低位直肠肌层内拖出术治疗先天性巨结肠的评价

Ｓｗｅｎｓｏｎ和Ｂｉｌｌ在 194 8年首先报道了经肛门拖出术治疗本病。196 4年 ,Ｓｏａｖｅ报道了直肠内拖出术 ,后来Ｂｏｌｅｙ对此手术方法进行了改进 ,成为现在临床常用的Ｓｏａｖｅ术 ,但仍存在某些情况下直肠粘膜剥离困难 ,保留过多肌套可能会出现某些机能障碍。1992年以来 ,我们针对这些问题改进手术方法 ,缩短了保留的肌套 ,同时也减少了术中出血 ,缩短了手术时间 ,并取得了初步满意的效果。临床资料1.一般资料 :1992年以来我们共收治先天性巨结肠4 6例 ,男 2 8例 ,女 18例 ;年龄 7ｄ～ 8岁 ,其中小于 1个月的17例 ,4岁以上的 4例。…     

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。     

经肛门拖出术治疗先天性巨结肠23例

长期以来采用Ｓｏａｖｅ手术治疗小儿先天性巨结肠[1] ,近来我们采用不开腹 ,经肛门一期根治术治疗 ,创伤小 ,术后恢复快 ,并发症少。1　材料与方法小儿先天性巨结肠 2 3例 ,男 15例 ,女 8例 ,年龄 2 6天～ 4岁。以病史、体征、肛诊和钡灌肛等初步诊断 ,选择其降结肠无明显扩张的病儿 ,常规消毒腹部及会阴皮肤 ,插尿管。肛门扩张后 ,缝 4针牵引线。在齿状线上 4ｃｍ处直肠后壁取全层活检进一步确诊。齿状线以上粘膜下注入肾上腺素盐水 ,以利于止血和剥离。在齿线上 0 2ｃｍ处环行切开直肠粘膜 ,剥离直肠粘膜 6～ 8ｃｍ ,见直肠肌层随粘膜牵…     

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。     

经肛门改良Soave根治术治疗先天性巨结肠疗效观察

目的:观察经肛门Soave根治术治疗先天巨结肠术后排便及其它并发症情况。方法:自2001年9月～2003年9月对24例年龄20天～6个月的先天性巨结肠患儿行肛门Soave根治术,术后定期随访,随访时间3个月～2年,对患儿大便控制能力,粘连性肠梗阻,及小肠结肠炎等的发生率进行评价。结果:术后并发症有小肠结肠炎5例(21.8％),便秘1例(4％),污粪2例(8％)。结论:经肛门Soave根治术术后可获得良好的排便控制。     

完全经肛门拖出术和腹腔镜辅助拖出术治疗先天性巨结肠疗效比较的meta分析

目的 比较完全经肛门拖出术和腹腔镜辅助拖出术治疗先天性巨结肠(HD)的疗效.方法 检索PubMed、EMBASE、The Cochrane Library、中国知网、万方数据库和维普信息资源系统,筛选出1998年1月至2020年5月期间发表的有关完全经肛门拖出术与腹腔镜辅助拖出术治疗HD的对比研究.由两名评价员独立完成...     

经肛直肠内拖出巨结肠根治术的手术方法的探讨

目的探讨经肛门直肠内巨结肠根治(改良Sovae)术的手术方法,手术中注意事项,以提高其疗效。方法103例巨结肠患儿经钡灌肠、直肠测压、直肠活检及切除后病理检查确诊。结果与常规巨结肠手术方法相比,所有患儿均顺利完整地剥离黏膜,无出血或黏膜破损,无吻合口瘘,无鞘内感染,无大便失禁。结论经肛先天性巨结肠根治(改良Sovae)术安全易行,任何年龄的先天性巨结肠患儿狭窄段位于直肠或乙状结肠;短段型;常见型先天性巨结肠,均可经肛巨结肠根治术,尤其是经肛门间接分离直肠黏膜的方法,具有解剖平面清楚,剥离快,极少出现黏膜破损,几乎无出血,操作简单,安全可靠,术后效果好等优点,正确、精细的操作可有效的预防术后并发症的发生。     

