改良Soave结合结肠切端缩口缝合术治疗先天性巨结肠疗效评价

目的 评价改良Soave结合结肠切端缩口缝合术治疗先天性巨结肠的术后疗效.方法 回顾性分析2005年7月至2009年8月在我院行改良Soave结合缩口缝合术的32例巨结肠患儿术后恢复情况,设为观察组,选取32例行单纯改良Soave根治术的患儿为对照组.观察术中扩张段肠管断端病理切片、术后复查肛诊、肛门镜、钡灌肠及直肠肛管测压并对二组患儿排便功能进行评分.结果 观察组中26例扩张段断端神经节细胞数量正常,无明显变性,6例神经节细胞数量减少,存在变性,对照组中前者28例,后者4例.肛诊及肛门镜示术后半年以上缩口缝合结肠黏膜皱褶基本消失.钡灌肠示结肠均无明显扩张,结肠形态恢复良好.观察组和对照组术后1年排便功能评分及直肠肛管测压中的肛管高压区长度、肛管静息压、直肠感觉阈值,分别为6.6±1.3、(2.0±0.7)cm、(53.1±3.9)mmHg、30～55 ml;6.8±1.2、(1.9±0.6)cm、(52.6±4.7)mmHg、35～60 ml,均无统计学差异.术后并发症观察组有吻合口狭窄1例,二组轻度污粪各1例.结论 改良Soave结合结肠切端缩口缝合巨结肠根治术后结肠及排便功能恢复满意,与单纯改良Soave术式疗效无差异.扩张但功能良好的近端结肠切端管径大于肛门口径时,可行结肠切端缩口缝合术,该术式可成为改良Soave手术较好的辅助手段.

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Objective To evaluate the efficacy of modified Soave procedure combined with colon plication for the treatment of Hirschsprung's disease (HD) in children.Methods Between July 2005 and August 2009,32 HD patients of the plication group underwent modified Soave procedure combined with colon plication at this center.Another 32 patients who underwent modified Soave procedure were enrolled as the controls.The pathological examinations,follow-up,barium enema,anorectal manometry,and anorectal function were retrospectively reviewed and analyzed to evaluate the surgical efficacy.Results Of the 32 patients of the plication group,26 had normal ganglion cells at both ends of the dilated intestine,and decreased ganglia number and ganglia degeneration were found on the other 6 patients.However,among the 32 control patients,decreased ganglia number and ganglia degeneration was only found on 4 patients.Rectoscopy suggested that mucosa rugae caused by colon plication could eventually disappear half a year after the surgery.On patients' barium enema radiography,no dilated intestines were observed.No difference of the defecation function scores between the plication group and control group at 1 year after operation was found (defecation function score,6.6 ± 1.3 vs 6.8 ±1.2).Moreover,there was no difference of high pressure zone length (2.0 ± 0.7 cm vs 1.9 ± 0.6 cm),anal canal resting pressure (53.1 ± 3.9 mmHg vs 52 ± 4.7 mmHg) and sensation threshold (30～55 ml vs 35～60 ml) between the 2 groups 1 year after operation.Postoperative complications included anastomotic stenosis was noted on 1 patients of the placation group,1 of the plication group and 1 control patient had mild soiling.Conclusions Modified Soave procedure combined with colon plication improves the defecation function of the HD patients.     

先天性巨结肠根治术后医源性直肠阴道瘘的再手术治疗CSCD

Objective To explore the causes of iatrogenic rectovaginal fistula after pull-through in Hirschsprung’s disease (HD) and summarize the experiences and efficacies of reoperation. Methods From December 2007 to December 2020 , retrospective review was conducted for clinical data of 6 HD children with iatrogenic rectovaginal fistula after pull-through. The surgical procedures for repairing rectovaginal fistula included transabdominal and transanal Soave , transperineal or transanal surgery. Results A total of six girls were included. Clinical manifestation was vaginal excretion. Injuries occurred in initial surgery (n =4) and during redo pull-through (n =2). The reasons for re-operation were postoperative abdominal hemorrhage and aganglionic segment residue. Rectovaginal fistula with anastomotic retraction and stenosis were successfully repaired by transabdominal and transanal Soave procedure in single time(n =4). The remaining two cases underwent simple local repair of rectovaginal fistula , including fistula closure after anal repair twice (n =1) and failed closure after five local (perineal/anal) repairs (n =1). Conclusion Rectovaginal fistula after pull-through in HD is a serious iatrogenic injury. It should be separated close to rectal submucosa/rectal wall to avoid vaginal injury. Transabdominal and transanal Soave procedure has a high success rate for repairing rectovaginal fistula and managing anastomotic retraction and stenosis. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

