腹骶会阴肛门直肠成形手术前后的护理

腹骶会阴肛门直肠成形手术前后的护理江苏省徐州市儿童医院赵冬梅１９８０年，Ｐｅｎａ开拓性地采用后矢状入路肛门直肠成形术治疗小儿肛门直肠畸形以来，小儿高位肛门直肠畸形的治疗效果有很大提高，大大减少了术后肛门失禁。肛周污粪的发生率，是目前公认的最佳手术方法...     

前矢状入路直肠肛门成形术治疗肛门闭锁并直肠前庭瘘

目的 探讨应用前矢状入路直肠肛门成形术（ASARP）治疗肛门闭锁直肠前庭瘘的效果。方法 回顾性分析1994－1999年采用ASARP治疗肛门闭锁直肠前庭瘘16例的临床资料。结果 16例术后获随访2个月至5年，肛门功能临床评分达优13例，良3例；切口感染1例。结论 本方法疗效满意，是治疗肛门闭锁直肠前庭瘘较佳的手术方式。     

后矢状入路肛门直肠成形术手术技术探讨

由Pen^～a医生设计的后矢状入路肛门直肠成型术(Posterior Sagittal Anorectoplasty,PSARP)进一步改善了中高位直肠肛门畸形的治疗效果。其不仅在解剖学上提出与控制排便相关的肌肉复合体的概念，在手术设计原理上提出以“复原”(Restorative Surgery)     

重建直肠角肛门成形术治疗肛门直肠闭锁

１９８６年,高春芳首先将重建直肠角式人工肛门应用于直肠癌根治术中［１］,术后肛门功能恢复满意。受此启发,１９８８～１９９６年,我们采用重建直肠角、经腹会阴一期肛门成形术,治疗高位先天性肛门直肠闭锁伴阴道、尿道及舟状窝瘘５８例。术后随访２～８年,其排便功能满意。本文介绍该手术方式并总结５８例的治疗体会。１　临床资料本组新生儿２０例,１岁１５例,３岁１０例,６岁８例,１２岁５例。男３２例,女２６例。根据Ｘ线检查及手术所见,按肛门直肠畸形国际分类标准［２］,本组５８例直肠盲端均在耻骨尾骨线（ＰＣ线）…     

先天性肛门直肠畸形的治疗现状

肛门直肠畸形是小儿比较常见的消化道畸形。发生率大约在1／5000左右。肛门直肠畸形种类繁多，病理改变复杂。除肛门直肠本身缺陷外，往往还伴发肛周肌肉和神经的缺陷以及其他系统畸形。这对外科医生是一个很大的挑战。从1980年Pena提出后矢状入路肛门直肠成形术（posterior saglttal anorectoplasty，PSARP）以来，手术纠正肛门直肠畸形已取得了革命性进展，不但手术视野更清晰，而且术后并发症相对降低。但问题仍然存在，比如不同类型肛门直肠畸形的手术方案选择仍存在争议，多项长期随访结果指出大多数肛门直肠畸形患儿术后并不能达到功能上的恢复。本文拟对近年来这些方面的研究报告综述如下。     

小儿肛门直肠畸形术后排便障碍的原因及治疗

目的探讨小儿肛门直肠畸形术后排便障碍的原因及治疗.方法 1985年1月～1998年12月共治疗肛门直肠畸形120例,对106例进行随访,其中男性78例,女性28例,年龄4～14岁,平均年龄10岁,随访率为80%.结果 38例高位肛门直肠畸形(36%),术后均有排便障碍(100%);32例中间位肛门直肠畸形(30%),术后15例有排便障碍(14%);36例低位肛门直肠畸形(34%),术后有6例排便障碍(6%).结论在高位肛门直肠畸形的病人中,术后均无正常排便,这可能与同时伴有脊髓神经及脊柱畸形有关.中间位及低位肛门直肠畸形术后有排便障碍与外科手术技术有关.腹腔镜手术技术应用于中高位肛门直肠畸形的治疗,使术后排便障碍大大减少,从而大大地提高了病人的生活质量.     