单纯经肛门直肠及内括约肌切除术治疗先天性巨结肠的探讨(附101例报告)

目的 探讨单纯经肛门直肠黏膜及内括约肌切除术治疗新生儿及儿童先天性巨结肠的效果. 方法 本组101例,在齿状线水平将直肠黏膜与肛管皮肤交界处环形切开,切开略大于直肠1/2周径的前壁肌层至黏膜下层,沿黏膜下层向上分离;后壁沿直肠纵肌向上分离,前后壁共同分离直达腹膜反折水平进入腹腔,切除大部分内括约肌及直肠后壁肌鞘行巨结肠根治术. 结果 101例均手术顺利,手术时间45～190 min,平均90 min.术中出血＜10 ml,无术后尿潴留,无伤口感染、肛门回缩及肛门狭窄.术后肠炎发生率2.3%(2/86),污粪的发生率由术后2个月的27%(22/82)下降至术后6个月的4%(3/82).78例肛门直肠测压,手术后1、2、3、6个月肛管静息压力比手术前明显减低(P＜0.05). 结论 经肛门内括约肌及直肠后壁肌鞘切除治疗巨结肠安全易行,可有效预防术后并发症的发生,同样适合在基层医院推广应用.     

经肛门巨结肠根治术的远期疗效

<正>先天性巨结肠(hirschsprung's disease,HSCR)是一种常见的小儿消化道畸形,是新生儿肠梗阻的常见原因,其发病率为1/5000～1/4000,居小儿消化道畸形第二位~([1])。HSCR的主要病理改变是在胚胎发育的5～12周神经嵴细胞迁移障碍,导致末端肠壁黏膜下及肌间神经丛神经节细胞缺如,引起病变肠管持续痉挛性收缩,蠕动消失,近端肠管扩张而出现腹胀、呕吐及     

直肠内结肠拖出斜弧形吻合术治疗小儿先天性巨结肠19例

目的探讨小儿先天性巨结肠新的手术方法。方法采用直肠内结肠拖出,结、直肠斜弧形吻合术治疗小儿先天性巨结肠19例。结果全部经过顺利,无一例吻合口瘘。术后随访,16例排便正常,2例肛管狭窄,系直肠前壁保留过短之故,1例常排稀便,系结肠切除过多所致。结论结肠、直肠/肛管前后壁斜弧形吻合间距只要不短于3cm,术后不会发生肛管狭窄。该术式用于治疗小儿先天性巨结肠具有手术操作简单、易掌握、创伤小、术后痛苦及并发症少等优点。     

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

Purpose

The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT).

Method

The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007.

Results

Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 ± 216 days, and the mean body weight at TERPT was 4.5 ± 2.8 kg. The average operating time was 189 ± 49 minutes, and mean length of bowel resection was 11.1 ± 3.2 cm. The mean postoperative hospital stay was 8.0 ± 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 ± 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 ± 6.9 weeks vs 7.3 ± 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased (P = .018).

Conclusion

Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.     

内括约肌部分切除在经肛门Soave巨结肠根治术中的应用

目的探讨内括约肌部分切除对经肛门Soave巨结肠根治手术疗效的影响。方法前瞻性人组2003-2012年间广东省东莞市人民医院收治的153例先天性巨结肠患儿,均予以经肛门Soave巨结肠根治术治疗。按简单单双号法将患儿分为部分切除组（77例）和单纯切开组（76例）,分别于术中进行内括约肌部分切除或仅单纯切开直肠后壁肌鞘。比较两组患儿术后并发症及排粪控制功能的差异。结果部分切除组患儿较单纯切开组术后直肠肌鞘内感染[1．3％（1／77）比11．8％（9／76）,P〈0．05]、小肠结肠炎[2．6％（2／77）比13．2％（10／76）,P〈0．05]、吻合口狭窄[3．9％（3／77）比22．4％（17／76）,P〈0．01]及腹胀[10．4％（8／77）比25．0％（19／76）,P〈0．05]的发生率均明显降低。两组术后1年排粪控制功能比较差异无统计学意义（Kelly评分：5．1±0．5比5．2±0．6,P〉0．05）。结论与单纯切开直肠后壁肌鞘相比,内括约肌部分切除能明显降低经肛门Soave巨结肠根治术后直肠肌鞘内感染、腹胀、吻合口狭窄和小肠结肠炎的发生率,同时并不会加重术后远期排粪控制功能的损害。     

Duhamel operation vs. transanal endorectal pull-through procedure for Hirschsprung disease: A systematic review and meta-analysis

Objective

To compare treatment outcomes in children with Hirschsprung's disease who underwent treatment using the Duhamel or TERPT surgical procedures.