限制性后人字入路直肠肛门成形及外括约肌成形术治疗中低位无肛合并直肠会阴瘘

目的 针对中低位无肛合并直肠会阴瘘的患儿改良一种新的手术方法,使之较现行的方法如Pena、后切术更加简便、更符合生理以减少手术并发症.方法 切口采用限制性(即限制在3 cm以内)后人字切口,显露瘘管和直肠下端,在直肠下端的后方将肛门外括约肌复合体部分切开,将两侧的肌纤维环包于直肠下端.完成外括约肌成形术,在中线后切瘘管及直肠壁,于正常肛隐窝处完成肛门成形.结果 24例先天性无肛合并直肠会阴瘘(X线侧位片直肠盲端在P-C线或至Ⅰ线间)患儿进行了该手术,术后全部病例进行随诊:除1例5岁患儿术后便秘,全部患儿恢复自主排便,可控制,无失禁及溢粪.1例患儿术后肛门切口轻度感染经切开引流治愈.结论 该手术较Pe(n)a手术操作更加简便,局部创伤小,术后避免直肠回缩,减少了术后并发症,且术后不必扩肛;不同于传统的"后切术",术中进行肛门外括约肌成形,术后随诊疗效满意.

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Objective To study the clinical outcomes of anorectoplasty and external anal sphincterplasty via posterior approach with Y-shaped incision to repair intermediate and low anorectal malformation complicated with rectal perineal fistula in children. Methods Twenty four patients with intermediate and low anorectal malformation complicated with rectal perineal fistula were enrolled in this study. Via the posterior approach, a Y-shaped incision (＜3 cm) was made to expose the lower rectum and fistula. The external anal sphincter was identified and dissected at the posterior aspect of the lower rectum. The external anal sphincterplasty was performed by overlapping the ends of the muscle around the lower rectum. The rectal perineal fistula was resected and anorectoplasty was performed. Results All surgeries were successfully performed. Voluntary bowel movement and fecal continence was restored on 23 patients after surgery. One 5 years old patient still had constipation. Mild incision infection was found on 1 patient, and was cured after opening the incision and draining the pus. No fecal incontinence or anastomotic stricture was noted. Conclusions Compared with Pena surgery, anorectoplasty and external anal sphincterplasty via posterior approach with Y-shaped incision is less complicated and invasive to repair intermediate and low anorectal malformation complicated with rectal perineal fistula. By using this procedure, better sphincter shape and fecal function is achieved on patients.     

腹腔镜辅助高位肛门直肠畸形成形术后中期随访研究

Objective To evaluate postoperative anorectal functions of patients with high-type anoreetal malformations who underwent laparoscopically assisted anorectal pull-through (LAARP). Methods From Jan 2002 to Dec 2005, LAARP was performed on 10 patients with high-type anorectal malformations. All the patients were followed up and their clinical data were compared with patients who underwent posterior sagittal anorectoplasty (PSARP) (n = 12) performed before 2002. All pa-tients underwent colostomy at newborn period. Anorectal functions were evaluated with Kelly's clinical scoring and anoreetal manometry. At follow-up, the age of patients ranged from 3 to 5 years and from 5 to 6 years in the LAARP group and in the PSARP group respectively. Results The age at evaluation in the LAARP group was significantly younger than that in the PSARP group (47. 2 ± 8. 3 months vs 74. 5 ± 9. 3 months, P<0. 05). Kelly's clinical score was 3. 7 ± 0. 9 vs 3. 4± 0. 8 for the LAARP group and PSARP group respectively. The results of resting anal pressure and high pressure zone length showed that no significant difference was noted between the two groups, while the positive rate of rec-toanal inhibitory reflex in the LAARP group was significantly higher than that in the PSARP group (80 % vs 41%, P<0. 05). Conclusions Midterm follow-up study revealed that satisfactory fecal con-tinence can be achieved in patients with high-type anorectal malformations treated with LAARP, which may be an effective alternative. However, long-term follow-up is needed to evaluate the anorec-tal functions of patients treated with LAARP or PSARP     