Pea术式治疗中高位肛门直肠畸形的并发症及对策

目的探讨Pena术式治疗中高位肛门直肠畸形的并发症及预防治疗措施。方法回顾性分析行Pena肛门成形术的58例中高位肛门直肠畸形患儿的临床资料及肛门排便功能情况、并发症，采用肛门功能临床评分标准进行评价。结果58例中优良者45例（83．3％），差者9例（偶有污粪6例，大便失禁1例，便秘2例），有并发症者8例（14．8％），其中直肠黏膜脱垂3例，粪便潴留2例，大便失禁1例，尿漏1例，直肠回缩1例。结论真正理解Pena的“无血、解剖式”手术技术的精髓，提高手术技巧和精细操作，加强术后康复训练是减少并发症的关键。     

直肠肛门畸形术后患儿排便功能康复训练

目的探讨直肠肛门畸形术后排便功能康复训练的方法及效果。方法对直肠肛门畸形患儿61例分别行腹腔镜辅助和倒"Y"字肛门成形手术,术后43例可自主排便,18例排便异常,对排便异常患儿采取肠道治疗、肛门功能和排便训练,持续1年。结果1年后,17例恢复排便功能,1例大便失禁患儿症状有所改善。结论早期积极手术治疗以及直肠肛门畸形术后加强新肛门排便功能的训练,有助于患儿排便功能恢复,改善其生活质量。     

成年人后矢状切口肛门直肠成形术(英)

自从Pena和Devries倡导应用后矢状切口肛门直肠成形术以来，这一术式已被许多外科医生用于高位肛管直肠畸形的处理。利用后矢状切口使结肠和直肠游离到足够距离而不需剖腹探查、修补直肠尿道瘘或直肠阴道瘘，重建肛门并保存排便控制能力。本文是利用后矢状切口作肛门直肠成形术治疗成年人肛管和直肠疾患。     

后矢状入路经肛管结肠拖下术治疗高中位肛门闭锁

目的探讨后矢状入路经肛管肌鞘内结肠拖下术治疗高中位肛门闭锁的方法。方法回顾分析6例高中位肛门闭锁病例，经后矢状入路，找到直肠盲端，切开肌层，在黏膜下分离至Douglas窝，环形横断肌层，经肌鞘内拖下结肠与肛门皮肤缝合。结果术后随访0．5—2．5年，排便功能良好。结论该术式能良好显露横纹肌复合体，层次清楚，损伤小，并同时重建了内括约肌，提高了排便控制功能。     

Follow-up studies of anorectal malformations after posterior sagittal anorectoplasty

Background/Purpose: There are few follow-up studies comparing posterior sagittal anorectoplasty (PSARP) with conventional procedures for patients with anorectal malformations (ARM). The authors have examined retrospectively postoperative anorectal function of patients with ARM treated with PSARP compared with those treated with conventional methods. Methods: Anorectal function in 23 patients with high and intermediate type anorectal malformations (PSARP group), who underwent PSARP more than 4 years previously, were assessed by Kelly's clinical scoring system and objective studies. These results were compared with those in 14 cases (5 high and 9 intermediate type cases; control group), who underwent other conventional surgical procedures. Results: Using Kelly's clinical scoring system, scores of the PSARP group compared with the control group were good in 48% versus 21%, fair in 48% versus 58%, and poor in 4% versus 21%, respectively. Barium enema studies suggested better anorectal sphincteric function in patients with high anorectal malformation in the PSARP group. Magnetic resonance imaging (MRI) studies showed more correct placement of the rectum through the striated muscle complex in the PSARP group at the I-line level. Manometric studies showed no difference in maximum resting pressure, anal canal length, and the incidence of anorectal reflex between the two groups. Conclusions: The favorable results of MRI and barium enema studies can be explained by direct visualization of the striated muscle complex with the aid of electrical stimulation as well as no harmful effects of amputation of the sphincter muscle in PSARP. However, manometric studies suggest anorectal function in patients with high and intermediate anorectal malformations is limited even after PSARP. Long-term postoperative follow-up with adequate bowel management is required for all patients with high or intermediate anorectal malformation.     

'High' anorectal malformation in boys: need for clarity of definition and management

Posterior sagittal anorectoplasty is purported to be the approach of choice for the treatment of both intermediate and high variety of anorectal malformations. The authors describe their devastating experiences with 2 cases of high variety of anorectal malformations in which defects were repaired thorough the posterior sagittal approach. In the first case, because of the high level of the rectal pouch, complete urethrovesical disconnection was done along with inadvertent mobilization and pull-through of urinary bladder. The patient subsequently required major reconstructive procedures. In another case, the bladder was partially mobilized before the mistake was realized; the high-lying rectum was later identified, and a pull-through was performed without any ill consequences. The authors infer that only the patients with rectal pouches ending caudal to the third sacral vertebra should have their definitive surgery performed through posterior sagittal approach. They suggest that PS3 line should be the watershed in management of anorectal malformation in boys.     