经肛门I期先天性巨结肠根治术临床观察

目的 探讨经肛门I期先天性巨结肠根治术的治疗方法和临床效果。方法 对12例已证实为短段型或普通型先天性巨结肠患儿行经肛门I期先天性巨结肠根治术。年龄3月至5岁，平均1．8岁。结果 全组手术顺利，无死亡。术后1周左右出院，随访半年，术后有1例出现轻度排便困难，经保守治疗痊愈。有3例出现不同程度的污粪，3-6月后痊愈。无严重并发症，生长发育良好。结论 经肛门I期巨结肠根治术适用于患短段型或普通型先天性巨结肠症的婴幼儿，手术创伤小，不需开腹，合并症少、手术时间短，效果满意。     

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

Background/Purpose

Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD.

Methods

Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination.

Results

Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05.

Conclusions

The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.     

Single-stage transanal endorectal pull-through for Hirschsprung's disease: perspective from a developing country

Background/Purpose

The aim of this study was to evaluate the feasibility, results, and cost-effectiveness of totally transanal endorectal pull-through (TEPT) in the management of rectosigmoid and midsigmoid Hirschsprung's disease (HD) in a low-income country.

Methods

Between March 2004 and December 2005, 19 children underwent totally TEPT procedure. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 19 patients was HD confined to the rectosigmoid region in 15 and midsigmoid in 4. None had a preoperative colostomy. Follow-up period ranged from 4 to 20 months (mean, 8 months).

Results

Ages ranged from 0.25 to 65 months, with a mean of 16.24 months. Weights ranged from 3.4 to 13 kg, with a mean of 6.5 kg. Mean time from diagnosis to pull-through procedure was 26 days (range, 6-39 days). The mean length of rectosigmoid resection was 30 cm (range, 20-50 cm). The mean operative time was 95 minutes (range, 75-140 minutes). Mean intraoperative blood loss was 25 mL (range, 15-40 mL). There was one death unrelated to the procedure. One patient had enterocolitis 3 months postoperatively. Average frequency of defecation was 3 (range, 1-6) stools per day. TEPT was associated with a shorter operating time, less blood loss, early return to feeds, and an overall reduced cost.

Conclusion

The safety and cost-effective benefits of transanal endorectal pull-through in the treatment of HD are of special interest for a developing country. Our data also suggest that functional outcome following TEPT is highly satisfactory and comparable with other established procedures.     

Functional outcome after operation for Hirschsprung disease—transanal vs transabdominal approach

Background

It has been hypothesized that the extensive transanal dissection in transanal endorectal pull-through (TEPT) for Hirschsprung disease (HD) can impair the anal sphincters in neonates and thereby cause incontinence. Theoretically, transabdominal endorectal pull-through might have less impact on the sphincters. The aim of this study was to compare functional outcome in HD patients operated with either TEPT or laparotomy-assisted endorectal pull-through (LEPT) with particular focus on soiling and fecal incontinence.

Patients and Methods

Anorectal function in 52 children older than 3 years is reported. The patients were operated for HD with either TEPT (n = 28) or LEPT (n = 24) and followed prospectively. Functional outcome was recorded by standardized interviews. The Krickenbeck criteria were used to classify voluntary bowel movements, soiling, and constipation.

Results

The median age at follow-up was 5.7 years (3.1-13.2) for TEPT and 10.1 years (7.7-16.2) for LEPT. Twenty-nine patients reported soiling at final follow-up. There was no difference in the rate of soiling between children operated with TEPT (54%) or LEPT (58%). Constipation was reported in 11 children (TEPT, 25%; LEPT, 17%).