加速康复外科技术在肛门闭锁并直肠前庭瘘中的应用CSCD

Objective To explore the efficacy and safety of enhanced recovery after surgery (ERAS) in children with anal atresia and rectal vestibular fistula. Methods From January 2017 to October 2021, prospective review was conducted for 50 children with anal atresia and rectal vestibular fistula undergoing transanal analoplasty. They were randomized into two groups of ERAS and non-ERAS (n =25 each). ERAS group received enema once in the morning of operation day, oral 12.6% carbohydrate liquid 2 h pre-operation, intraoperative heat preservation, target-oriented rehydration ,no indwelling catheter post-operation, postoperative analgesia and other new measures; non-ERAS group had traditional perioperative treatment. Blood glucose at the beginning of anesthesia, blood glucose 24 h post-operation, white blood cell count ( WBC), C-reactive protein (CRP), time of initial exhaust and defecation post-operation, amount of intraoperative infusion, time of postoperative intravenous infusion ,time of postoperative hospitalization, expenditure of hospitalization incidence of complications and readmission rate at Day 30 post-discharge were compared between two groups. Results No significant inter-group differences existed in average age, weight, preoperative WBC, CRP, hemoglobin, albumin, prealbumin or blood glucose at admission. Blood glucose at the beginning of anesthesia in ERAS and non-ERAS groups was (4.92±0.50) and (4.53 ±0.42) mmol/L, blood glucose (5.03 ±0.66) and (5.96±41.18) mmol/L at 24 h post-operation. WBC at 24h post-operation (9.97 3.24) x 10°/L and (8.28 ±3.51) x 10°/L;CRP at 24 h post-operation (3.63±4.00) and (9.03±15.77) mg/L;initial postoperative exhaust and defecation time (12.1 ±6.4) and (14.0 ±9.3) h;intraoperative infusion volume (83.1 ±32.2) and (136. 1±68.4) mL;postoperative intravenous infusion time (4.68 ±1.25) and (6.6 ±1.68) days; postoperative hospital stay (7.12 ± 1.56) and (10.56 ±3.58) days; hospitalization expense (13 314. 34 ±2 856.86) and (16 088.69 ±3 282.34) CNY ;complications occurred (n =3,12%) and (n =6,24%) ;overall satisfaction was 88% and 60%. Both groups were cured and discharged and there was no re-admission within 30 days post-discharge. No inter-group differences existed in initial exhaust or defecation time, WBC and CRP at 24 h post-operation (P >0.05).In nonERASgroup, blood glucose declined at the beginning of anesthesia while postoperative blood glucose level rose with statistical difference (P <0. 05) ; overall satisfaction of ERAS group was higher than that of non-ERAS group with statistical difference (P lt; 0.05). Conclusion Conceptual application of ERAS is both safe and effective in children with anal atresia with rectovestibular fistula. It can effectively shorten the average time of hospital stay, curtain the length of postoperative hospitalization and lower hospitalization expenditure. A wider popularization is worthy. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.     

Therapeutic laparoscopy for superior mesenteric artery syndrome in 5 children: Treatment experience and lite-rature review北大核心CSCD

Objective To investigate the clinical characteristics and therapeutic laparoscopy treatment for superior mesenteric artery syndrome(SMAS) in children. Methods A retrospective study on 5 children with SMAS who failed to respond to the conservative treatment in the Second Hospital of Shandong University from March 2017 to March 2022 was carried out.All the patients underwent the laparoscopic lysis of the ligament of Treitz and duodenal lowering procedure.The clinical data were analyzed and literature retrieved from Wanfang and PubMed databases were reviewed. Results There were 3 boys and 2 girls in the 5 cases with SMAS.The average age was (12.4±1.4) years, and the preoperative body mass index was (15.2±0.8) kg/m2.The patients were admitted to the hospital with vomiting, abdominal pain and emaciation symptoms, and the duration of symptoms was (8.4±7.8) months.Gastroscopy, laparoscopic lysis of the ligament of Treitz and duodenal lowering procedure were performed successfully in all the patients, without conversions to open surgery.The average operation duration was (66.0±10.7) min.Food intake was allowed 1 day after surgery.Chylous fistula occurred 4 days after operation in one patient, whose symptom relieved after 11 days of conservative treatment.One patient still had nausea and vomiting symptoms 10 days after operation and was healed by knee-chest posture treatment.No other short-term complications were observed.The median postoperative duration of stay in the hospital was 7 (6-22) days.The patients were followed up for 9-56 (median: 21) months.All of them recovered well and gained weight.One patient had mild recurrent symptoms, and was cured after conservative treatment.A total of 15 literature on the treatment of SMAS by laparoscopic lysis of the ligament of Treitz was retrieved, and the cure rate was 40%-100%.Only one group of these cases had a cure rate below 75%. Conclusions The laparoscopic lysis of the ligament of Treitz and duodenal lowering procedure is safe, effective, simple and minimally invasive treatment for children with SMAS.It can be used as the first choice for most pediatric patients. © 2022 Chinese Journal of Applied Clinical Pediatrics. All rights reserved.     

腹腔镜下高位肛门闭锁肛门成形术及中期临床评估

目的 评估腹腔镜下高位肛门闭锁成形术后临床疗效和直肠肛门功能.方法 2004年6月至2007年9月收治高位肛门闭锁患儿61例,33例行腹腔镜下肛门成形术(LAARP),平均年龄5.3个月;28例行后矢状入路肛门成形术(PSARP),平均年龄4.9个月.随访包括手术时间、住院时间和并发症.手术后3～4年对患儿进行排便功能的Kelly评分(KCS)、磁共振成像(MRI)和直肠肛管向量测压(AVVM)评估.结果 LAARP和PSARP组手术时间分别为(112.5±12.4)min和(120.4±18.5)min(P＞0.05),LAARP组住院时间(11.3±2.1)d短于PSARP组(14.6±2.3)d(P＜0.01).两组患儿KCS无显著差异(3.52±1.42比3.49±0.82,P＞0.05).MRI显示:LAARP组33例患儿中在I线上和M线上各有1例存在直肠位置偏移;PSARP组28例患儿中I线上有4例存在直肠位置偏移,M线上有3例存在直肠位置偏移.直肠肛管向量测压结果显示:与PSARP组相比,LAARP组非对称指数小,向量容积大,静息时和收缩时肛管压力高(P＜0.05).但高压带长度(15.2±5.8比15.1±6.2 mm)和直肠肛管抑制反射阳性率(84.8%比85.7%)无显著差异.结论 高位肛门闭锁患儿LAARP术后排便控制满意,与PSARP相比,LAARP术后住院时间短、直肠位置更准确.长期随访对评估LAARP术后功能非常必要.