Continence after posterior sagittal anorectoplasty

Posterior sagittal anorectoplasty (PSARP) was introduced in 1982 by Pe?a and De Vries as a new operation for patients with a high anorectal malformation. The degree of postoperative continence is reported to be high. During the past decade, too, new insights have been gained into the embryology of anorectal malformations. Evaluation of PSARP in relation to current understanding of the development and anatomy of the anorectum and the pelvic floor has led us to conclude that optimal continence cannot be expected. Fifty patients with a high anorectal malformation underwent PSARP between June 1983 and May 1990. Postoperative follow-up consisted of anamnesis (subjective) and electrostimulation, defecography, and anorectal manometry (objective). All patients are alive, and all but one are being evaluated regularly. Subjectively, the majority of patients were more or less incontinent, with soiling of pants at least once a day. On the basis of objective criteria, virtually all patients appeared to be incontinent, and in only one patient was the mechanism of defecation almost unimpaired after PSARP. From this study, we conclude that although PSARP provides a good aesthetic result, patients will never acquire normal continence.     

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method

Background/PurposeIn an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure.MethodsA multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process.ResultsAfter five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula.ConclusionsA modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees.Type of studyDiagnostic studyLevel of evidenceLevel V (expert opinion)     

Currarino triad: a case report

The authors report a case of Currarino triad with a combination of anterior sacral meningocele and mature teratoma, sacral body deformity, anorectal stenosis, and tethered cord. A newborn girl suffered from vomiting, abdominal distension and constipation. Initially, a diverting colostomy was performed at the age of one month. 7 months later, at the age of 8 months, we performed posterior sagittal anorectoplasty (PSARP): As a result, extirpation of teratoma, excision of meningocele, untethering of the spinal cord, and anorectoplasty were achieved simultaneously without complication. We suggest the use of an MRI to specify the presence of anosacral and spinal cord anomalies in patients with intractable constipation and we recommend combined pediatric and neurosurgical assessment and management for all cases of Currarino triad.     

Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through

Purpose

The objective of this study is to analyze the clinical outcomes and anorectal manometry (AM) in infants with congenital high anorectal malformations treated with posterior sagittal anorectoplasty (PSARP) and laparoscopically assisted anorectal pull through (LAARP).

Materials and Methods

From August 2005 to December 2008, 23 patients with congenital high anorectal malformations were randomly distributed into PSARP and LAARP groups. All of them underwent LAARP (11 cases) or PSARP (12 cases) at 2 or 3 months old. Clinical outcomes and results of anorectal manometry were compared between patients at the age of 17.4 ± 4.9 and 19.3 ± 6.2 months (P = .4270), respectively.

Results

Kelly's clinical score for patients in LAARP and PSARP groups was 3.91 ± 1.14 and 3.83 ± 1.40 (P = .8827), respectively. Anal canal resting pressure and high-pressure zone length were 29.4 ± 7.2 vs 23.4 ± 6.5 mm Hg (P = .0479) and 14.9 ± 3.0 vs 13.9 ± 3.1 mm (P = .4414), respectively. Rectal anal inhibitory reflex was observed in 81.8% (9/11) and 83.3% (10/12) patients (P = 1.0000), respectively. The mean length of stay during the second hospitalization was 10.6 ± 0.9 and 14.3 ± 1.4 days (P < .0001), respectively.

Conclusions

Although no significant difference can be noted in clinical scoring between both groups, the results of anorectal manometry indicate that LAARP can significantly improve anal canal resting pressure and reduce the length of stay.     

Posterior sagittal anorectoplasty is superior to sacroperineal-sacroabdominoperineal pull-through: a long-term follow-up study in boys with high anorectal anomalies

BACKGROUND/PURPOSE: It is unclear which surgical method offers best long-term functional results in patients with high anorectal anomalies. The purpose of this study was to compare the long-term outcome of sacroperineal-sacroabdominoperineal pull-through (SP-SAP) to that of posterior sagittal anorectoplasty (PSARP). METHODS: Only boys with high anorectal anomalies (rectourethral fistula) were included in the study to get fully comparable patient groups. From 1975 to 1987, 36 consecutive patients underwent anorectal reconstruction: 19 had SP-SAP (1975 to 1983) and 17 PSARP (12 with internal sphincter-sparing technique, 1983 to 1987). The late bowel function (age at follow up, SP-SAP, 19 years; range, 15 to 22; PSARP, 13 years; range, 10 to 19) was evaluated by clinical interview and examination, and anorectal manometry. RESULTS: Six (35%) of the PSARP patients and one (5%) of the SP-SAP patients (P < .04) were always clean without any adjunctive measures. Three PSARP patients and two SP-SAP patients stayed clean with daily enemas. In the PSARP patients with soiling, the median frequency of soiling episodes in a month was four (range, 1 to 16), in the SP-SAP patients, 20 (range, 2 to 28, P < .001). None of the SP-SAP patients but 8 of 17 of the PSARP patients had constipation requiring diet or oral medication. Two PSARP patients and four SP-SAP patients had occasional faecal accidents. The median daily bowel movements in the PSARP group was one (range, one to four) and in the SP-SAP group, three (range, one to five, P < .001). The PSARP patients had significantly higher anorectal resting and squeeze pressures and voluntary sphincter force (cm/H2O, PSARP: mean resting, 47+/-9; mean squeeze, 106+/-29; mean voluntary sphincter force, 60+/-22; SP/SAP: mean resting, 27+/-10; mean squeeze, 68+/-22; mean voluntary sphincter force, 41+/-17; P < .01). Thirteen (76%) of the 17 PSARP patients and none of SP-SAP patients had positive rectoanal reflex indicating functional internal sphincter. CONCLUSIONS: In boys with high anorectal anomalies, PSARP clearly is superior to sacroperineal and sacroabdominoperineal pull-through in terms of long-term bowel function and faecal continence.     