Conclusions

The functional outcome and in particular the rate of soiling did not differ between patients operated with LEPT or TEPT.     

Analysis of problems, complications, avoidance and management with transanal pull-through for Hirschsprung disease

Background

The primary aim of this study is to detail the problems, complications, their avoidance, and management with transanal pull-through developed from experience with 65 patients.

Methods

A retrospective study of 65 patients who underwent transanal pull-through between January 2002 and December 2006 was conducted. Their medical charts and operative notes were reviewed for problems encountered during surgery, postoperative period, and follow-up.

Results

In 46 patients, a primary transanal pull-through was performed, whereas in 19 with a prior colostomy, followed staged pull-through was done. The minimum follow-up was 6 months, with an average of 22 months after surgery (range, 6-47 months). Sixteen patients (25%) experienced at least 1 complication. These included inadvertent full-thickness mobilization of the rectum in 3 (4.6%), retraction and bleeding of colonic mesenteric vessels in 2 (3.7%), difficulty in mobilizing intraperitoneal colon in 1 (1.5%), and a false-positive frozen section in 2 patients (3%). Early postoperative complications occurred in 7 patients (11%), which included sphincter spasm in 3 (4.6%), anastomotic leak in 1 (1.5%), cuff abscess in 2 (3%), and enterocolitis in 1 (1.5%). Late postoperative complications in 46 patients (70%), occurring from 1 week till 3 months of follow-up included perianal excoriation in 22 (34%), increased stool frequency in 20 (31%), anal stenosis in 3 (4.6%), and enterocolitis in 2 patients (3%). Methodology is detailed for avoidance and management of problems and complications. Individual patient analysis, complications timing, and strategy for management are discussed.

Conclusion

Patient outcomes for transanal pull-through have improved significantly as a result of combination of experience and the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.     

Further evidence on totally transanal one-stage pull-through procedure for Hirschsprung's disease

Background/purpose

Fifteen consecutive children aged 20 days to 12 years with biopsy-proven Hirschsprung’s Disease (HD) underwent a transanal pull-through procedure over a 17-month period. These patients have been divided into 2 groups. The first was a series of 9 patients, which helped us gain familiarity and confidence with technical and postoperative gestational problems, and the second series was of 6 patients, which fully corroborates and adds further evidence on the minimally invasive nature of the technique. Mucosectomy of aganglionic bowel, access to the peritoneal cavity, division of rectosigmoid mesenteric vessels, pull-through of normoganglionic colon, colectomy, and coloanal anastomosis all were performed transanally. Patients underwent a program of progressive anal dilatations and were assessed for postoperative clinical course, continence, constipation, diarrhea, postoperative enterocolitis, perianal excoriations, and anal stricture.

Results

Mucosectomy was done under direct vision. Operating time ranged from 150 to 350 minutes. The average length of bowel resected was 13.5 cm with a range of 8 cm to 25 cm. There were neither intraoperative nor significant postoperative complications. All but 2 patients accepted full oral feedings on postoperative day 2. Mean hospital stay in the first series of 9 patients was 7 days, range, 5 to 12 days; that of the second series of 6 patients was 5 days, range, 4 to 8 days. All children currently experience 1 to 6 bowel movements per day at a follow-up period of 1 to 17 months.

Conclusions

A one-stage pull-through procedure for HD can be performed successfully with a completely transanal approach. This technique is associated with excellent early clinical results. Many more cases and a longer follow-up period will be required to compare long-term results with other one-stage procedures for definitive treatment of HD.     

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

Background

The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children.

Methods

Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children.

Results

The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders (P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3° ± 15.1° vs 84.7° ± 8.3° vs 79.0° ± 11.6°, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6° ± 15.9° vs 111.0° ± 14.3°, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 ± 8.2 vs >188 hours, P < .01; 6.3 ± 4.1 vs >60 hours, P < .01; 11.8 ± 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 ± 5.6 vs 28.1 ± 10.1 hours, P < .05; 12.2 ± 6.7 vs 9.8 ± 4.0 hours, P < .05).

Conclusions

The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the “neorectosigmoid”, an open and fixed anorectal angle, and ischemia of the pull-through segment.