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Objective To evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus who underwent laparoscopically assisted anorectal pullthrough (LAARP). Methods From January 2004 to July 2007,33 consecutive patients (28 males and 5 females,age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty ( PSARP,n = 28) at the same time period. Anorectal function of these patients was evaluated using the Kelly's score,anorectal vector volume manometry(AWM) and magnetic resonance imaging (MRI) at the age of 3. 1 to 4. 4 years. Results The operative time in LAARP and PSARP groups was 112. 5 ± 12.4 and 120.4 ± 18.5 min (P ＞ 0. 05), respectively. The length of hospital stay in LAARP group was shorter than that of PSARP group (11. 3 ± 2. 1 vs. 14. 6 ± 2. 3 days,P＜0. 01). No significant difference was observed between LAARP and PSARP groups regarding Kelly's score (3. 52 ± 1. 42 vs. 3. 49 ± 0. 82). Although MRI revealed the lower rate of poorly aligned rectum in LAARP group than PSARP group at both I-line (3. 0% vs. 14. 3%) and M-line (3. 0% vs. 10. 7%) levels,no statistically significant difference was noted (P＞0. 05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P＜0. 05), without significant differences in the length of high-pressure zone (15. 2 ± 5. 8 vs. 15. 1 ± 6. 2 mm) and the presence of rectoanal relaxation reflex (84. 8% vs. 85.7%). Conclusions Satisfactory fecal continence can be achieved in patients with high/intermediate type imperforate anus after LAARP. LAARP has some advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

一岁以内复杂先心病双向格林手术结果分析

目的 总结1岁以内复杂先心病患儿行双向格林手术病例的临床特点及预后分析.方法 1998年1月至2008年12月,34例单心室、肺动脉闭锁等复杂先心病畸形患儿均接受了双向格林分流手术.其中体外循环下18例,非体外循环下16例.男性21例,女性13例.平均年龄(0.66±0.21)岁,体表面积(0.16±0.05)m2.术前经皮血氧饱和度(73±9)%,术前肺动脉压(12.19±3.68)mmHg.结果 手术死亡2例,术后出现并发症5例(胸腔积液4例,乳糜胸1例).术后肺动脉压(17.74±3.62)mmHg,经皮血氧饱和度(84±16)%.手术时间(173.55±42.16)min.结论 对于1岁以内复杂先心病患儿,双向格林手术是一种简单、可靠的手术方式.对于难以解剖根治或Ⅰ期Fontan手术的紫绀类肺血少复杂先心病患儿,此手术可缓解患儿的缺氧状况以及改善肺血管发育,为以后手术创造了机会.

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Objective To present the outcomes of bidirectional Glenn procedure to treat complex congenital heart disease in infants.Methods Between January 1998 and December 2008,34 patients with complex cyanotic congenital heart defects underwent bidirectional Glenn operations at this center.The 38 patients,whose mean body surface area was (0.16 ± 0.05) m2,consisted of 21 males and 13 females with a mean age of (0.66 ± 0.21) years.Their clinical data were retrospectively analyzed to evaluate the clinical outcomes.Results Before surgery,mean transcutaneous oxygen saturation was (73 ± 9) %,and mean pulmonary pressure was (12.19 ± 3.68) mmHg.On pump bidirectional Glenn procedures were performed on 16 patients,and off pump procedures on 18 patients.Mean operation time was (173.55 ± 42.16) minutes.After operation,mean vena cava pressure was (17.74 ±3.62) mmHg,and mean transcutaneous oxygen saturation was (84 ± 16)%.Two patients died after surgery,and 5 patients suffered severe complications.Echocardiographic follow-up showed functioning Glenn shunts without any obstruction at the anastomosis.Conclusions Bidirectional Glenn procedure is effective to treat complex congenital heart disease in infants.     

Clinical feature analysis of subdural effusion/hematoma after shunt use of adjustable valves in children with hydrocephalus北大核心CSCD