Anterior sagittal anorectoplasty for rectovestibular and anovestibular fistula.

Rectovestibular (or anovestibular) fistula is the most common form of anorectal anomaly in female infants. In the surgical repair of these malformations, anal transplantation has been in widespread conventional use. Based on the idea of posterior sagittal anorectoplasty, we devised a new approach, anterior sagittal anorectoplasty, in which, in the lithotomy position, the anterior portion of sphincter muscles are cut through a median perineal skin incision and then the rectum is pulled through the center of these muscles to make its opening at the normal position. The operation has been performed in 12 patients with satisfactory results.     

Impact of spinal cord malformation on bladder function in children with anorectal malformations

Purpose

Risk factors for the presence of neurogenic bladder dysfunction (NBD) in children born with high anorectal malformations (ARMs), were investigated, to identify the need for urodynamics in these patients.

Material and Methods

The study included 37 patients with high ARMs (21 boys and 16 girls). Bladder function was evaluated with urodynamics both before and after anorectoplasty (posterior sagittal anorectoplasty [PSARP]). All patients were investigated with spinal radiograph. Spinal ultrasound was performed in the neonatal period, and magnetic resonance imaging was added in case of abnormal ultrasound or urodynamics and in case of cloacal malformation.

Results

In ARM patients with rectourethral and vestibular fistulas and cloacas, NBD was identified in 9 children (25%). The bladder dysfunction was innate in all cases except in one girl with cloaca, indicating that the risk of iatrogenic denervation seems minimal using the PSARP technique. All children with innate NBD had a spinal cord malformation either as spinal cord regression or tethering with or without a lipoma. Concerning vertebral status, almost all children with NBD had partial sacral agenesis. Abnormal perineal appearance was highly correlated to NBD in boys, especially in those with a spinal cord regression malformation. Innate NBD was not found in any child with normal spinal cord.

Conclusion

From these results, we suggest that spinal ultrasound and perineal inspection are used as screening procedures for NBD in children with ARM. Urodynamic investigation is recommended only when spinal cord anomalies or other signs indicative of NBD are present. In case of spinal cord malformation, repeated urodynamics during follow-up is mandatory because of the risk for developing tethered cord syndrome.     

Anorectal Anomalies in Adults-Laparoscopic Management and Review of Literature

Anorectal malformations (ARMs) are one of the most common congenital anomalies dealt by surgeons. The reported incidence of ARMs range between 1:3,300 and 1:5,000 live births. These defects are invariably detected and treated in infancy or early childhood. There is a group of patients among these who have fistulous external opening from the rectum. These may not present in child hood and may continue to live with fecal incontinence till adult hood. One of such anomalies is rectovaginal fistulas which comprises of only 4% of all anomalies. Delayed management in such cases increases surgical and functional complications. Traditionally high and intermediate anorectal anomalies are treated by posterior sagittal anorectoplasty (PSARP). This involves cutting of sphincter muscles in the midline and then placement of rectum in the sphincter complex. The continence results of this operation are less than ideal. Laparoscopically assisted anorectal pull-through (LAARP) has potential advantage of precise placement of the rectum inside the sphincter complex without dividing and weakening the muscles, diminished soft tissue scarring around the rectum leading to improved rectal compliance. Three adult female patients with ARMs were managed through LAARP procedure. It involves dissection around rectum, identification and ligation of fistula tract, creation of neoanus and pull through of rectum into neoanus. Results-Continence was good in all our patients which they regained after 3 to 4?days of surgery. On follow up which ranged from 6?months to 2?years all were passing well formed stools 1?C2 times a day and have symmetric anal contraction with strong squeeze on digital rectal examination. Conclusion-LAARP offers an excellent option to the patients of ARM over conventional posterior sagittal anorectal approach because if its theoretical advantages of early recovery and better continence. Long term followup is needed to substantiate these results.