肛阴道瘘患儿,均行骶部“∧”形切口骶会阴一期肛门成形术,回顾分析其治疗结果。结果17例患儿术后均无排便失禁,1例伴轻度直肠粘膜脱垂,骶部切口无一例感染。结论中位及较低高位无肛阴道瘘患儿,经骶部“∧”形切口行骶会阴一期肛门成形术,可免除分期手术的痛苦,无需行肠造瘘,骶部切口愈合好,肛门排便功能基本达到正常。     

Rectovaginal Fistula: A New Approach By Stapled Transanal Rectal Resection

Many surgical procedures have been developed to repair rectovaginal fistulas even if no “procedure of choice” is reported. The authors report a case of relatively uncommon, complex, medium-high post-obstetric rectovaginal fistula without sphincteral lesions and treated with a novel tailored technique. Our innovative surgical management consisted of preparing the neck of the fistula inside the vagina and folding it into the rectum so as to enclose the fistula within two semicontinuous sutures (stapled transanal rectal resection); no fecal diversion was performed. Postoperative follow-up at 9 months showed no recurrence of the fistula.     

Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula

Background/Aim

Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly.

Methods

All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty.

Results

Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions.

Conclusions

Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.     

Double termination of the alimentary tract in females: a report of 12 cases and a literature review

Twelve female infants with double termination of the alimentary tract were reported. One patient had a high rectovaginal fistula, but in the other 11 cases the tract opened into the bowel uniformly at the level of the levator ani (anorectal-vestibular fistula). In these patients, diagnosis of the anatomical level of the fistula was made definitely with our radiological technique. Excision of not only the fistulous tract but also the anterior half of the rectum below the fistula is essential to achieve a cure without recurrence. The pathogenesis of this condition is discussed and the pertinent literature reviewed.     

Anorectal Agenesis with a Rectourethral Fistula Diagnosed in an Adult: Report of a Case

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.     

Rectovaginal Fistula Repair Utilizing a Cadaveric Dermal Allograft

Rectovaginal fistula repair is commonly performed through the vagina. When recurrent fistulae occur, healthy tissue such as a muscle or fat pad may be interposed to facilitate healing and prevent recurrence. A woman developed a postpartum rectovaginal fistula after her third-degree perineal laceration failed to heal completely. Two subsequent fistula repairs were performed, with recurrence following each procedure. The fistula was ultimately repaired by performing a layered closure and interposing a cadaveric dermal allograft between the rectovaginal septum and vaginal epithelium. Allogenic cadaveric graft may be a viable alternative to traditional autologous flaps for the repair of recurrent or complicated rectovaginal fistulae.     

经会阴离断直肠末端一期手术治疗先天性肛门闭锁并肛前瘘

目的总结经会阴离断直肠末端一期手术治疗先天性肛门闭锁并肛前瘘的初步经验。方法回顾性分析19例临床资料,其中肛门闭锁合并直肠前庭瘘9例、直肠阴道瘘2例、直肠会阴瘘7例和直肠尿道瘘1例。均经会阴离断直肠末端一期行经会阴肛门成形和肛前瘘修补手术。结果所有患者手术顺利,术后恢复良好,平均随访3年(1个月~6年),瘘管未复发,肛门排便和控便功能满意。结论经会阴离断直肠末端一期肛门成形和肛前瘘修补治疗先天性肛门闭锁并肛前瘘创伤小,疗效满意。     

经阴道分层修补治疗成人直肠阴道瘘32例疗效观察

为探讨经阴道分层修补治疗成人直肠阴道瘘的临床疗效,采用此方法治疗直肠阴道瘘患者32例,术中患者取截石位,分2层或3层分别修补直肠黏膜、直肠阴道隔和阴道黏膜,注意确保缝合后无张力。结果显示,本组32例患者均治愈。随访1～3年,均无复发。结果表明,经阴道分层修补治疗成人直肠阴道瘘手术创伤小、操作简单、不损伤括约肌、复发率低,是一种较为理想的术式。     

肛门闭锁合并直肠阴道瘘围手术期护理

为探讨肛门闭锁合并直肠阴道瘘围手术期的护理方法，减少并发症的发生，采用调节饮食、控制排便、保持肛门会阴部创口清洁干燥、加强功能锻炼的方法并进行效果观察比较。结果显示，15例中，14例创口愈合良好，1例创口愈合缓慢，换药15d后创口愈合。功能恢复结果优6例，良8例，差1例。结果表明，充分的术前准备，术后控制排便，保持会阴创口干燥等护理方式为手术取得成功奠定了重要基础，提高了患者的生活质量。