Objective To analyze the clinical data of children with hydrocephalus suffering from subdural effusion/hematoma after shunt(SEHS) with adjustable valves, and to provide reference for postoperative follow - up. Methods A total of 102 children with hydrocephalus treated with adjustable valves in the Department of Neurosurgery, Wuhan Children's Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology from August 2017 to September 2021 were enrolled and studied retrospectively. There were 16 cases with SEHS, 11 of whom were male and 5 were female. The age ranged from 3 months to 13 years (median;2. 5 years). The age, clinical manifestations, the time of SEHS occurrence, treatment methods (pressure regulation only or combined with drilling and drainage), and prognosis of the patients were analyzed. The pressure adjustment treatment was to increase the by 10-20 mmH2O (1 mmH2O =0.0098 kPa) each time and the patients were followed up 2-4 weeks after the adjustment. If SEHS didn't improve according to the follow - up results, pressure regulation combined with drilling and drainage was recommended. Results Of the 16 patients with SEHS, 3 cases were over 3 years old, and the other 13 cases were 3 years old or below. Eleven cases were treated by pressure regulation only, and 5 cases who were all aged 3 years received pressure regulation combined with drilling and drainage. Symptoms occurred in 2 patients, including vomiting in 1 case, and head and limb shaking in the other case. Fourteen cases were asymptomatic. The time from shunt operation to the occurrence of SEHS was 1 month in 5 cases, who were all cured by pressure regulation only. SEHS occurred in 5 cases > 1-3 months after shunt surgery, and 2 cases of them were treated by pressure regulation combined with drilling and drainage. Three cases had SEHS > 3-6 months after shunt surgery, and 1 case of them was treated by pressure regulation combined with drilling and drainage. SEHS occurred in 3 cases more than 6 months after shunt surgery, and 1 case of them was treated by pressure regulation combined with drilling and drainage. For the patients who received pressure regulation combined with drilling and drainage, the time from shunt operation to the occurrence of SEHS was 1 month and 21 days, 2 months and 7 days, 4. 5 months, 7. 5 months, and 25. 0 months, respectively. The time from the occurrence of SEHS to the last reexamination with no SEHS detected was 1 month in 7 cases (all were cured by pressure regulation only); >1-3 months in 5 cases (3 cases were treated by pressure regulation combined with drilling and drainage); more than 3 months in 4 cases (2 cases were treated by pressure regulation combined with drilling and drainage). For the patients who received pressure regulation combined with drilling and drainage, the time from the occurrence of SEHS to the last reexamination with no SEHS detected was 1 month and 14 days, 2. 0 months, 3. 0 months, 7. 0 months and 8. 0 months, respectively. Except for 2 cases who experienced pressure regulating valve failure, all other cases were cured. Six cases were unilateral SEHS, and the SEHS volume was about 11 to 75 mL (median;39. 0 mL). Ten cases were bilateral SEHS, and the SEHS volume was about 23-380 mL (median; 158. 2 mL). The 6 cases were all cured by pressure regulation, and 5 cases of them had SEHS at the shunt tube insertion side. Conclusions SEHS in children with hydrocephalus is generally asymptomatic and rarely causes clinical symptoms. SEHS mostly occurs within 6 months after operation, especially within 3 months. SEHS found in 1 month after surgery can be cured by increasing the shunt valve pressure only. Therefore, SEHS can be cured by pressure regulation only by shortening follow - up and identifying SEHS early after shunt operation. This will also reduce the probability that patients require the drilling and drainage operation. © 2022 ＣｈｉｎＪＡｐｐｌＣｌｉｎＰｅｄｉａｔ. All rights reserved.     

托特罗定在小儿神经原性膀胱的应用评价

目的 评价托特罗定治疗小儿神经原性膀胱的有效性和安全性.方法 随访126例2002年1月至2009年9月收治的神经原性膀胱患儿,男71例,女55例,年龄(6.2±3.1)岁,全部病例行清洁间歇导尿,81例同时服用托特罗定(0.1 mg·kg-1·d-1,2次/d),45例未服用托特罗定.就诊时和治疗3个月后分别行尿动力学和临床评价.结果 导尿+药物组中8例因副作用终止治疗,其中3例出现口干,2例头晕,3例便秘加重,73例坚持服用托特罗定.就诊时导尿组膀胱容量、膀胱顺应性、逼尿肌压分别为(119.3±19.6)ml、(4.0±1.1)ml/cmH2O、(56.7±10.4)cmH2O.3个月后膀胱容量、膀胱顺应性、逼尿肌压压分别为(122.0±20.1)ml、(4.1±1.1)ml/cmH2O、(55.8±10.9)cmH2O,无明显变化.11例(24.4%)逼尿肌过度活动减轻,13例(28.9%)漏尿分数下降.药物+导尿组就诊时膀胱容量、膀胱顺应性、逼尿肌压分别为(119.8±17.6)ml、(4.4±1.3)ml/cmH2O、(55.1±11.7)cmH2O,3个月后膀胱容量、膀胱顺应性、逼尿肌压分别为(149.6±23.1)ml、(7.5±2.3)ml/cmH2O、(38.4±11.6)cmH2O,膀胱容量、膀胱顺应性明显增加,膀胱内压降低.58例(79.5%)逼尿肌过度活动减轻,53例(73%)漏尿分数下降及家长表示满意.结论 托特罗定可抑制逼尿肌过度活动,降低膀胱内压,增加膀胱顺应性和膀胱容量,较少有副作用,有利于保护上尿路功能,并可减轻尿失禁的程度,对于反射亢进型小儿神经原性膀胱的治疗是安全、有效的.

Abstract：

Objective To evaluate the efficacy and safety of tolteroding to treat neurogenic bladder in children. Methods 126 patients (71 boys and 55 girls of 6. 2 ± 3. 1 years old) with hyperreflexia neurogenic bladder who were treated during January 2002 to September 2009 were followed up. All patients were performed clean intermittent catheterization. 81 patients took tolterodine(0. 1mg· kg-1 ·d-1 ,2 times/d) and 45 patients did not use tolterodine. Urodynamic and leakage score were evaluated before the treatment and 3 months later. Results 8 patients stopped tolterodine due to side effect,such as dry mouth in 3, dizziness in 2, sever constipation in 3. 73 patients took tolterodine all the time. Before treatment, the bladder volume, compliance and detrusor pressure in catheterization group were 119. 3 ± 19. 6 ml、4. 0 ± 1. 1ml/cmH2O 、56. 7 ± 10. 4 cmH2O, respectively. Three months after the treatment, bladder volume, compliance and detrusor pressure were 122. 0 ± 20. 1 ml、4. 1 ± 1. 1ml/cmH2O 、 55. 8 ± 10. 9 cmH2O, respectively. There was no significant difference. Detrusor overactivity in 11 patients(24. 4％)and leakage score in 13 patients (28. 9％)decreased. Bladder volume, compliance and detrusor pressure in catheterization + tolterodine group in the beginning were 119. 8 ± 17. 6ml、4. 4 ± 1.3ml/cmH2O 、 55. 1 ± 11.7 cmH2O, respectively. 3 months later, bladder volume, compliance and detrusor pressure were 149. 6 ± 23. 1 ml、7. 5 ± 2. 3ml/cmH2O 、38. 4 ± 11.6 cmH2O, respectively. Bladder volume and compliance increased and detrusor pressure decreased significantly. Detrusor overactivity in 58 patients(79. 5％)and leakage score in 53 patients(73％)decreased. The parents satisfied with this result. Conclusions Tolterodine could inhibit the detrusor overactivity, so it could decrease detrusor pressure and increase bladder volume and compliance and protect kidney. It was effective to the children with hyperreflexia nerurogenic bladder.     

电刺激生物反馈治疗先天性巨结肠术后大便失禁的疗效分析

目的探讨电刺激生物反馈治疗先天性巨结肠改良Soave术后大便失禁的近期和远期疗效。方法采用加拿大产Laborie生物电反馈刺激仪,对37例先天性巨结肠改良Soave术后大便失禁的患儿进行盆底肌电刺激、生物反馈治疗。37例中,普通型31例,长段型5例,全结肠型无神经节细胞症1例。新生儿期手术2例,3~6个月手术23例,6个月至1岁手术6例,1岁以后手术6例。所有患儿在医院接受10次以上生物反馈治疗,每周2次,并每天在家进行盆底肌收缩训练。结果 37例均获随访,随访时间1~4年,37例中,经10次生物反馈治疗后,症状完全消失34例(91.89%),其中有8例(21.62%)半年后又出现污粪现象,再次予10次生物反馈治疗后,症状完全消失;3例(8.11%)仍有污粪现象,其中2例为新生儿期手术后一直污粪的患儿,经3个疗程生物反馈治疗后明显好转,在腹泻时仍会出现污粪现象。结论内括约肌损伤可能是先天性巨结肠改良Soave术后大便污粪的原因之一,电刺激生物反馈疗法是一种可靠、无创、有效的治疗方法。     

盆底肌训练治疗小儿肌原性大便失禁的临床评价

目的 评价盆底肌训练治疗小儿肌原性大便失禁的临床效果.方法 2002～2005年间选择两院大便失禁患儿28例,男19例,女9例,年龄4～12岁,其中肛门闭锁术后23例,先天性巨结肠术后5例,临床评分在3～4分之间.肛门直肠测压结果表明全部病例直肠感觉正常,肛管静息压和收缩压低,收缩压在80 mm Hg以上.应用生物反馈仪行肛门括约肌及盆底肌训练2周,1次/d,30 min/次,2周后嘱患儿在家中进行盆底肌肉收缩训练,1年后随访.所有患儿训练前、训练2周后及训练后1年行肛门测压,并进行临床评分.结果 5例患儿不能配合而放弃治疗.其余23例训练2周后肛门收缩压、持续收缩时间和肛门功能临床评分均明显提高,而肛管静息压无变化.1年后14例(A组)能坚持训练的患儿,肛门功能进一步提高,肛管静息压也较前增加,9例(B组)未能坚持训练回复到训练前的水平.结论 盆底肌训练对小儿大便失禁有良好的疗效.盆底肌肉的训练应该长期坚持,才能保持疗效.     

肛门外括约肌重建术后盆底肌训练的临床意义

目的 评价盆底肌训练在肌原性大便失禁肛门外括约肌重建术后的应用价值.方法 大便失禁患儿27例,年龄5～12岁,男17例,女10例,均为先天性肛门闭锁术后.临床评分均为差,全部病例行股薄肌肛门外括约肌重建术,术后3个月16例行盆底肌生物反馈训练,2周后在家中自行盆底肌收缩训练.11例未坚持行盆底肌训练.结果 术前训练组肛管静息压、肛管收缩压、持续收缩时间分别为(16.7±4.9)mmHg、(61.6±14.6)mmHg和(2.3±0.7)s,未训练组分别为(15.5±4.1)mmHg、(59.3±13.0)mmHg和(2.2±0.7)s,两组间无明显差别;1年后训练组肛管静息压、肛管收缩压、持续收缩时间分别为(35.4±8.7)mmHg、(150.6±17.8)mmHg和(7.2±1.2)s,肛门功能评价优12例,良3例,差1例,未训练组分别为(21.1±3.1)mmHg、(94.7±12.7)mmHg和(4.6±0.8)s,肛门功能评价优3例,良6例,差2例,均好于术前,但训练组治疗效果要明显好于未训练组.结论 股薄肌肛门外括约肌重建可改善肌原性大便失禁的肛门控便功能,但手术后坚持行盆底肌训练对于手术疗效的提高有重要价值.在大便失禁的治疗时不能单纯依赖手术,还要充分重视重建括约肌的功能训练.     

Rectal manometry in patients with isolated sacral agenesis

OBJECTIVE: The authors evaluated rectal manometry of children with sacral root abnormalities secondary to isolated sacral agenesis. METHODS: The anorectal manometric recordings of seven patients with isolated sacral agenesis (four with partial agenesis and three with complete agenesis) were retrospectively evaluated and compared with tracings from healthy control subjects. Characteristics of the internal anal sphincter (IAS), the rectoanal inhibitory reflex (RAIR), voluntary external anal squeeze pressure, and threshold of rectal sensation to distension were analyzed. Characteristics of the patients' neurologic function with attention to urinary and fecal continence were obtained by chart review. RESULTS: All seven patients had urinary and fecal incontinence. IAS resting pressure was the same in patients and control subjects. In the three patients with total sacral agenesis, IAS relaxation was more complete and lasted longer after balloon distention of the rectum. These patients also had significantly lower voluntary external anal squeeze pressure and blunted sensation of rectal distension. CONCLUSIONS: Abnormal parasympathetic innervation associated with sacral agenesis is associated with changes in anorectal function. Manometric findings suggest that there is modulation of the RAIR by extrinsic innervation, which may explain the fecal incontinence in these patients.     

Long-term functional, manometric, and endosonographic evaluation of patients operated upon with the Duhamel technique

Long-term functional results, anal endosonography (AES), and anal canal manometry were recorded in 48 patients aged 10 to 24 years (median 18) operated upon with the Duhamel technique for Hirschsprung's disease; 60.4% had perfect fecal control, 31.3% occasional staining and/or gas incontinence, and 8.3% constant fecal soiling, and 10.4% complained of constipation. Compared to normals, the patients had significantly reduced anal canal resting and squeeze pressures. AES visualized scar tissue in both the internal and external anal sphincter. Accepted: 16 December 1996     

Investigations for incontinence and constipation after surgery for Hirschsprung's disease in children

Surgery for Hirschsprung's disease is associated with high rate of morbidity, in the form of either constipation or incontinence or a combination of the two. This study investigates the mechanisms responsible for incontinence and/or constipation following the pull-through operation for Hirschsprung's disease. There were 19 children (15 boys and 4 girls), who at the time of study; 16 had undergone Duhamel, 1 Rehbein, and 2 Soave operation. We classified patients according to their symptoms into 3 groups: Group A was incontinent of faeces; Group B was constipated and incontinent of faeces, and Group C was constipated only. The median age at referral was 6 years, and the median period after operation was 5 years. All patients were investigated by intestinal transit study, endoanal sonography and anorectal manometry. Group A had normal or rapid transit study, as opposed to Groups B and C, who had delayed-transit study. On endoanal sonography, all children had an intact internal and an external anal sphincter, below the level of pull-through operation. The anorectal manometry showed a significantly lower resting anal pressure in the incontinent Group A as compared to the constipated children with or without incontinence in Group B or C (38 mmHg versus 57 or 66 mmHg respectively). The rectal pressure was also significantly higher in children in Group A as compared to those in Group B or C (71 mmHg versus 42 or 36 mmHg). The ratio of rectal/anal pressure was higher in incontinent children in Group A, as compared to constipated children in Group B or C. Therefore, constipation can be caused by high anal resting pressure and a weak rectal peristalsis, while faecal incontinence can be secondary to poor compliance and elevated rectal pressure in the presence of normal or low anal sphincter resting pressure. Aperients are the mainstay of treatment of constipation, however, children with incontinence are more difficult to treat. We did not attempt to define the pattern of nerve plexus because of poor results of revision operation for residual hypoganglionic segment and intestinal neuronal dysplasia. Treatment of these children can become more rational, if furnished with detailed functional studies. We advocate investigation of the anorectal function at an early stage in symptomatic children after surgery for Hirschsprung's disease, and less invasive treatment should be considered before embarking on major surgery.     

股薄肌成形术联合排便训练治疗患儿大便失禁

目的总结股薄肌成形术联合肛门排便训练治疗患儿大便失禁的操作经验和远期疗效。方法回顾性分析1996年4月-2011年4月本院收治的23例行股薄肌成形术联合术后排便训练的大便失禁患儿病例资料。其中男14例,女9例;初发19例,复发4例。先天性无肛行肛门成形术14例,先天性巨结肠术后大便失禁7例,外伤2例。大便失禁患儿分为3组,其中完全失禁6例,稀便失禁8例,肛周污便9例。23例患儿均进行了股薄肌成形术并术后肛门排便训练。术后定期随访,分别测量术前和术后2周、6个月和2 a各组患儿的肛门静息压和最大收缩压,并用SPSS 13.0统计学软件进行对比分析。结果 23例患儿均成功实施了股薄肌成形术,并坚持术后的排便训练,术后通过2～14 a随访,主观症状效果明显满意者13例,有效7例,完全无效者3例,满意率达86.95%(20/23例)。各组患者术后肛门静息压和最大收缩压较术前均有明显改善(Pa<0.05),经过肛门排便训练2 a后测值较术后早期有明显改善(P<0.05)。结论股薄肌成形术联合术后肛门排便训练能够有效改善小儿大便失禁的症状和生活质量。实用儿科临床杂志,2012,27(6):465-466,472     

先天性巨结肠经肛门Soave Ⅰ期拖出术后功能随访

目的评估先天性巨结肠经肛门Soave Ⅰ期拖出术后排便功能。方法随访2000年10月-2004年10月经肛门Ⅰ期拖出术44例，开腹Soave术35例，腹腔镜Soave术29例，Ikeda-soper术39例。术后随访1～5年。对围手术期疗效（术前准备时间、手术时间、术中输血量、术后禁食天数、应用抗生素时间、住院天数及费用）及术后排便控制能力（Kelly评分和直肠肛管测压）进行评估。结果经肛门Ⅰ期拖出术平均手术时间（75±20）min、费用（8198．81元）低于开腹术[（92±25）min；10264．45元]、腹腔镜术[（125±25）min；12504．67元]（P〈0．05）；术前肠道准备（2d）、手术时间（75±20）min、术中输血量（0例）、术后禁食天数（2d）、应用抗生素时间（4±1）d、住院天数（11±2）d及费用（8198．81）元较Ikeda-soper术[（4±1）d；（240±30）min；32例；（5±1）d；（7±2）d；（19±3）d；15243．78元]显著降低（P〈0．01）。经肛门Ⅰ期拖出术后的近远期并发症发生情况与开腹术、腹腔镜术无显著差别（P〉0．05）；Soave术后3个月小肠结肠炎的发生率（12例）高于Ikeda-soper术（3例）（P〈0．05），但就经肛门Soave术（5例）与Ikeda-soper术（3例）比较，差异无显著性意义（P〉0．05）。经肛门Ⅰ期拖出术和Ikeda-soper术患儿术后12个月Kelly评分无差别；术后1年直肠肛管测压均未引出直肠肛管抑制反射，术后肛管高压区长度、肛管静息压、直肠感觉阈值无统计学差异，但经肛门SoaveⅠ期拖出术后主动收缩压（52．3±15．6）mmHg低于Ikeda-soper术后（55．7±15．4）ramHg。结论经肛门SoaveⅠ期拖出术创伤小、并发症少、费用明显低于开腹、腹腔镜Soave术以及Ikeda-soper术，适用于治疗小年龄婴幼儿的短段型和常见型先天性巨结肠。     

Electromyographic and manometric anorectal evaluation in children affected by neuropathic bladder secondary to myelomeningocele.

BACKGROUND: Fecal incontinence, with or without persistent constipation is often underestimated in children affected by spina bifida. Medullar lesions to the L-S metameres result in a slowing of rectal and/or rectal-sigmoid motility, loss of anal or rectal sensation, deranged external anal sphincter function, altered motility of the anal levator muscles, and loss of motor coordination of the internal sphincter. We conducted an electromyographic and electromanometric evaluation of the anorectal tract in a group of children affected by myelomeningocele (MMC) in an attempt to evaluate the degree of functional damage and to provide appropriate treatment. METHODS: Anorectal manometry was conducted in 83 children affected by MMC (2-16 yrs, mean age: 8.4 yrs); surface electromyography was also performed in 37 of these children. We thus evaluated overall sphincter pressure, the inhibitory anal reflex, the rectal sphincteric reflex and rectal motility during stimulation and at rest. Recording perfusion catheters (0.1 ml/sec) were placed at rectal and anal level; rectal stimulation was conducted with an endorectal balloon. RESULTS: In all patients there was a reduction in overall sphincter pressure (15-25 mmHg; n.v. 45+/-25 mmHg) and the functional length of the anal canal (1-1.8 cm) compared with age matched controls. The inhibitory anal reflex was normal in all patients, although its amplitude, duration and sensitivity were not constant. Similar findings were obtained for the rectal-sphincteric reflex. The rectal sigmoid motility results were difficult to interpret: sudden, fast and high pressure waves of peristaltic progression were followed by prolonged pauses. No correlation was found between urodynamic and anorectal manometric data. Treatment consisted in daily emptying of the rectum so as to avoid fecal retention. Fifteen patients, who presented prolapse and sphincteric hypotonia ( 相似文献